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mr peabody

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Risky sex and the recreational use of MDMA

by Georgette Monserrat | Psychedelic Science Review | 21 Aug 2020

MDMA is associated with feelings of positivity but does it also increase risky sex behavior?

When used recreationally, MDMA elicits prosocial feelings such as empathy, closeness, and an increase of positive word use. A 2009 study suggests at least one mechanism to explain why this happens: researchers found that 15 volunteers taking MDMA experienced a significant and positive correlation between increased oxytocin levels in the blood and the positive prosocial feelings described above. Oxytocin is also known as the “love hormone” and is released naturally in various situations, including post-coitus.

There is abundant research showing an association between sensation seeking, impulsive decision making, and sexual risk-taking. Regarding MDMA, what feelings does it alter? And what is MDMA’s association with sexual activity? In psychedelic research, it’s important to look at the factors surrounding risky sex, including impulsivity and sexual behaviors in the context of MDMA.

MDMA and impulsivity

A study by Morgan, published in Neuropsychopharmacology in 1998, looked into the association between MDMA and impulsivity. Researchers recruited undergraduate and graduate student volunteers through poster advertising and vetted the subjects through interviews. The 44 participants were divided into the following three groups:
  • Non-Drug control group – 16 people who reported never using illicit drugs.
  • MDMA group – 16 recreational users of MDMA who had used it at least 20 times.
  • Poly-Drug control group – 12 people with drug histories and characteristics similar to MDMA users but who reported never taking MDMA.
Study participants completed various tests including:
  • Self Reporting Mood (Likert) scale — Used a 6 point rating from “not at all” to “extremely” on the categories of happy, depressed, joyful, pleased, fun, frustrated, anxious, and angry
  • Personality Impulsiveness, Venturesomeness, Empathy (IVE) test — Impulsiveness & Empathy has a 19 point rating scale and Venturesomeness has a 16 point rating scale. The higher the score, the more they displayed that characteristic.
  • Tower of London (TOL) test — This test assesses executive functioning. Participants had two different arrangements of balls and had to match the order of the second group to the first one in a set amount of moves.
  • Matching Familiar Figures (MFF20) Test — A behavioural measure of impulsivity. Participants are given a stimulus figure and then are shown 6 different options of which they must pick the one that matches exactly to what they were shown.
The data indicated no significant differences in empathy scores or TOL test scores across groups. However, in the TOL test, the participants in the Non-Drug group took significantly longer thinking before answering compared to participants in the other two groups. This demonstrates that participants in both drug groups were more impulsive when answering the TOL test (although it didn’t affect their test scores).

In the MFF20 test, the MDMA users committed significantly more errors than the Non-Drug and Poly-Drug groups. This test also illustrates that the MDMA group carelessly answered without thinking and reaffirms that the MDMA group is more impulsive given that they committed more errors than the other two groups.

Additionally, the results of self-reports and behavioral measures indicated that MDMA users had an increase in impulsivity and venturesomeness compared to Non-Drug users. The data also showed that MDMA users exhibited an impulsive characteristic trait, with heavier MDMA users exhibiting even higher levels of impulsivity.

There are limitations to the Morgan study including a small sample size of participants and relying on self-reporting.

Sexual behaviors while using MDMA

A qualitative study conducted by McElrath in 2005 examined MDMA and the sexual behaviors displayed while on it. This test consisted of 98 face-to-face interviews with current and former MDMA users.

McElrath used several recruitment strategies to attract participants across Northern Ireland. These included:
  • Placing posters in music shops and health centers.
  • Advertising in a music magazine.
  • Contacting diverse local organizations including STD (sexually transmitted disease) clinics, drug counseling centers, university unions, and LGBTQ programs.
  • Volunteer Referral Program: participants would refer other participants to the study.
  • Recruiter Referral program: recruiters would bring in participants for a small stipend.
  • The interviewers also reached out to their own contacts.
Of the total participants, 69% were male between 17-45 years old and the rest were female. Additionally, 16% of them identified as gay or bisexual.

The table below shows the breakdown of the drug use history of study participants. Note that 84% of participants consumed beer, lager, ale, or stout on a weekly basis and 32% used Cannabis on a daily basis.



McElrath’s qualitative research showed some interesting results: MDMA users had an increase in openness regarding sexual exploration which was defined as bisexuality or group sex. A 28 year old MDMA user expressed his feelings about sex on MDMA as, “You want to creatively indulge yourself in new forms of sex.”

Additionally, the 18-25-year-old MDMA users were more likely to engage in risky sex. Although “risky sex” is subjective, it was defined as having sex with multiple partners or sex without a condom.

Regarding overall arousal, there were mixed results: some MDMA users saw an increase while others had a decrease in sex drive. Those affected the most by the inability to ejaculate were male MDMA users of 25 years of age or younger. Some respondents (both male and female) reported not being aroused at all, but MDMA did elicit feelings of emotional intimacy, love, trust, and sensuality without sexuality. A young 22-year-old woman stated, “You feel loved up . . . I would have very little sexual encounters when I’m on E. In fact, none, because I’m more interested in the emotional aspects.”

It wasn’t just females who expressed feeling this way on MDMA. A 28-year-old male also had a similar perspective on sex with MDMA, “It wasn’t like the horn you get with speed, it was a lovey-lovey kind of thing.”

The limitations of this study are the small sample size, the data having been collected in the late 1990’s, and the subjectivity of “risky sex.” The study was also a purely qualitative and based on people’s subjective experiences. Furthermore, it is difficult to decipher how much of people’s experiences are due purely to MDMA as respondents also engaged with a variety of other drugs and alcohol on a monthly, weekly, and even daily basis. In addition, the study lacked data on what drugs were combined with MDMA during the experiences the participants shared in their interviews.

Conclusions

Overall, the data indicates that MDMA elicits positive and negative feelings from emotional intimacy and closeness to increased impulsivity and increased sexual risk with young adults. However, “sexual risk” is subjective across ages and cultures, especially with more non-traditional relationships, like polyamory, on the rise. Additionally, MDMA affects people differently with some having an increased sex drive while it is decreased for others.

More research is required to examine how MDMA specifically affects today’s population across races, gender identification, relationship styles, and neurodiversity.

 
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mr peabody

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Opioid overdoses take the lives of many young people.

Simple nasal spray saves lives*

by Steinar Brandslet | Norwegian University of Science and Technology | Medical Xpress | 3 Sep 2020

In the EU, thousands die each year from heroin or opioid overdoses. European users now have a better option available for helping each other.

Time is of the essence when a person has overdosed on heroin or other opioids. Mortality is high. But a friend can give an antidote quickly if it's readily available.

Users and their relatives have been part of the team as Norwegian researchers and industry developed a practical solution for twelve European countries: a nasal spray that not only is easy to store and use, but that has a low risk of withdrawal symptoms afterwards.

"Evidence of effective treatment for everyone, including those who take drugs, has always been our driving motivation," says NTNU professor Ola Dale in the Department of Circulation and Medical Imaging.

Known remedy, but cumbersome to use

Dale is a specialist in anaesthesiology and clinical pharmacology, and has worked with both painkillers and nasal sprays for a long time as a way to save lives. He wanted to give users a better option to help save each other.

Naloxone is a known remedy for reversing overdoses and preventing overdose deaths. Rescue kits have been used by healthcare workers since the 1970s, and by friends and family since the late 1990s.

But the temporary sprays have been cumbersome to use, and their efficacy has been questionable. Nor did the temporary sprays undergo the normal trials to test their effectiveness and side effects until 2015. Doses that are too high can cause strong withdrawal symptoms later.

In 2009, Dale became aware of the problem and decided to do something about it. It has taken close to 12 years to reach this point, but since 1 July the nasal spray Ventizolve has finally hit the market.


Naloxone in the form of a nasal spray can save lives.

No dreaded withdrawal symptoms

"Our nasal spray contains a lower amount of naloxone than other approved sprays. We arrived at a dose that is effective in the vast majority of overdose cases, without the overdose victims having to pay the high price of much feared withdrawal symptoms," says Dale.

The work to develop a new nasal spray has met with a lot of resistance during all these years. It was delayed by a flood in Bangkok and had small deviations in the production timeline of the spray. But Dale and his many assistants never gave up.

Dale has been on four research trips abroad, and international contacts have proven useful. Academic pharmacist Phatsawee Jansook in Bangkok took on the task of formulating a spray solution adapted to nasal use.

Later, medical student Ida Tylleskär came on board, and shortly afterwards Arne Skulberg joined as a Ph.D. candidate. He is an anesthetist at Oslo University Hospital, Ullevål, where the nasal spray could be tested on healthy volunteers.

Skulberg won the national final of the Researcher Grand Prix in 2014 for his work with the nasal spray. Tylleskär defended her doctoral dissertation on nasal sprays and overdoses in August.

To begin with, the research team received help from the Norwegian Institute of Public Health's "Biopharmaceutical production" vaccine laboratory. The facility closed and in 2014, the researchers realized that they had to find an industry partner.


Naloxone is used as part of the treatment to rapidly reverse an opioid overdose.

Launched in Europe

"We would never have succeeded in making our product without an industrial partner coming into the picture. Alone we couldn't have met the many formal requirements of the Norwegian Medicines Agency," says Dale.

The group therefore contacted Farma Holding/Dne (formerly the Norwegian Ether Factory). Today the company name is dne pharma.

Dale says that "in contrast to the Norwegian Directorate of Health, Farma Holding/Dne believed in the team and the project's commercial potential."

dne pharma has now ensured that the researchers have secured marketing authorization for Ventizolve in 12 European countries. Drug overdoses are a major problem in Europe.

"In 2017, 8200 people died from overdoses in the EU. Including Norway and Turkey, we're talking about 9400 deaths," says Geir Simonsen, CEO of dne pharma.

These deaths often happen to people in their 30s and 40s who die long before their time.


The design breaks all the usual rules. The spray needs to be easy to open quickly.

Users were advisors

"We wanted to document that the spray is as good as the standard treatment—that is, when the health personnel in the ambulances inject someone who's overdosed with naloxone," says Dale.

A study is currently underway in Oslo and Trondheim where the spray is being compared to the standard treatment.

"We couldn't have carried out this study without dne pharma," says Arne Skulberg who now leads the study. "The study will include 200 overdose incidents, and we're close to reaching that number."


Users have been involved in designing the nasal spray so that it will be easy to carry, recognize and use.

Active opioid users were involved in the planning of the study. The advice they gave made it possible to get the study approved by the Regional Committee for Medical and Research Ethics, says Dale.

"Already at the study design stage, input from the user group helped create a robust study rooted in the user environment," says Skulberg.

Users also collaborated with the design company Anti in Bergen to design the packaging.

Tom Morgan from the design company Anti created packaging that broke with ordinary pharmaceutical industry thinking. It was designed to function on the users' terms: easy to carry in your pocket, and easy to recognize on dark and cold days and nights in a bag or purse. A single package also needed to have room to include the spare spray.

Hope more people will carry spray with them

The hope is that the final product—two sprays containing naloxone and a case—will increase the probability that the spray will become, and continue to be, something that users take with them.

"We're also hoping for the spray to gain maximum distribution throughout society. The idea is to make the spray extra accessible by giving it to people who are at greatest risk of witnessing an overdose, like users, family members, social workers, security guards and the police," says Tylleskär.

*From the article here :
 
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mr peabody

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Toronto getting its first safe drug supply sites

by Lauren Pelley | CBC News | 21 Aug 2020

$1.6M in federal funding will help launch multiple sites, health providers say.

Safe supply sites are set to open in Toronto for the first time — a shift that comes amid a worsening opioid overdose crisis, thanks to new funding from the federal government.

On Thursday, local MPs announced nearly $1.6 million in funds for harm-reduction efforts in the city, with close to $600,000 earmarked for a safer supply pilot project through a Parkdale-based organization.

The goal? Providing easier access to prescription opioids for drug users through existing community agencies, and potentially preventing deaths.

The announcement follows months of rising overdose deaths. In July alone, there were 27 suspected fatal opioid overdoses reported by Toronto paramedics, a grim new record for the city, and hinting at several issues flagged by harm reduction advocates:

Amid the ongoing COVID-19 pandemic, drug users are further isolated, and the illegal supply has grown more toxic thanks to broken supply chains.

Now, with safe supply sites aiming to prevent more deaths, here's how that process will actually work.

What are safe supply sites?

Safe supply sites are facilities that help drug users gain access to legal prescription versions of drugs that are often purchased illegally and potentially contain toxic substances.

In some cases, that could include a whole spectrum of drugs, from hallucinogens like MDMA and LSD to heroin and other opioids.

In Toronto, this federally-funded project will be focusing on prescription opioids.



Federal government funds first major safe drug supply program.

Who's operating the Toronto sites?

The new funding includes more than $582,000 for a 10-month emergency safe-supply pilot project led by the Parkdale Queen West Community Health Centre, a west-end centre that already works with drug users.

"It will provide pharmaceutical-grade medication to people experiencing severe opioid use disorder and connect patients with important health and social services, including treatment, which may be more difficult to access during the COVID-19 outbreak," according to federal officials in a news release.

That health centre hopes to operate two sites, while a coalition of east-end agencies aims to operate several more — all of which will be run through existing bricks-and-mortar facilities and community outreach programs.

How will they work?

The sites will focus on agencies' existing clients, not the broader public. Those drug users will be able to gain prescriptions for hydromorphone tablets — a type of opioid — that they can pick up at a pharmacy, then take orally or inject.

Angela Robertson, executive director of the Parkdale Queen West Community Health Centre, said it's a drug covered by the Ontario Drug Benefit program, so the majority of their clients who are on Ontario Works or disability support won't have to pay when picking up the prescriptions.

The new safe supply sites run by the Parkdale team will be operated alongside other wraparound services, giving drug users additional supports, according to federal officials, including a "harm reduction drop-in program, evidence-based information, supplies, food and referrals to other service providers."



Will this fix the opioid crisis?

Critics warn dispensing drugs this way could actually worsen the opioid overdose crisis.

"Activists and drug policy leaders, in their zeal to undermine the previous 'war on drugs' or the criminal justice approach to addiction, are unwittingly creating a prison system of their own: a mental prison of perpetual, state-sponsored drug use," argued McMaster University psychiatry resident Jeremy Devine in the July issue of Policy Options, as CBC News previously reported.

And governments have long been hesitant to embark on safer supply initiatives — including the current Ontario government, which has held off on backing these kinds of sites.

But harm reduction advocates, and a growing number of government officials at various levels, argue these programs can save lives.

"We are building a more humane, a more dignified, a more evidence- and health-informed approach to drug use," said Coun. Joe Cressy, chair of Toronto's board of health.

Toronto resident Akia Munga, who is both a drug user and advocate, stressed that drug users often face discrimination and roadblocks when trying to gain access to legal drugs through the traditional medical system, and said safer supply programs can meet those needs with less judgment.

"It changes the way that your day looks. It changes the way that you use. It gives you options — it allows you to choose between an illicit supply, and something you don't know, and allows you to use something that's prescription-grade and tested," Munga explained.

What are the next steps?

After this pilot project, it's not yet clear if there will be further injections of federal funding support.

That's worrisome for advocates who maintain this new cash already came too late.

"Many of these deaths, these thousands of deaths, could've been prevented by faster action," said Jason Altenberg, CEO of the South Riverdale Community Health Centre, one of the east-end organizations launching new sites.

Others like Munga also say the current safe supply setup doesn't go far enough, and needs to be expanded to a broad array of drugs beyond lower-dose hydromorphone — a concern highlighted by drug users in B.C., where safer supply programs have existed for months but aren't always meeting the needs of people struggling with addiction.

Some advocates and medical professionals are also calling for the eventual decriminalization and regulation of all drugs for personal use.

 
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mr peabody

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Paul Harkin and members of the harm reduction team at GLIDE in San Francisco’s Tenderloin district.

Drug overdose deaths rising in the West

by Joel Achenbach | Washingto Post | 21 Feb 2020

SAN FRANCISCO — Downstairs at the medical examiner's office, the bodies lay side by side on stainless-steel tables and shelves, shrouded and anonymized in white bags, each person identifiable only by a protruding foot that had been toe-tagged.

Upstairs, Luke Rodda, the chief forensic toxicologist, looked over his morning docket and the terse reports from first responders.

Male, 33, "prior history of fentanyl overdose," found at bus stop.

Male, 27, "white powder in baggie."

Male, 51, found by construction worker, syringe next to him.

There had been at least nine apparent drug-related deaths over the previous three days in late January, Rodda said.

“This is our new norm now,” he said.

These individual tragedies are part of a national drug crisis that has shifted west. Drug overdoses are rising in many states west of the Mississippi, and dramatically so in California, even as they are falling across much of the East.

This trend has only recently become clear in government mortality data, including new numbers released Feb. 12. The increase in overdoses in the West is an ominous development that comes after a short period of progress in bringing down the overall drug-overdose death toll.

Drug deaths dropped 4 percent nationwide from 2017 to 2018, according to final mortality statistics released Jan. 30 by the Centers for Disease Control and Prevention. Secretary of Health and Human Services Alex Azar heralded the new numbers as evidence that the Trump administration’s efforts to combat the overdose epidemic “are beginning to make a significant difference.”

But the provisional CDC statistics released last week, which include estimated underreporting of deaths by medical examiners, show a slight uptick in fatal overdoses nationally over the first half of 2019.



In California, fatal drug overdoses over the previous 12 months increased 14 percent between July 2018 and July 2019, the last month for which the CDC has compiled provisional data — an additional 728 deaths.

In contrast, Illinois’ fatal drug deaths were down 8 percent, Pennsylvania’s down 10 percent, Michigan’s down 13 percent and Maine’s down 20 percent.

The overdoses in the West are driven largely by opioids, particularly illicit fentanyl, a synthetic drug that is roughly 50 times as powerful as heroin. Fentanyl has finally arrived in force in the western United States. Because fentanyl is so potent, and its dosage so easily miscalibrated, it is killing people who previously had managed their addictions for years.

Historically, the West Coast opioid market has been dominated by black tar heroin, a gunky substance not easily mixed with white powder fentanyl. That’s the orthodox explanation for why fentanyl first became popular in the eastern United States, where white powder heroin has historically been favored and drug dealers could more easily blend fentanyl and heroin.

Fentanyl started becoming more common here around 2015. The medical examiner’s latest, provisional numbers tell an alarming story: Deaths in San Francisco from fentanyl and/or heroin jumped from 79 in 2017 to 134 in 2018, and then more than doubled to 290 in 2019.

People are dying from other drugs as well, with a large spike in deaths linked to the potent stimulant methamphetamine. Efforts to cut off access to meth precursors sold in pharmacies have helped shut down local meth labs like the ones made famous in the TV show “Breaking Bad.” But that opened a new market for the Mexican drug cartels, said Daniel Comeaux, special agent in charge of the Drug Enforcement Administration’s San Francisco division.

“You have no mom and pop labs anymore because so much is coming from the Mexican cartels,” Comeaux said in an interview in his office in the heart of the Tenderloin district. “As much as we’re seizing, they’re producing.”​

And even the most experienced users of heroin can be fooled by fentanyl: “If you’re a new user of fentanyl, you don’t even know necessarily how much to take.”

Kral works on harm reduction — an approach that provides people with tools and support to limit the negative consequences of drug use.



Harm reduction advocates emphasize that the overdose crisis is driven by social factors, including economic inequality, the housing crisis that is tied to a rise in homelessness in San Francisco, systemic racism and the criminalization of drug use.They say the overdose epidemic should be treated as a matter of public health and not as a law enforcement issue.

“The war on drugs has created this problem,” said Eliza Wheeler, a leader in the harm reduction community.

Paul Harkin, director of harm reduction at GLIDE, a multi-service social center, pointed out that testing kits, including chemically treated strips similar to pregnancy tests, could help users know what’s in their drugs and help them avoid overdosing. “Unfortunately, America is very puritanical. We have to decriminalize in the way Portugal did, and we have to do drug testing so we know what’s in the drug supply,” he said.

That’s particularly a problem with fentanyl, which delivers an immediate, powerful high but can also render the user unconscious and unbreathing almost instantly.

“I’ve never seen so many people die,” said Chris, a young man in a hoodie standing near Eighth and Market streets in an area with open drug use. He did not want to give his full name because of concerns about trouble with law enforcement. He said he takes fentanyl and meth and has been on drugs for 15 years. He spoke in a light pre-dawn rain while, just a few feet away, young people stood at a bus stop waiting to board buses to technology companies in other locations in Silicon Valley.

Chris was engaged in conversation with a man named Brian, 29, who had been sitting unsheltered in the rain, leaning against a fence. Brian said he lives outside and prefers to do so. He said he’s been using meth for 10 years. Neither Chris nor Brian is interested in seeking drug treatment.

“It’s like a 24-hour party out here,” Chris said.

“That’s such a bougie comment,” Brian said.

The use of drugs in public and the burgeoning homeless population are sources of dismay for many of the more affluent residents of the city. Harm reduction activists believe that the law enforcement focus on impoverished and homeless drug users is unfair given that wealthy people often use drugs without repercussions.

“People are interested in open-air drug dealing because it’s visible to people and makes our city look bad,” said Kristen Marshall, a harm reduction worker who distributes naloxone to drug users.

She noted that thousands of overdoses have been reversed by peers on the street who were supplied with naloxone as part of harm reduction efforts. For many years, San Francisco saw a growing population of drug users but had a strikingly low rate of fatal overdoses. But that was before fentanyl showed up.

The statistics of drug use and overdoses do little to capture the gritty reality of life on the downtown streets of San Francisco. The drug use is in plain sight in the Tenderloin and the South of Market neighborhoods. One morning on Market Street recently, a young man in a hoodie was bent over at a bus stop in front of a hotel, injecting himself with a needle. He had slit both pants legs to improve access to his legs. One leg was bleeding. He looked dazed as he stood up, and did not respond when asked his name and whether he needed assistance.

Asked again whether he was okay, he looked puzzled and said, “I feel like there’s something alive in my body and I don’t know what it is.”

 
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mr peabody

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Platzspitz Park, nicknamed “Needle Park,” sits next to a river by the National Swiss Museum in downtown Zurich.
It’s a clean, peaceful space now, but in the 1980s was filled with heroin users and dealers.


The incredible story of Zürich’s journey to harm reduction

by Andre Seidenberg | FILTER | 9 Sep 2020

Drugs, troublemaking, bad grades. At the close of 1968, Sidi was expelled from school. Now, the party could begin in earnest.

He made music and lived in a filthy shared apartment, pretentiously calling itself a commune. Sidi deemed himself an expert on drugs. After all, he had spent time reading several books on the subject, not to mention the original Malleus Maleficarum recipes. He was surrounded by people who were dependent on heroin. They’re nearly all dead now.

Sidi completed high school on the side. And since he had always had a foible for the brain, if for no other reason than how it dealt with drugs, at some point he began to study medicine.

While cramming for his state’s exam, Sidi’s apartment was open to anyone and everyone. Üse was Evi’s boyfriend and Evi, who was also crashing at Sidi’s, was a friend of Sidi’s youngest sister.

One evening, Sidi was sitting in front of the TV, watching the evening news. Üse was lying on the mattress next to him in the flickering blue shadows. Sidi suddenly noticed that not only had Üse stopped talking, he had also stopped breathing. Sidi switched on the lights. Üse was blue in the face.

Sidi applied CPR according to every rule in the book, the whole, horrid time thinking of the tabloid headlines: “Junkie Dead, Doctor Sat and Watched.”

Well, that didn’t happen. Üse survived, and made it to the hospital. But according to the grapevine, he died of AIDS 10 years later. Shortly after that fateful evening, Sidi completed his medical studies.

Sidi, that’s me. I was a doctor for 40 years, practicing in Zürich, Switzerland. Nearly half of the city’s heroin-dependent people visited my practice at least once. I must have seen about three-and-a-half thousand. Some of them came again and again over the years. Many simply called me S.


The author as a young doctor in the 1980s. Photograph courtesy of André Seidenberg.

History in the fading

It was in 1992 that the Platzspitz city park (pictured top)—right by Zürich train station and internationally nicknamed “Needle Park”—was cleared out by the police, who had previously tolerated drug use and sales there.

This was eventually followed, however, by a far more enlightened policy. My friend and colleague Peter Grob calls that “history in the fading.” I can’t just sit back and let that fading happen.

Back then, in Switzerland alone, twice as many people died each year of overdose and AIDS as have died from terror attacks in all of Europe since 2010. The horrors and death were on our streets, right in front of our eyes.

Switzerland found itself at a crossroads, and chose to take the path of careful consideration instead of ostracization, incarceration and destruction of fellow human beings. From the mid-1990s, we vastly expanded syringe services and methadone access, and also permitted the limited prescribing of heroin—a policy with many well-studied benefits, which spawned a number of imitators around the world.

The success of Swiss drug policy exemplifies the liberal, humane side of Switzerland. I believe this is still important now, for Switzerland and elsewhere. Any society refusing to integrate its marginalized members is a looming danger to itself. Take the overdose crisis in the USA. And the catastrophe in many regions of the former Soviet Union, of which far fewer people are aware. Then there’s Iran, where so many people are drug-dependent, suffering from tuberculosis, AIDS and hepatitis.

On February 5, 1992, police cordoned off and closed Platzspitz. For years, neglected, destitute people—as well as regular Joes and well-groomed staffers from the international finance district directly behind the train station—had obtained their drugs there. Every day, more than 2,000 people were estimated to buy heroin and cocaine, and another thousand cannabis or other drugs, and many lived at the park. People openly sold drugs, shot up, conducted sex work and not rarely—thanks to unsafe practices and contaminated supplies—died there.
"The reward for the filterlifixers’ efforts was the residual heroin in filters. Without exception, those I knew got HIV and hepatitis C."
Nowadays, when an aged Sidi takes his dog for a walk in Platzspitz Park, he sees the ghosts of back then. I’m overcome with sadness as I recall desperate people lying on the carousel in deepest winter, day and night at sub-zero temperatures, wrapped in thick blankets.

Peter Grob, working for the HIV prevention organization ZIPP-AIDS, would distribute sterile needles in the public toilet building. I remember the jostling crowds in front of the hand-in counter.

I gaze over at the stone bench by the Sängerdenkmal (Singer’s Memorial). The same guy would sit there all the time, his pants around his ankles, searching with a needle for a living blood vessel in his inner thigh.

Filterlifixers, people who provided cigarette filters for use in preparing heroin, would bring over shopping carts from the train station. They would set up a stolen construction plank, laid over the cart, as a shop counter.

Their wares included spoons to hold the “brown sugar” (contaminated street heroin, mixed with ascorbate or lemon juice) as it bubbled over a candle’s flame, belts, water and the odd disinfectant—but most of all, those new and used cigarette filters.

The reward for the filterlifixers’ efforts was the residual heroin in filters. You could get a fairish shot from 10 or 20 filters. Without exception, the filterlifixers I knew got HIV and hepatitis C.

But how had we got there?

A poisonous atmosphere

At the end of the ‘60s, for the first time, two full-time police officers were assigned exclusively to drug-related offenses in Zürich; 25 years later, there were hundreds in the city, fighting the War on Drugs. Drugs were the major reason for incarceration in Switzerland. As of 1967, drug users were banished from every nook and cranny of the city. Dozens of restaurants, bars and clubs were closed—Schwarzer Ring, Odeon, Blow-up, to name just a few.

Armed police cleared squares and parks all over the city, patrolling them for days or weeks to prevent people from returning. Riviera, Bellevue, Seepromenade and Hirschenplatz were repeatedly subjected to this senseless routine.

No matter. The small-time sellers, mostly addicted themselves, stayed addicted and simply shifted their businesses to wherever the police currently were not. New and younger customers were found in these locations, rapidly expanding the market. Finally, the police resigned to the inevitable and turned a blind eye, for five years, to the Platzspitz drug bazaar.
"Our society became afflicted with suspicion and hate."
By the mid-’80s, AIDS fatalities were no longer limited to the most marginalized populations. Initially, no one knew much about the new disease, who it affected and how. But it soon became clear that unprotected sex and unsafe injection were the main driving forces. At that time, 80-90 percent of injecting drug users who sought medical help had the virus. Switzerland had more HIV-infected citizens than anywhere else in Western Europe.

Fear and anxiety were logical consequences, but they often escalated into panic. Our society became afflicted with suspicion and hate. Regulars at the local bar, but also members of Parliament, cried out for branding infected people with tattoos, or even isolating them in concentration camps. Some gay people, having finally seen some easing of homophobia, were horrified at the thought of now being “lumped together” with drug users.


Switzerland’s low-threshold opioid substitution program allows stable patients to receive take-home doses
of methadone, buprenorphine or morphine. Here, a worker at a substitution program prepares a week of
doses for a patient.


Fortunately, rationality would eventually win out over this poisonous atmosphere.

Initially, however, only those drug users who agreed to abstinence were given help. Those who were unwilling were denied guidance and medical care. Cold turkey, without any form of sedative or soothing support, was torture—agonizing pain throughout the body, uncontrollable shivering, diarrhea, terror.

Heroin-dependent people on turkey, wearing fluttering hospital gowns and pushing their IV poles with one hand, a cigarette in the other, could sometimes be seen racing downtown to find a fix to deliver them. Neither police, nor threats, nor even the prospect of death could dissuade them.

In 1983 and ’84, I was an emergency doctor in Zürich. People would come in from the Sihl riverbed, where they lived in huts rigged of cardboard and tin. One had festering wounds on his fingers and legs. Was it a cocaine-induced necrosis, or epidemic typhus from rat bites? Back then, it often felt like guesswork. And then there was the brand-new HIV/AIDS, to boot.

In 1984, my friend and fellow physician Andreas Roose and I began voluntarily touring the city’s shelters, where HIV-contaminated needles were passed around like joints. The danger was obvious and acute. Shelter workers and the private youth aid organization ZAGJP (Zürich Consortium for Youth Problems) helped us to spread lifesaving information and resources, distributing sterile syringes.

But Emilie Lieberherr, a Social Democratic Councilmember and director of Zürich’s social services, who suspected trouble from leftist intrigues, wanted to forbid the distribution of clean injection supplies in her institutions.
She peered down at me and said, “Aren’t you that brazen young doctor who is opposing my directives?”
We countered that we had prescribed the distribution for medical reasons. Lieberherr then appealed to the cantonal physician, Professor Gonzague Kistler, and controversy blew up. Zürich media was full of the Needle Exchange Conflict.

It escalated to such a point that, for a time, my career was at risk. But soon, a lucky coincidence turned the tables.

Late one night, long after the city police had cleared the sidewalks, I was summoned, as emergency doctor, to the Hotel Trümpy, where I found a beleaguered Emilie Lieberherr. After I assisted her, the hotel owner and I helped the tall, stately politician to the elevator.

She peered down at me and said, “Aren’t you that brazen young doctor who is opposing my directives?”

This gave the brazen young doctor the opportunity to have a nice long chat with her. Lieberherr insisted on getting the big picture and allowed me to win her over. She subsequently, and passionately, led the campaign for a mitigating drug policy in Zürich, gaining the city council majority.

In the needle exchange conflict, cantonal physician Kistler and health director Peter Wiederkehr threatened to revoke the licenses of recusant practitioners. In an inflammatory letter, Kistler told me it was imperative to protect “the upper echelon.”

In response, more than 300 of us licensed practitioners signed a document declaring we would continue to provide people with sterile syringes. We were supported by the cantonal medical association, as prohibiting the action lacked even the ghost of a legal or rational footing.

The so-called needle exchange prohibition was the act of an imperious cantonal physician, who had no authority over licensed doctors anyway. For guidance, Kistler looked no further than Professor Ambros Uchtenhagen, a University of Zürich psychiatrist, whose unshakeable opinion was that abstinence was the only treatment for addiction.



Life and limb

In July 1986, I placed the following announcement in the Zürich Tagblatt:

“Dear Mr. Policeman, I urgently request you to refrain from collecting fresh syringes from drug users. Taking sterile syringes is against the law and may possibly lead to arrest or fines, as it has been proven that doing this poses a threat not only to the person’s life and limb, but also, by propagating viruses, to public health.”

The police had no right to confiscate injection utensils from drug users. They rescinded their confiscation directive and the so-called needle exchange prohibition faded into obscurity.

At Platzspitz, ZAGJP, the Association of Independent Physicians (VUA) and the Red Cross launched a needle and syringe distribution campaign from a bus. The police tolerated the action.

Since the onset of the ‘80s, immunologist Peter Grob had been inoculating people who used drugs against hepatitis and carrying out blood testing for epidemiological field studies. Supported by the city of Zürich, he could now install a permanent needle exchange, ZIPP-AIDS (Zürich Intervention Pilot Project against AIDS), in the Platzspitz public toilet. Approximately 10,000 sterile injection utensils were handed out daily, in exchange for used supplies, which were then properly disposed of. ZIPP-AIDS also offered anonymous HIV testing.

Amid crises of housing and poverty, the city’s shelters were overflowing. I also organized emergency aid in trailers run by Pastor Ernst Sieber. Later, in 1988, his relief organization, Stiftung Sozialwerke Pfarrer Sieber, built an emergency addiction treatment center on the Konradstrasse. Although Sieber’s primary focus was spiritual guidance, he also saw the necessity of minimizing harm however possible.
"Suggestions included needle exchange, controlled consumption spaces, methadone and, taking things a step further, heroin prescribing."
At Emilie Lieberherr’s behest, the Zürich city council invited Basel Criminal Court President Peter Albrecht and myself to a drug policy hearing. Which measures could best reduce harms to individuals and to society as a whole?

Suggestions included needle exchange, controlled consumption spaces, methadone and, taking things a step further, heroin prescribing. The minimal impact of repressive tactics on drug consumption was firmly acknowledged. The city council accepted some of the ideas, publishing them as Ten Drug Policy Program Points.

Since 1988, the health department had been running the Krankenzimmer für Obdachlose (infirmary for homeless people) on the Kanonengasse. The city then opened a whole series of contact and drop-in centers for local injecting drug users. Until recently, the city health services had also revamped a dozen cigarette vending machines to dispense injection utensils.


The drug consumption room is around the corner from the train station and was placed there because so many users
gathered together and injected heroin. Now they use inside, with clean supplies and medical staff.


A funeral a week

Zürich and the Swiss gradually came to understand that though they might not desire drug use, it cannot be eradicated. The transition from abstinence dogma to harm reduction needed time to take hold. Needle exchange reduced the risk of HIV infections, but so many were already infected that at first, things just got worse.

From 1985, my practice was located in Zürich-Altstetten. My partner Christian La Roche and I treated about 200 HIV/AIDS patients in our joint practice. Almost every week we found ourselves at a funeral. Back then, being HIV-positive was a death sentence. No one knew how long it would be until AIDS arrived.

Enrique spent his days sitting on the waiting room sofa. He had nowhere else to go. His flesh wasted away to the bone, his long-lashed eyes were deep caverns, blinking in slow motion and his smile as delicate as a whisper. Occasionally, he’d take a sip through a straw before dragging himself to the toilet again. He died of extreme diarrhea.

Marie, a single mother of a delicate little girl, had AIDS. Triggered by her immune deficiency, she suffered from the Cytomegalovirus, threatening her with blindness and suffocation. Twice a day, Marie had to inject ganciclovir into a rubber depot implanted under her skin. Her sweet little girl would lead her half-blind, feverish and trembling mother through their stuffy, hot apartment. Marie soon died of pneumonia.

Gundula was an office worker. She also had an implanted catheter depot under the skin of her collar bone, into which she injected not only medication, but cocaine and sugar cocktails. Gundula had an ivy-entwined tattoo that read “For You: In Life and Death.” She was HIV-positive. She worked up to the very end, in the office during the day, and doing sex work at night, on cocaine. She died of a bacterial valvular suppuration.
"I remember Marco, Mona, Bodo, E.T., Jösi, Lisa. Hundreds of stories of miserable death."
Then there was Long-finger, a pianist. He came to my practice much later, but we knew each other from our wild youth, living together in Zürich’s Enge district. Ten pianists and one cellist shared the villa. The pianists lived in spacious salons, each with their own piano. I was the cellist; the nursery was enough for me.

Of course, Long-finger had a different name back then. He was the youngest among us and lived with a beautiful older pianist of 21. She didn’t notice when he began to shoot up; when she did, she wanted to throw him out.

Long-finger soon applied his sensitive fingers to breaking into drugstores. It took the police 12 years to catch him. Long-finger did not have HIV; he shot only the best, always using fresh needles. Wishing to avoid street heroin after his long prison term, he came to me for methadone treatment. I recognized him immediately but was surprised to hear he had been using heroin for so long—I had never known.

Long-finger came at the right time because I was finally able to treat people with methadone. The cantonal physician had been forced, by a legal decision, to approve the treatment. With methadone, Long-finger’s life was saved.

I also remember Annaliese, her twins and her husband Pino. I remember Marco, Mona, Bodo, E.T., Jösi, Lisa. Hundreds of stories of miserable death.

Deadly promises, another Platzspitz

For a long time, there was no effective medical treatment against HIV/AIDS. What was also truly unbearable was the torture heroin-dependent people suffered at the hands of the state. Even though methadone was a viable option to provide relief and reduce harm, it wasn’t a cure-all.

Despite admitting in his early 1980s WHO assessment that methadone was an effective treatment for opioid addiction, Professor Uchtenhagen considered the methadone program a threat to his ultimate goal of permanent abstinence. All the way up to 1987, even terminally ill heroin users had to wait more than three months before being granted methadone treatment. For many, this came too late. They were already dead.

Even now, in my older, supposedly milder days, I cannot hide my rage at the cluelessness and obstinate ignorance of our former health officials. I fought and won every dirty legal conflict with the health authorities. They were powerless to revoke my license and were obliged to grant me authorization for methadone treatment. Soon, I was a common media figure, taking pleasure in exposing my opponents publicly. Their promises weren’t just empty, in some cases they were deadly.

At the end of the ‘80s, many doctors had one or two patients in methadone treatment. In our shared practice in the Altstetterstrasse, Christian La Roche and I had up to 50 at any one time. Many city practices were overwhelmed by the enormous numbers of heroin-dependent people.

So, we founded an association for low-risk drug use (Arbeitsgemeinschaft für risikoarmen Umgang mit Drogen, or Arud) and, in 1992, opened the first low-threshold methadone dispensary. We ignored the high-handed cantonal regulation that required proof of a failed withdrawal attempt before approving methadone treatment—for a limited time, and solely as an emergency measure aiding withdrawal.
"Armed police continued to drive heroin users through downtown Zürich, even over the genteel Bahnhofstrasse."
After Platzspitz was shut down in February 1992, the drug scene did not, of course, disappear. With truncheons, shields and tear gas, armed police continued to drive heroin users through downtown Zürich, even over the genteel Bahnhofstrasse.

There, at the defunct Letten train station and under the Kornhaus Bridge, the police left them to their own devices, doing their best—in vain—to contain the drug scene there.

Members of Albanian and Nigerian trafficking organizations directed their dealers from the Kornhaus Bridge. Customers would mill below, between defunct railroad tracks, in a morass of syringe packages, needles and excrement, searching for veins in the pale light of streetlamps. The district’s residences and schools degenerated. Families with children and means moved away. Access to emergency medical care and social work went backwards.

Under the direction of Judge Barbara Ludwig, the same two or three hundred people were repeatedly “deported” back to the wealthy Zürich suburbs or Aargau Canton and soon returned.

The Letten district, Zürich’s last major public drug scene, was itself cleared on February 14, 1995. But this time the outcomes were different. In between the shut-downs of Platzspitz and Letten, better infrastructure to help heroin-dependent people had finally been installed.


The Letten district in the early 1990s. Photograph by Gertrud Vogler.

Adequately controlled agonist treatment

The Arud low-threshold methadone dispensary model proved effective, and was soon copied throughout Switzerland. Richer communities were now able and obligated to tend to their own addicted children, taking pressure off the city’s care system. Over the years, blanket medical and social care has been developed.

Today, the majority of opioid-dependent people in Switzerland receive methadone treatment. Very few have entirely stopped taking illicit drugs, but most can lead entirely normal lives.

Twenty-five years ago, a thousand people died each year of drug-related causes in Switzerland—about four hundred of them died of heroin overdoses, the rest primarily of AIDS, hepatitis and purulent infections. Drug-related causes were the major factor in deaths of people in their 30s and 40s.

Today, not only are overdoses increasingly rare, but HIV, since 1996-97, can be effectively treated. Hepatitis C can not only be cured, there is hope it can be eradicated completely.

The Swiss “Four-Pillar” policy—prevention, therapy, repression and harm reduction—was an imperfect but workable national compromise. The only truly new element was harm reduction, and the efficacy of the other elements must still be viewed critically. Long-term prevention and abstinence-oriented therapy have yet to prove their worth in scientific studies. After detoxification cures, relapses are par for the course, often ending in fatal overdoses. Thus, the abstinence ideal, as opposed to long-term methadone treatment, at least doubles excessive mortality, today as much as back then.

An adequately controlled agonist treatment best meets the needs of dependent people and of society as a whole.
"We proudly presented vials altogether containing a half-kilogram of pure, federally produced, Swiss-quality heroin."
In 1994, I became medical director of the first heroin dispensary at Zurich’s Arud polyclinic on the Stampfenbachstrasse.

During the grand opening media circus, we proudly presented diacetyl morphia vials altogether containing a half-kilogram of pure, federally produced, Swiss-quality heroin. Since then, I have privately called myself the biggest small-time heroin dealer in town.

The heroin pilots were highly successful. Even the most long-term, criminally involved heroin users would see their lifestyles transform nearly immediately—demonstrating that the inherent properties of the drug were not the salient issue. And most importantly, nearly all of them survived.

Switzerland’s failure to capitalize fully on this opportunity is a continuing source of regret, however. Heroin treatment never officially went beyond the test phase, and less than 3 percent of dependent people have received heroin treatment to date.

For many years, my anger was more powerful than my fear. I exposed myself and my family to considerable unpleasantness. We were subjected to telephone harassment. I was spat on, beaten and received death threats. More than once, I hurt myself with HIV-infected materials. Each time, my wife and I anxiously sat out the three-month waiting period until the laboratory results came.

Was it worth it? I’d say yes. My patients could so easily have been me. They were people just like me, struggling in life. When I was able to help them, it meant everything.

 
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mr peabody

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Peter Krykant parks a white van on the streets of Glasgow to give people a safe space to inject illegal drugs.
“People don’t get any more opportunities after they’re dead,” he said.

How a man with a van is challenging U.K. drug policy

by Allison McCann | New York Times | 21 Nov 2020

GLASGOW — A former drug user turned activist is addressing Scotland’s alarming drug death crisis by running the nation’s first drug consumption room — and risking arrest to do it.

Every Friday for the past two months, Peter Krykant has parked his white van on Parnie Street in central Glasgow, around the corner from a games shop and several art galleries, and waited for people to come by and inject illegal drugs.

Inside the van are two seats and two tables, each with a stainless steel tray and hypodermic needles, as well as several biohazard trash cans. The van is also equipped with naloxone, the medication used to reverse an opioid overdose, and a defibrillator. (There are Covid-19 safety precautions, too: hand sanitizer and a box of masks.)

Mr. Krykant usually opens the van by 10 a.m., and on this particular day three people were already waiting to get inside. This was something of a surprise, since the Scottish police had charged him with obstruction the week before when he refused to open the vehicle to officers, knowing several people were inside taking drugs. He wasn’t sure anyone would come back after that scare.

Scotland is in the midst of its worst drug crisis on record, and one of the worst in the world. The country has tallied five straight years of record-setting, drug-related deaths and now holds a per capita death rate three times higher than anywhere else in Europe.

Overdoses are more common in Scotland, by some measures, than even the United States. In 2018, Scotland had nearly 20 drug-related deaths per 100,000 people, compared with 18 deaths in the United States and around five in Ireland, Finland and Sweden.

Mr. Krykant is adamant that drug consumption rooms will help slow the rate of overdose deaths in Scotland by allowing drug users to inject under supervision and with naloxone on hand.

Mr. Krykant chats easily with several men waiting to be let inside. He asks them what type of drug they’ll be injecting, writes it down and then opens the sliding back door.

In addition to Mr. Krykant, at least one other trained volunteer is on duty; they take turns watching for the police and checking on the people inside.

A 25-year-old man who would give only his first name, Gezzy, for fear of arrest, said he had injected both heroin and cocaine that day. Dressed in a navy blue tracksuit with a clean haircut, he talked candidly about the death of his ex-girlfriend, who suffered an overdose seven weeks earlier.

“This is what we needed,” he said. “There are too many overdoses.”

Mr. Krykant, a former addict himself, said he had “learned very quickly that harm reduction is the most fundamental thing.”

“People don’t get any more opportunities after they’re dead,”
he said.

Drug consumption rooms are facilities that legally allow people to take illicit drugs under the supervision of trained professionals, in a sterile environment and with clean equipment. They have been shown to reduce overdose deaths and blood-borne viruses like H.I.V., decrease public injecting and more quickly connect people to treatment services.

“In all recorded injections that have taken place in these spaces across the world, there has not been one recorded death,” said Andrew McAuley, a public health professor at Glasgow Caledonian University.

The first legal facility opened in Switzerland in the mid 1980s, and over the last three decades they have been established across Europe, Canada and Australia, around 200 in all.

Despite their effectiveness and Scotland’s increasingly dire drug problem, they remain illegal throughout Britain.

The Scottish government has expressed its support, but Westminster has not budged. “We have no plans to introduce drug consumption rooms, and anyone running them would be committing a range of offenses,” a spokesperson for the British Home Office said in a statement.

But Mr. Krykant thinks blaming Westminster is an easy out.

“All we’ve been hearing is that it’s the U.K. government’s fault,” he said, adding: “We could have drug consumption rooms in Scotland right now if there was political will.”

With Scotland in control of its own health care and policing — a system known as devolution — Mr. Krykant and other drug policy advocates argue that the Lord Advocate, Scotland’s chief public prosecutor, could provide legal cover in the form of a “letter of comfort” stating that drug consumption rooms could operate without fear of criminal prosecution. (The Lord Advocate provided similar guidance this spring for naloxone.)

But he has so far declined to do this, saying the facilities require a legal solution that addresses civil liability and the full range of exemptions from criminal law.

To date, the police have not shut down the van, nor have they made any arrests. In a statement, they seemed to suggest they would leave well enough alone — for now, at least.

“The establishment of any form of safe consumption location contravenes the U.K. Misuse of Drugs Act 1971,” an assistant chief constable of Police Scotland, Gary Ritchie, said in a statement. “Any attempt to circumvent the law, as it stands, by providing an unregulated and unlicensed facility may expose already vulnerable people to more risk and harm.”

For Mr. Krykant, the goal of the van is to challenge drug policy more than to curb Scotland’s soaring drug deaths.

“We may keep people alive, but this has always been about a push for an official establishment,” he said. “We can’t provide a service for hundreds of people from the back of one transit van.”

Mr. Krykant grew up in Falkirk, about 20 miles from Glasgow, and said he was taking drugs on a daily basis by the time he was 11 years old. By 17, he was injecting heroin, and a few years later found himself in Birmingham, England, living on the street and begging for money to fuel his drug habit.

He was eventually approached by an outreach team in Birmingham and offered a chance to enter a residential treatment program. “I grabbed my bag and enough drugs to take on the train and got myself there,” he said.

After that, he moved to Brighton in southern England and completed another program, and has been clean now for two decades. He returned to Falkirk in 2013 with his family and started working in drug recovery services.

But he started to grow disillusioned with the work he was doing. As an outreach coordinator for a charity, part of his job was testing homeless people in Glasgow for H.I.V. and hepatitis C.

“We would be walking away from people who tested negative, knowing that they were going to be back in the alleyway later that day,” he said.

In February, he attended a conference sponsored by the Scottish government and heard about the promise of drug consumption rooms. He was intrigued. A few weeks later he traveled to Copenhagen and met with the people who opened Denmark’s first mobile site in 2011. Less than a year later, the Danish Parliament legalized supervised injection facilities.

“I took my inspiration from what happened there,” he said. “They quickly got the legal framework and now have the world’s largest safe consumption facility.”

He traveled back to Scotland and decided to do the same.

He invested 500 pounds, or about $650, of his own money and crowd-funded the remaining £2,400 to purchase the well-traveled van and outfit it with the necessary equipment. On Aug. 31 — International Overdose Awareness Day — he drove it to Parnie Street for the first time.

“Almost all of the interventions that work to help people were started through civil disobedience,” said Alex Kral, an epidemiologist from the nonprofit research institute RTI International. “Needle exchange programs, naloxone programs. Safe consumption sites are no different.”

Mr. Kral said the situation in Scotland was “completely parallel” to the United States. Despite attempts by cities like Seattle and Philadelphia to establish drug consumption rooms, the country currently has no legal sites. (One unsanctioned facility has operated since 2014 in an undisclosed location.)

Mr. Krykant chose the van’s parking spot carefully. Within a 30-second walk is an alleyway where drug users publicly inject. It is filled with discarded needles, slivers of foil and small spoons.

James Muir, 34, said that when the van was not there he usually injected in alleys like the one nearby or in parking lots around Glasgow. He said he had been to the van about three or four times now, adding, “I think it’s really good.” I asked if he was worried about the possibility of the police showing up and arresting him over drug possession.

“The guy reassured me he locks the van,” Mr. Muir said of Mr. Krykant. “I trust him.”

 
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Advocates fear worsening overdose crisis in 2021*

by Nick Wells | The Canadian Press | 17 Dec 2020

With overdose deaths rising across Canada, advocates for drug users are calling for the implementation of a national safe supply program as part of an effort to save lives.

Failing to do so, they say, will lead to more deaths from overdoses across the country.

A public health emergency was declared in 2016, a year that saw 991 deaths. More than 1,500 people have died in British Columbia from illicit drug overdoses in 2020.
Ontario’s chief coroner’s office estimates 50 to 80 people per week are dying of overdoses.

British Columbia’s government created a safe supply program in March, allowing doctors and nurses to prescribe pharmaceutical alternatives to illicit drugs.

Karen Ward, a drug policy and poverty reduction consultant with the City of Vancouver, said the concept of the program needs to be expanded across the country.

“It’s like you’re struggling to tread water in a tsunami,” she said in an interview, referring to the number of overdoses in B.C.

Experts say COVID-19 has exacerbated the situation as the supply of illicit drugs became more toxic when the border was closed and more drugs were made or altered in Canada. The pandemic has also impeded access to key harm reduction services, such as supervised consumption sites.

The federal government issued data on Wednesday showing 17,602 people have died from opioid overdoses between January 2016 and June 2020.

Between January and June of this year, 86 per cent of all opioid overdose deaths occurred in British Columbia, Alberta or Ontario.

“It will get worse. It will, definitely. Unless we stop talking and do some very specific things,” said Ward. “Let’s do safe supply. Nothing is perfect, but let’s find ways to prescribe in your community, in your area, right away. Or it will get worse.”

Along with a national safe supply program, Ward argues decriminalization is something governments should be considering.

It would mean police wouldn’t charge someone caught with a small amount of drugs and they would not seize the substance.

She is also critical of the scope of B.C.’s safe supply program, arguing health professionals need to be more willing to prescribe pharmaceutical alternatives.

“We need a variety of ways to access the health benefits that we have decided are necessary,” Ward said.

The federal government announced $9.5 million in funding for four safe supply pilot projects in Ontario in September, but advocates say that the small size of the project doesn’t do enough.

Last month, Vancouver council voted unanimously to ask the federal government to decriminalize small amounts of illicit drugs for personal use.

Federal Health Minister Patty Hajdu was unavailable for an interview, but her office sent a statement saying it is reviewing Vancouver’s proposal.

“The COVID-19 pandemic has worsened the ongoing opioid crisis. We have lost too many Canadians to overdose and all levels of government must redouble our efforts to save lives,” she said in the statement.

Prime Minister Justin Trudeau said in September that he supported safe supply but maintained his stance against drug decriminalization.

Dr. Mark Tyndall, a professor at the school of population and public health at the University of British Columbia, said more support is needed for safe supply programs and decriminalization efforts.

“Safe supply, to me, is the only real practical thing to do,” he said in an interview.

It’s frustrating to see governments and public health agencies not put as much effort as they could into saving the lives of drug users, said Tyndall, who used to head B.C.’s Centre for Disease Control and worked to launch an opioid vending machine in Vancouver’s Downtown Eastside.

“I’m pretty pessimistic,” he said on what the next year holds for drug users. “The chance of you overdosing from street drugs are probably higher than they were five years ago … we haven’t really made any significant changes that have made people safer.”

Zoe Dodd, a co-organizer with the Toronto Overdose Prevention Society, said governments need to understand the wider impact that overdoses are having.

“If we don’t seriously address the overdose crisis, we will lose a workforce,” she said.

Along with safe supply and decriminalization, more support is needed for people who work and volunteer at overdose prevention sites.

Safe supply, combined with drug decriminalization, is needed to truly make a difference, Dodd said.

*From the article here:
 
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UK’s first full heroin-prescribing scheme extended

by Andy Gregory | INDEPENDENT | 24 August 2020

The UK’s first fully-fledged scheme to provide heroin users with a safe and legal supply of the drug has been extended for a further year, after showing “very promising results”.

Heroin-assisted treatment has been used successfully for decades in Switzerland, based in part on Britain’s long-forgotten model of heroin prescribing, and despite “impressive” UK trials, government funding for post-pilot schemes was removed in 2015.

But in Cleveland and Glasgow, police and local health experts have pushed in recent years for the creation of two of the UK’s first fully-fledged centres, both of which are now up and running, providing access to medical-grade diamorphine twice per day and to wider social support.

Campaigners celebrated the first “dramatic” results from Middlesbrough’s scheme on Wednesday, which found a vast reduction in re-offending rates and use of street drugs, and significant improvements in participants’ health and quality of life, including seeing those homeless at the outset placed in accommodation.

Thirteen of the city’s most at-risk heroin users, who had found other treatments unsuccessful and were of concern to criminal justice agencies and health services, accessed the programme – which will now be largely funded by money seized from criminals. Eight remain, while five dropped out or were suspended.

Researchers studied six of the participants over 29 weeks in the programme, who prior to the scheme had been responsible for at least 541 crimes at an estimated cost to the public purse of £2.1m.

Between them, they committed just three lower-scale offences over 29 weeks of treatment.

After this period, four had not reoffended. One completed their probation period but committed one crime – down from an average of three offences every six months prior to the programme.

The other participant, who had previously not gone longer than two weeks between prison sentences having committed some 239 crimes, committed two offences during treatment.

“I used to shoplift to feed my habit,” one of the participants told researchers. “I needed at least £40 a day for my addiction. Even day, seven days a week. That’s £40 I’d sell it for so it had to be £80’s worth of their stock. Seven days a week at £80 a day."

“I don’t need to do that now. I’ve stopped doing all that.”


The estimated annual cost of each participant's diamorphine is £12,000, in addition to staffing and administration costs. Tablet and powder forms of diamorphine are considerably cheaper but Home Office regulation restricts their use.

In addition to a 99 percent reduction in illicit heroin use and 98 percent for cocaine, researchers noted clients’ on average used less of every other type of drug measured, save for tobacco. Four of the cohort did not test positive for illicit heroin at any point between weeks 19 and 29.

With the need to constantly fund street heroin removed, individuals were able to engage on a one-to-one basis at the clinic with various agencies including health, housing and welfare.

Though this additional engagement was put on hold because of coronavirus, the twice daily supervised diamorphine injections have continued, with a 98 per cent attendance record.

None of the six were homeless after one month, with four in secure accommodation after four months. At the outset, just two of the cohort lived in secure accommodation, with an additional two sleeping rough.

Furthermore, scores for their psychological and physical health – based on self-declarations – all more than doubled after just one month of treatment, rising by 329 percent and 142 percent respectively after seven months.

The number of self-declared hospital visits and ambulance requirements were also reduced, with only four ambulance call-outs and no A&E visits in six months, compared with two of each in the month prior to treatment.

“The latest analysis suggests the pilot has delivered very promising results and so it was very important we find the funding to continue,” said Cleveland Police and Crime Commissioner Barry Coppinger, who launched and part-funds the scheme.

“I’m delighted that money seized from criminal gangs who have blighted local communities is now being used to fund this pioneering approach that brings hope to users and their families and improves local life for residents and businesses.”

He added: “We should not forget we are talking about entrenched users who have been on a cycle of committing crime to fund addiction for over 20 years. Prison, increased sentencing, police crackdowns and all other efforts to break that cycle have failed nationally and, indeed, globally.

“There have been setbacks, as was expected, and Covid has thrown up a whole new challenge that no-one could have expected, but overall the early signs are very promising.”

Martin Powell from Transform Drug Policy Foundation, who has been campaigning for the roll-out of HAT clinics for years, added: “These results are a testament to incredible work, which has led to reduced crime, fewer ambulance call outs and lower costs to the NHS."

“Most importantly, vulnerable lives have been turned round. None of the clients are now sleeping rough, and their treatment has been stabilised."

“But we shouldn’t be surprised. Heroin prescribing clinics have achieved similar benefits from Vancouver to Geneva. This only adds to the evidence for their value."

“The government should ensure all areas have the funds needed to adopt this approach, for the benefit of everyone.”


Starting in the 1920s, Britain’s model of prescribing heroin to those who required it was known globally as the British System, with the number of known users – who could pick up prescriptions in Boots the chemist – rarely surpassing 1,000 until the late 1960s.

This practice was effectively prohibited in the 1970s and, as the black market grew, the number of heroin users grew to more than nearly half a million by the mid-1990s.
Read more

“The UK only developed a heroin problem the moment doctors were stopped from prescribing it,” said former undercover drugs detective Neil Woods, co-author of Drug Wars, which charts the history of the British system.

“Gifting such a lucrative market to organised crime was madness. Doing so has taken us on the journey to the point where children are now exploited to sell it through county lines.”

Meanwhile, Swiss researchers developed heroin-assisted treatment, basing their model in large part on the old British System, and setting up the first such clinic in 1994.

The model has since spread to Germany, Holland, Denmark and Belgium, and was also trialled successfully in Darlington, Brighton and London in the years leading up to 2009.

After lead researcher John Strang, of King’s College London, recommended it be made available to select users following “impressive” results, three post-pilot centres were opened in 2012.

But despite a pledge to honour Dr Strang’s recommendations, central government funding was later removed and the schemes were closed in 2015.

Mr Woods, now chair of LEAP UK – an anti-drugs war partnership of former law enforcement officials - welcomed the “dramatic” results from the Cleveland clinic, saying: “What politician or police leader can ignore results like this?”

Despite an effective ban in the 1970s, diamorphine prescriptions have since remained legal under Home Office regulations, and – as revealed by The Independent last August – 280 people still received a prescription for take-home diamorphine in 2017-18.

As such, some have pushed for the heroin-assisted treatment model to go further in allowing a wider proportion of heroin users access, and by eventually allowing for take-home prescriptions to reduce the necessity of daily clinic visits.

“Imagine what could be achieved if this was made easier and cheaper through government action?” Mr Woods said.

“More liberal heroin prescribing could mean that vulnerable people are rescued from the exploitation of organised crime before they are in such a mess, before they’ve been further traumatised by the system."

“Forget vacuous moral judgements. It’s time to save lives and reduce crime. Cleveland have shown the way.”


The results of the first year of Middlesbrough’s programme will be evaluated by Teesside University starting in October 2020.

Following its extension, the next year of the scheme will be largely funded by money seized from criminals under the Proceeds of Crime Act.

 
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Even with a license to prescribe buprenorphine, many doctors aren't giving it to their patients

by Aubrey Whelan | Medical Xpress | 2 Sep 2020

Only about half of the physicians licensed to prescribe buprenorphine—an opioid-based medication to treat addiction—actually prescribe it to patients.

Buprenorphine has been marketed as more accessible than methadone, another opioid-based addiction medicine that long has been dispensed only through federally licensed treatment centers. Bupe, as many patients and practitioners call it, can be prescribed from physicians' offices and taken at home, but significant federal restrictions still surround its prescription and use.

Physicians who treat substance use in Philadelphia said the study shows the need for more doctors to be licensed to prescribe buprenorphine—or to remove the licensing requirement altogether. After all, many argue, no such special license is needed to prescribe the painkillers that are at the root of so many addictions.

Doctors must take a special course in order to prescribe buprenorphine and, once they pass, may take on no more than 30 patients with opioid use disorder. (Later, they can ask to take on a larger patient load, and some doctors are permitted to prescribe buprenorphine to up to 275 patients.)

As of 2018, only about 5% of physicians had a license to prescribe buprenorphine—despite increasing demand for the drug and an overdose crisis that killed 70,000 people in the United States last year alone.

"(Bupe) can be prescribed for pain without any of these regulatory requirements. When prescribing it for opioid use disorder, it's layered with all these barriers. There's a stigma around the medication," said Beth Connolly, the project director of Pew's substance use prevention and treatment initiative. "It was really important to study what some of the barriers are, and whether people are actually prescribing it."

The study looked at the monthly buprenorphine patient volume for physicians licensed to prescribe the drug between April 2017 and January 2019. Just over 50% wrote at least one prescription during that time period. And most of the physicians who did regularly prescribe it didn't hit their "patient cap," in some cases prescribing to just a handful of patients.
The problem isn't necessarily that individual doctors aren't prescribing to as many patients as possible—it's that so few doctors can prescribe buprenorphine at all, said Jeanmarie Perrone, the director of the Division of Medical Toxicology and Addiction Medicine Initiatives in the University of Pennsylvania's Department of Emergency Medicine.

"I think what we need is more doctors in general—to let anyone prescribe," said Perrone, who has spearheaded an initiative to get more emergency physicians licensed to prescribe the medicine.

"Treating addiction can be complex," she said, "and an individual doctor with 275 buprenorphine patients on their roster might have trouble providing the support and attention to patients at this level," Perrone said.

"I wouldn't challenge someone too much if they said, 'I know my cap's at 30, but I want to provide the best care for these 27 people I'm caring for,' " said David O'Gurek, an associate professor of family medicine at Temple University Health System.

"Still," O'Gurek said, "the stigma of addiction treatment keeps other doctors from considering getting licensed."

"You hear from doctors,
'My practice is going to become overrun with people with opioid use disorder,' " he said. "But the reality is that people with opioid use disorder are likely already currently in your practice. Whenever I'm giving a training, I talk about how, as a family physician, doing this type of care is probably the easiest thing I do all week. There's complications and stress, but those exist in a regular primary care day."

During the COVID-19 pandemic, some of the federal restrictions around buprenorphine and methadone have been relaxed in the name of social distancing. Buprenorphine can be prescribed via telemedicine now—previously, federal law required an in-person appointment. And patients can obtain take-home doses of methadone—previously a privilege for just a few.

Connolly said that "Pew's researchers have anecdotal evidence that more people have been accessing buprenorphine treatment in general, and added that she hopes the relaxed requirements around prescribing can be sustained after the pandemic passes."

Silvana Mazzella, the associate executive director of Prevention Point—the Philadelphia public health organization for people with addiction—said "staff had been terrified they would lose patients in the medication-assisted treatment programs during the pandemic. Many of Prevention Point's clientele are homeless and don't have phones to access telehealth options."

"But we actually went up in adherence,"
Mazzella said. "With limited treatment and almost nothing being open during the first two months of COVID-19, people were clinging to whatever resources they had."

But the pandemic has complicated addiction treatment in other realms. In the three Penn emergency departments where Perrone has pushed for more buprenorphine prescriptions, the number of patients seeking help for withdrawal plummeted during the pandemic, likely for fear of contracting COVID. Withdrawal is a key opportunity for doctors in the ER to encourage someone into treatment.

"About 20 patients a month came to the ER needing buprenorphine before the pandemic," Perrone said. "That's dropped to about six a month," she said, "and many of the patients who have made it to her ERs say they relapsed during the pandemic."

"I see a lot of people whose last (buprenorphine) prescription was in March,"
she said. "And you ask them, and they've all fallen off because of logistics, access (to healthcare), fear, money, housing, everything."

Physicians said they hope the lessons they are learning about addiction treatment during the pandemic spur permanent changes.

"We need to address the reasons why people are (licensed to prescribe buprenorphine) and aren't using it. We need to make sure we're building the type of treatment system patients need and want, one they design on their own," O'Gurek said. "I think health systems right now are so taxed and still sort of in pandemic mode. But it really is a critical opportunity to really evaluate the way we were doing things before, and how we do things onward."

Explore further : One-third of primary care physicians do not support the use of medications for treating opioid use disorder

 

mr peabody

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Jacob Vnenchak, a behavioral health technician, sprays down the door handle with disinfectant
at the Garden State Treatment Center in Sparta, N.J.


‘Relapsing left and right’: Trying to overcome addiction in a pandemic

by Emma Goldberg | New York Times | 4 Jan 2021

Substance-abuse centers are shutting and relying on virtual programming, just as more and more people turn to drugs and alcohol.

Jackie Ré, who runs a substance-use disorder facility in New Jersey, gathered the 12 female residents of her center in the living room on March 27 and told them that the coronavirus outbreak had forced the center to limit contact with the outside world.

"There was an immediate outcry: The women already felt disconnected and didn’t want their sense of isolation exacerbated," Ms. Ré said.

Within the next six months, nine left the program at Haley House in Blairstown against staff advice, and all but one relapsed.

“It’s been a nightmare,” Ms. Ré said. “For one woman it was a matter of days, another less than a week. I’ve never seen anything like it.”

Addiction is often referred to as a disease of isolation, and overcoming that challenge has only become more difficult during a pandemic that has forced people indoors — in some cases to live lonely lives, with drugs and alcohol as a way to cope with the stress.

Several studies have shown that binge drinking has increased during the pandemic, and a recent report from the Centers for Disease Control and Prevention cited a “concerning acceleration” of opioid-related overdoses last year.

At the same time, many treatment centers have closed down or limited in-person visits.

The New York Times spoke to several residents of addiction treatment facilities who expressed dismay at the loss of in-person counseling. Many of them declined to give their full names as part of the anonymity granted by their recovery programs.


Jackie Ré, the program director at the Haley House, said the majority of the residents left the facility
in March after strict virus measures were enacted.


Because of virus outbreaks, while others struggle to retain residents after having been compelled to restructure their programming or eliminate visits from family and bar trips outside the facility.

A recent survey of 165 centers by the National Association of Addiction Treatment Providers, a nonprofit organization that represents hundreds of centers, found that 43 percent had to reduce patient capacity, nearly a third saw a decrease in patient retention and 10 percent had to shut down because of the pandemic. The majority of the closures have been in the Northeast, according to the association, because of the outbreak’s early concentration in New York.

“In the 80-year history since addiction treatment began, we’ve never experienced anything as challenging as this,” said Marvin Ventrell, chief executive of the N.A.A.T.P. “You have to put people in social settings to heal, and Covid conspires against that.”

The threat to these centers may begin easing, as residents and staff of addiction treatment centers in New York State recently began to receive the vaccine as part of the first phase of the rollout.

But at the moment, because of the difficulties of congregate living and treatment, the association of treatment providers reported that 44 percent of their centers are conducting half their programming virtually.

In New York City, the Hazelden Betty Ford Centers, which offer outpatient services, switched to entirely virtual care in mid-March. At first, the organization scrambled to remake a program that had relied so heavily on in-person gatherings.

Staff had to identify a virtual platform compliant with substance-abuse confidentiality regulations. They also had to accommodate patients who didn’t have internet-connected devices or stable Wi-Fi connections.

They worried, most of all, about people who were isolated in their homes relapsing.

“Many of our clients were riddled with fear and anxiety,” said Rose Foley, who runs mental health services for a Hazelden Betty Ford center in Chelsea, Manhattan. “I remember working with clients and hearing the sounds of sirens from outside their apartments. It was a traumatic time.”


Many facilities in the Northeast, including the Garden State Treatment Center in Sparta, N.J.,
were adversely affected once virus shutdowns began in the spring.


Clients struggled with the loss of their in-person support groups.

“What is more supportive than walking into a room and seeing a human you can touch?” asked one client, Maureen. “What’s been missing is body language, our ability to hug each other. All that stuff is important when people are going through the difficult experience of getting off drugs or alcohol.”

Some positives have come from virtual care. John Driscoll, head of recovery services at Hazelden Betty Ford, said the number of patients choosing to attend sessions biweekly has doubled. The organization’s recovery program for families, which used to be local, is now on video and open to families around the globe, serving more than 2,500 people since the summer.

Still, the emotional connections formed through in-person treatment are difficult to replicate on the computer. A recent study published in Drug and Alcohol Review found that a sense of loneliness can amplify the risk of drug and alcohol abuse in people with substance-use disorders.

“I had this image of what the rest of my life would look like with communities I could relate to, meetings I could go to for in-person accountability,” said Emily, 30, who successfully completed the program at the Alina Lodge recovery center in New Jersey in September. “Now I have to sit in my room by myself with a computer, which is how I got sick.”

Emily is now participating in a virtual recovery program.

Another woman who had been treated at Alina Lodge and Haley House, Sarah Manfredo, said every milestone she’d envisioned for herself evaporated after family visits and outside jobs were prohibited because of the pandemic.

Ms. Manfredo, 36, left the addiction treatment center in August and moved in with a fellow alumna of the program, who immediately relapsed. Few of the women she went through treatment with have stayed sober, an outcome that she attributes largely to the pandemic. “People are relapsing left and right,” Ms. Manfredo said. “The loneliness plays into it.”



Sarah Manfredo, who left an addiction program in August, now works as a behavioral health technician at Garden State Treatment Center.

Inside Haley House, the women felt cut off from the world and stifled, Ms. Ré explained. But those who left realized they could not resume their social routines and couldn’t attend in-person Alcoholics Anonymous meetings because the programming had gone virtual.

The challenges at Ms. Ré’s treatment center mounted this fall when a staff member tested positive for coronavirus and the facility went on lockdown. The residents wore masks and joined their counseling sessions by Zoom; they were given individually packaged meals, and staff had to quarantine from family.

But after nearly 14 days, two residents tested positive for the coronavirus and the facility had to start its quarantine again, amounting to almost a month of lockdown.

Before the coronavirus outbreak, just one in 10 Americans suffering substance-use disorders got the treatment they needed. The C.D.C. and the National Center for Health Statistics reported that 81,230 people died of drug overdoses in the 12-month period ending in May 2020, the largest number of drug overdoses ever recorded in a year.

Overdose-related cardiac arrests spiked in April, making up 74 of every 100,000 emergency medical calls nationally, more than 20 percent higher than usual, according to recent research from the Journal of the American Medical Association Psychiatry.

In the fall, the C.D.C. estimated that there would be a record-high number of fatal drug overdoses in 2020. An examination of hospital billing at Mount Sinai Hospital Downtown showed that in March, right as New York’s outbreak began, the hospital recorded the highest number of alcohol-related emergency room visits in 2020.

While overall non-Covid-19 emergency room visits dropped precipitously in March and April across New York, Dr. Erick Eiting, vice chair of operations for emergency medicine at Mount Sinai Downtown, said substance-use disorder patients were among some of the first to return. “You can tell people are having a hard time,” Dr. Eiting said. “They’re experiencing additional stressors that can contribute to substance-use disorders.”

Rebecca Linn-Walton, assistant vice president of the office of behavioral health at NYC Health + Hospitals, said: “We’re experiencing the uptick we all expected.”

Dr. Linn-Walton said NYC Health + Hospitals scrambled to distribute technological devices to vulnerable New Yorkers given the increased reliance on tele-health this year. More than 314,000 New Yorkers have had virtual psychiatric or substance-use visits since March.

Some people who struggle with these disorders found that the changes in normal life wrought by the pandemic provided the motivation they needed to finally get addiction treatment.

For Brendhan, 29, a respiratory therapist at Yale-New Haven Hospital, the early weeks of the coronavirus outbreak were a haze. He arrived at the hospital each morning at 6:30 a.m. and spent the day cleaning ventilators and delivering them to patients in need.

On May 28, he realized that the pressures of work were allowing him to ignore his addiction to alcohol; he called High Watch Recovery Center in Kent, Conn., and was admitted the next day.

He started his recovery there by isolating in a cabin and attending group meetings by Zoom while he waited for the results of a coronavirus test.

He eventually was able to join the rest of the residents in daily meetings, where he shared stories that he had never divulged even to family. After 106 days at the center, he moved into a sober living facility and quit his job at the hospital.

Offering in-person treatment has been challenging for those centers that do not have the resources to test their residents for the coronavirus regularly. Most instead opt to test and quarantine anyone newly admitted, as well as to regularly test staff members who have more contact with the outside world. They ask residents to keep at a distance during group meetings and meals.

At Haley House, the residents marked Thanksgiving under Covid-19 lockdown. Ms. Ré pushed four tables into separate corners of their large dining room and invited the residents to eat in small shifts, at a distance of more than 10 feet from one another. They also gathered to share their gratitude for small sources of joy amid self-isolation.

One young woman had asked if the kitchen at Alina Lodge could make her a corn salad for the holiday; when she received her requested dish, wrapped in tinfoil with a heart drawn on top, her eyes welled up. “There’s been positives through all of this,” said Ms. Ré. “The women are like sisters now, and they’re learning to go deeper on their spirituality. I call it the graces of Covid.”

 
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A patient picks up medication for opioid addiction at an outdoor clinic in Olympia, Washington. Nationwide,
treatment providers are finding new ways to make addiction treatment easier to access during the pandemic.


COVID-19 has eased drug treatment rules — and that's saving lives*

by Christine Vestal | Maryland Matters | 28 Dec 2020

When the pandemic hit in March, people in treatment for substance use disorder worried they would lose access to the medications and counseling they rely on.

In most places, that hasn’t happened.

In fact, for many in recovery, access to treatment has gotten a lot easier.

Since March, some patients have been allowed to take the life-saving medication methadone at home instead of risking COVID-19 exposure by visiting a crowded clinic every day. Buprenorphine patients have had their prescriptions renewed by phone instead of visiting their doctors every week or month. And addiction counseling and crisis support has become available over the phone.

Now, physicians and addiction experts are advocating for extending the emergency federal and state rules they say have saved thousands of lives by dramatically expanding access to addiction treatment.

The American Society of Addiction Medicine and other behavioral health organizations are supporting a bipartisan bill in Congress that would continue the addiction treatment telehealth rules beyond the pandemic.

“Telehealth sessions have been a lifeline for those walking the long road to recovery during a stressful, isolating time,” said Sen. Sheldon Whitehouse, a Rhode Island Democrat who is co-sponsoring the bill, in a news release.

“Our bipartisan legislation would ensure that recovery support continues to be widely available from the comfort of home after the pandemic wanes.”

Despite the changes, drug overdose deaths are still rising. Experts say that’s largely due to huge increases in the supply of illicit drugs, particularly those containing the deadly opioid additive fentanyl.

"The fear, stress, isolation and hopelessness that many Americans have experienced during the pandemic are likely causes of drug overdose deaths as well," said Dr. Paul Earley, president of the American Society of Addiction Medicine.



Nationwide, overdose deaths have been climbing over the past year, putting 2020 on track to be the deadliest yet for drug overdoses.

This month the federal Centers for Disease Control and Prevention published provisional data collected from states showing that more than 81,000 people died from a drug overdose in the 12 months ending May 2020, an 18% increase over the previous 12-month period.

That period mostly predates the pandemic, but overdose data collected by individual states since May shows continued increases. In Ohio, for example, a harm reduction group reported a rise in deaths through June that represented a 20% increase in the first six months of 2020 compared with the same period last year.

And in Minnesota the state health agency this month reported that drug overdose deaths in the state shot up 31% during the first half of 2020 compared with the first half of 2019.

Nationwide, if the nearly 12% rise in overdose deaths in the first five months of 2020 continues, the year-end total could dwarf death counts of previous years.

Those numbers are shocking, but treatment experts say thousands more likely would have died without the new rules and the resiliency of the addiction treatment industry.

“We were all very worried in the beginning of the pandemic,” said Linda Hurley, CEO of CODAC Behavioral Healthcare, a nonprofit addiction treatment provider with eight clinics in Rhode Island and one in Massachusetts.

“When you think about it, the antithesis of a recovery support system is isolation,” she said. ”And at the same time, the ultimate method of mitigating exposure to COVID is isolation. You could see how clearly those two things were connected in an exacerbating way.”

Allowing treatment providers to counsel clients over the phone has prevented a worst-case scenario, Hurley said. The positive effects of telehealth and other changes suggest that some of the pre-pandemic addiction treatment rules didn’t make much sense.

“I believe this pandemic has demonstrated that our trade, our medicine, has been overregulated for decades,” Hurley said.

Staying Connected

Before the pandemic, Medicare did not reimburse addiction treatment providers for audio-only telehealth counseling, even though similar consultations were covered for other health conditions. And only a few state Medicaid programs covered telephone counseling.

Addiction counseling by video or telephone can now be reimbursed under new rules, though the regulations are slated to expire when the pandemic emergency declaration lifts.

In a survey conducted by researchers at Brown University from August through October, a huge majority of people in treatment for drug addiction said they preferred talking to their counselors by phone rather than in person.

More than 90% of the surveyed patients said addiction counseling by phone was not only easier, but also more effective than in-person counseling.

"For many patients, addiction counseling by phone can be less intimidating," said Dr. Stephen Taylor, chief medical officer at Pathway Healthcare, an addiction treatment company.

"Once the pandemic began, he said, the counselors who work at his treatment facilities in Alabama, Mississippi and Tennessee began converting their scheduled in-person visits to Zoom or phone calls when patients told them they were fearful of visiting. Both counselors and patients quickly adapted," he said.

But in New York City, Allegra Schorr, co-owner of West Midtown Medical Group, a methadone treatment facility, said some of her patients say they miss the routine of visiting the clinic every day and seeing the doctors, nurses and other patients.

“Where we know there are co-occurring mental health disorders, isolation and depression, the need to connect is still there. And for some, it’s not as simple as a phone call."

“It’s very mixed,”
she said. “Some people keep asking ‘When can we come back?’”

Prescription Changes

In March, the Substance Abuse and Mental Health Services Administration responded to the pandemic by swiftly easing restrictions on the opioid addiction treatment medication methadone, allowing many more patients to take home a month’s supply of the daily maintenance drug.

At the same time, the federal Drug Enforcement Administration — which oversees the use of buprenorphine, another Food and Drug Administration-approved addiction treatment medication — relaxed rules that previously required patients to visit a medical professional at least monthly to renew their prescriptions.

The DEA also lifted a restriction requiring people taking buprenorphine for the first time to do so under the supervision of a doctor or nurse. Now medical professionals can guide new patients by phone as they begin treatment.

The bipartisan bill in Congress would allow doctors to continue issuing and renewing buprenorphine prescriptions by phone.

State Initiatives

Soon after the federal rule changes took effect, states and cities responded by tweaking their Medicaid and other addiction treatment rules. In some cases, states provided funding for innovative new treatment services.

“We saw a lot of scrappiness among treatment providers who tried new things that previously weren’t possible,” said Dr. Brendan Saloner, a professor at Johns Hopkins Bloomberg School of Public Health. His research team has conducted more than 500 interviews with drug users and people in treatment to gain a better understanding of how the COVID-19 pandemic has affected their lives and their treatment.

In Rhode Island, the state behavioral health agency set up a hotline in June for people seeking help with drug addiction. The trained professionals who answered the phones connected people to treatment facilities where licensed professionals prescribed buprenorphine over the phone and guided them through getting started on the daily medicine.

In New Jersey, New York, Ohio and Washington state, treatment clinics during the pandemic started making curbside and doorstep deliveries of both methadone and buprenorphine for patients who were quarantined or isolated because of age or health issues.

In New York City, teams of city-employed couriers used city vehicles to deliver the medications to homeless shelters, homes and hotels where patients were quarantined.

Many states dramatically increased supplies of free naloxone, an overdose rescue drug that can be used by friends, family, bystanders and first responders. Delaware announced that people struggling with addiction could order free naloxone by mail.

Maine, Rhode Island and other states expanded free syringe exchange programs, and drug courts in New Hampshire allowed virtual counseling as a way for drug users to avoid imprisonment for drug-related charges.

The Baltimore Model

When many of Baltimore’s other treatment providers temporarily closed at the start of the pandemic, one group’s patient list more than tripled.

Known as Project Connections, the loose coalition of doctors and nurses has provided buprenorphine and addiction counseling from a van parked next to the city’s central booking agency since 2017. Mainly through word-of-mouth, the group has expanded its patient rolls, treating thousands of mostly homeless, uninsured Baltimore residents, with little red tape or oversight.


Deborah Agus, director of Project Connections, a nonprofit addiction treatment group in Baltimore, talks to then-city council
member, now Baltimore Mayor Brandon M. Scott, at an outdoor site. Photo courtesy of Project Connections.

“Our patients don’t even need an ID to get treatment,”
said Deborah Agus, the group’s founder and executive director. "That’s because the medical professionals who provide treatment through Project Connections are not organized as an opioid treatment facility," she explained. "They work individually, like primary care doctors, so they’ve never been subject to the federal rules that apply to licensed treatment facilities."

In a November article in the Journal of Addiction Medicine, researchers at Johns Hopkins cited the group as an example of how access to treatment can be expanded, even during a pandemic.

“Since we operated mostly outside, not much changed for us,” Agus said. “We were able to stay open through the spring and summer by moving out of the van and setting up tents on the sidewalk. When it got hot, we bought fans. When it got cold in the fall, we bought heaters.”

Now that winter is in full gear, Agus said the group is using telephone counseling to stay in touch with patients. “We didn’t want people to think we’d shut down, though. So, we kept our van parked in the same place with someone sitting outside in a lawn chair to tell people the number to call for help.”

*From the article here:
 
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As a physician and a patient, I’ve seen the damage caused by the stigma of addiction. It must end.​


by Sean Fogler | STAT | 8Dec 2020

Although the disease of addiction is now obscured by the dark cloud of the Covid-19 pandemic, it continues to tear America apart. It’s a relentless killer, fed by anxiety and uncertainty, and enabled by the attitudes of the health care providers who are supposed to be caring for people with it.

I led two lives for more than a decade: I worked as a physician, caring for the sick and suffering. I also struggled with addiction, using cocaine and other drugs to manage post-traumatic stress — a consequence of surviving the 9/11 attacks on the World Trade Center. I loved my work, but the drugs kept me alive, managed my pain, and allowed me to function.

This duality showed me how people with mental illness and substance use disorders are treated by my colleagues in the health care system. I saw their judgements and their scorn, and I saw how U.S. drug policy was harming people right before my eyes.

The term stigma comes from Latin and Greek words that mean a mark on the skin, often made by a hot iron. In ancient Greece, this mark identified criminals, slaves, and outcasts — people who couldn’t be trusted, were dangerous, and had to be avoided at all costs.

Today, people with addictions aren’t physically marked with the equivalent of a scarlet “A,” but that doesn’t make the emotional mark any less real.

The stigma of addiction comes from the negative feelings that many health care professionals harbor for people struggling with substance use disorders, and their beliefs that poor personal choices, “moral failing,” and defects of character are to blame for the disease. These feelings and beliefs mirror those of the general public.

Health care workers may shame people with addictions more than others do. A study examining primary care physicians’ perspectives on the prescription opioid epidemic found that most were unwilling to work closely with, or have marry into their family, a person with an addiction to prescription pain medication. The majority also believed that individuals with an addiction are dangerous and employers should be allowed to deny them employment, something that happens every day across America.

Should a person with diabetes who struggles to control their blood sugar be denied the right to work, to provide for their family, or to pursue their life’s purpose? What about the person with asthma who smokes, or the person with heart disease who eats an abundance of fatty foods?

A recent study exploring emergency physicians’ attitudes toward patients with substance use disorders found that the majority had lower regard for patients with substance use disorders than for patients with other conditions affecting behavioral health. Among physicians participating in the survey, only 10% agreed that they “enjoy giving extra time to patients like this.” These physicians found it more rewarding to treat patients with obesity, diabetes, trauma, and even those with COPD who smoke.

Health care professionals should know better, and do better, but many don’t, even though they have pledged to “do no harm or injustice” to those they serve.

Stigma violates the right of people with addictions to be human, strips us of our dignity, and says to us that we have no value. It evokes feelings of shame so deep they are hard to know unless you’ve experienced them. This isn’t the kind of shame that guides us or tells us we’ve made a mistake. It’s toxic shame, the shame that tells us we are the mistake — something those of us with this disease come to believe. It tells us that we’re never safe and keeps us silent, hiding and alone, unvalued members of the human tribe. And that’s how many of us with this disease die: hopeless, spiritually empty, and alone.

Our health care systems have weaponized stigma in many forms, and it helps fuel America’s crisis of addiction.

In the very places that people with addictions hope to receive compassionate care, I have witnessed stigma unleash its power. The wrong word, a judging glance, or a prolonged wait to receive care can be a death sentence. Health care workers have become the barrier to effective treatment. People with addictions see this, know this, and choose to avoid us and the health care systems we work in. The stigma we deliver to people with addictions isn’t just a barrier to treatment, it also fuels the disease, continuing a deadly cycle that increases harm — to people who use drugs, and to those of us in recovery. I have watched the actions of health care workers mark and discriminate, sometimes in plain sight, but mostly hidden, where it delivers maximum harm.

The U.S. has waged its so-called war on drugs for decades. It has failed by every measure. Fueled by the iron law of prohibition and archaic drug policy, it was never really about drugs but always about controlling people — especially people of color.

In the past two decades, more than 750,000 lives have been lost to drug overdoses. The life expectancy of Americans has decreased and the number of people in prison for drug offenses has increased more than 1,000%. We have criminalized a disease and punish the people who live with it, not just in prisons and jails but also in our health care systems.

The policies that drive the war on drugs and that dictate how the health care system cares for people with substance use disorders are deadly. They drive people with addictions into the shadows, where they hide to survive. It’s a place I know well, as do many other health care professionals. Doctors, nurses, and other health care workers have higher rates of substance use disorders than the general population — in some specialties, much higher. They are also more likely to have mood disorders, burnout, and compassion fatigue, and die from suicide.

People who use drugs are marked and judged and confined to cages, cut off from each other, their families, and the connections that can help them heal.

People don’t die from overdoses. Though that cause may be listed on their death certificates, they die from trauma and pain, and they die from stigma and the isolation and self-harm that follows.

Restoring and maintaining supportive human connections between people with addictions and those able to help them can lead to recovery. This starts with facing stigma head on. I’m not talking about more buttons and posters, public relations campaigns, or storytelling. These do little to shatter the stigma that fuels the discrimination that takes lives. I’m talking about taking action to deconstruct the harmful policies that are the framework for a system that does great damage to those it claims to serve and to those working in it.

Addiction is a complex disease, and recovery from it is equally complex. There are many paths to improved health and recovery. It’s not just about abstinence as the gold standard and Alcoholics Anonymous or Narcotics Anonymous as the best way there. Any positive change should be celebrated. That might mean the cessation of drug use, but it might not. Sometimes the first step is using less of a drug, or using a safer drug, or using a drug in a safer way. Missteps should draw increased support, not punishment or isolation. More drug and alcohol treatment, medication-assisted therapy, and naloxone distribution are all steps in the right direction, but they will never be the solution to the addiction crisis.

Policing patients with contracts, pill counts, prescription drug monitoring programs, and urine drug screens do little to help people with addictions. They serve the system, and those working in it, not the people who seek compassionate care for a disease.

Combating stigma within the health care system is vital to solving America’s overdose crisis and improving the lives of those in recovery and those who continue to struggle with addiction. If we continue to rely on flawed drug policy and weaponize stigma, the overdose epidemic will continue to surge. The medical establishment, including professional boards, professional health programs, and medical groups and hospital systems, must take the lead and dismantle the policies that fuel stigma and punish patients and health care professionals for being human.

Dismantling stigma and the policies that fuel it will take sustained and unified efforts across health care systems. Important first steps are addressing the language clinicians use when caring for people with addictions, better professional education about addiction for clinicians, integrating people with lived experience with addiction into systems of care, and empowering them to help guide the policies and practices used each day for encountering and treating people with addictions.

Health care professionals must use their voices to advocate for improved care for people with addictions, including their colleagues with substance use disorders. This includes advocating for compassionate drug policy based on science and expanding access to the evidence-based strategies proven to work. This means making harm reduction a priority.

Addressing stigma and the diverse harms it delivers must be another priority. It will require reimagining the regulation and distribution of medications for substance use disorders and overdose. The current system is littered with barriers that reflect the belief that people with addiction don’t deserve life.

Health care professionals and policymakers need to rethink and reshape the Controlled Substances Act, legislation signed into law in 1970 that was less informed by science and more about waging a war on people. In its current form, the act drives the criminalization of addiction and the stigma that follows. It also deters health care professionals from treating those with this disease. Fear of surveillance, prosecution, and loss of license and career are powerful forces no practitioner can ignore.

Our nation also needs a central acting guiding force, an agency whose priority is protecting the health, well-being, and rights of people who use drugs and those in recovery. That can help remove people with addictions from the criminal justice system, a place where no disease should ever be managed.

Another priority is addressing the discrimination faced by people with substance use disorders, including health care professionals who struggle with this disease. They must be treated with the same care, compassion, and science used to treat any person with any disease. That currently isn’t the case. If health care professionals can’t address the stigma they direct towards their colleagues with addictions and give them high quality care, they won’t be able to do it for their other patients and will continue to fail when it comes to managing the disease.

Unless we begin to value the human rights and dignity of people with substance use problems and those in recovery, and continue to treat addiction as a mark of disgrace, we will never find a path forward for truly ending the war on drugs and the disease of addiction will continue to tear America apart.

 

mr peabody

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Packets of buprenorphine, which is used to treat opioid use disorder.

Stigma is killing people with substance use disorders*

by Richard Bottner, Christopher Moriates, and Matthew Stefanko | STAT | 2 Oct 2020

"It was dehumanizing,” Slade Skaggs told us about how health care providers treated him when he turned to them for help with his substance use disorder. “They made me feel like I was drug-seeking and that I was not deserving of their time or care.”

Fortunately, he finally got the help he needed and is now in recovery, serving as a peer-support specialist for others with substance use disorders.

Stigma — society’s negative attitudes and behaviors towards individuals because of their substance use disorders — propagated by people working in health care causes feelings of shame, limits access to care, and ultimately contributes to vicious cycles of addiction. This is particularly true for people living with opioid use disorder.

In the setting of Covid-19 and physical distancing, it is more important than ever to dismantle such stigma and develop effective continuums of care for vulnerable patients, including those with substance use disorders. In fact, economic uncertainty, social isolation, and burdened health care delivery systems contributed to a 42% increase in overdoses in the U.S. in May alone — the sharpest increase since 2016. Now is the time to improve attitudes toward and knowledge about substance use disorders among health care providers.

Historically, the medical community has not been supportive when treating people with substance use disorders. Stigmatizing patients with opioid use disorder deepens prejudicial feelings among health care providers such as fear, anger, or disgust. Such emotions result in discriminatory clinical care. A Massachusetts survey found that 24% of emergency, family, and internal medicine providers believed that their practices would attract undesirable patients if they treated individuals with opioid use disorder.

Also worrisome is the lack of faith physicians have toward using medication to treat opioid use disorder. Many do not think that treating this disorder with medication is any more effective than treatment without it, despite ample evidence that buprenorphine and methadone are highly effective and save lives. The belief that these medications do not work is built on a foundation of bias, not science.

Stigma from the provider community isn’t surprising. There are meaningful gaps — including limited quality measurement related to outcomes for people with substance use disorder, poor reimbursement practices for treating people with substance use disorders, and inadequate education of clinicians about how to best care for people struggling with addiction — that get in the way of the community coming to terms with the importance of treating individuals with substance use disorder with the highest quality medical care accompanied by genuine respect and compassion.

The Massachusetts study we mentioned earlier also showed that only 1 in 4 respondents who went to graduate medical school or social work school had received addiction-related training during medical education, a startling statistic relative to other chronic diseases.

Stigmatizing perceptions directed toward people with opioid use disorder actually increase during time spent in formal medical education, revealing the “hidden curriculum” of negative bias towards individuals with this condition. Stigmatizing language commonly used in medical records, such as “drug abuser,” influences the attitudes and prescribing behaviors of physicians, nurses, and other health care providers.

The impact of stigma on access to quality care and patient outcomes is significant. Because of the attitudes of health care professionals, people with opioid use disorder may defer seeking care for infections or other medical conditions until they are serious or life-threatening. Once they seek treatment, individuals are likely to downplay their substance use history out of fear that revealing it will affect the quality of the care they receive.

Clinicians must be educated and empowered to use patient-first and recovery-centered language, and to apply evidence-based medicine to their practice.

The first step is to widely share best practices that are likely to reduce the amount of stigma and bias experienced by people with opioid use disorder. There are simple things clinicians can do, such as replacing “drug addict” with “person with a substance use disorder” in conversations and in medical records, that have been shown to shape people’s perceptions and attitudes. One study conducted with more than 500 trained mental health and addiction clinicians found that those asked to read a patient vignette with the label “an individual with substance use disorder” were less likely than those who read vignettes containing the term “substance abuser” to say the patient was personally responsible for his or her illness and punitive action should be taken.

This should start in every U.S. health care organization today. “Every time a doctor talks to me in a way that allows them to look me in the eye and not be a paper on a clipboard, they’re reducing harm because all of a sudden I don’t feel shame,” says Skaggs in an interview we filmed with him. “I feel like I’m being treated as a human being worth loving.”

Beyond language, organizations should look closely at practices that may, purposely or inadvertently, result in discrimination toward patients with substance use disorders. Health care organizations must actively engage clinicians in professional development about substance use disorders and stigma; ensure that medications for opioid use disorder such as buprenorphine and methadone are part of the formulary and no barriers exist to initiating or continuing these lifesaving treatments; and support and advocate for institutional, state, and federal policy that allows for substance use disorders to be cared for as chronic medical conditions similar to diabetes or hypertension. Such systems improvements must be done within a health equity framework.

Another component of reducing stigma associated with substance use disorders is creating easily accessible tools to teach the basics around stigma reduction, such as the Reducing Stigma Educational Tools (ReSET) program we recently released. It features videos of Skaggs and other people with lived experiences related to substance use and stigma from the medical community. The two modules include pragmatic steps that any medical professional or health care trainee can take to improve care for this vulnerable group of patients. Shatterproof, the national nonprofit organization dedicated to transforming addiction treatment that one of us (M.S.) works for, recently launched a nationwide initiative to combat stigma.

Every organization has a role to play in controlling addiction, and this is especially true for the health care community.

There is no time to waste. The Covid-19 pandemic has not only made treatment and recovery support more difficult to access, but it is also intensifying the existing fear, uncertainty, and lack of social connection and cohesion that those with substance addictions already feel. The first, necessary, and immediate step to propelling solutions forward is looking inward at ourselves and our organizations to end stigma.

*From the article here :
 
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Psychedelics and addiction: A magic bullet?

by Craig Salerno, MA, LAC, LPC | PSYCHEDELIC SUPPORT | 10 Sep 10, 2020

The use of psychedelic medicine to treat addiction is an exciting and promising aspect of current research. Despite the hype, are psychedelics really a magic bullet for addiction? Join Craig Salerno, MA, LAC, LPC to separate fact from fiction when it comes to using psychedelics to heal addiction.


There is perhaps no topic more sensitive in the psychedelic medicine community than the question of what medicine work means for people who identify as addicts or individuals in recovery from substance abuse.

Because many models for healing from substance abuse and addiction rely on the importance of abstinence, often from all substance use, the question of whether psychedelics fit into an addiction recovery model is an important one. Can psychedelics be a part of healthy recovery, or is it best to avoid mind-altering plants and chemicals altogether?

The abstinence model, emphasized by the 12-Step Model and most mainstream treatment models, asserts that mind-altering substances cannot be consumed safely by individuals who are addicted to drugs or alcohol. Much like an allergy, it is believed that the body and mind are particularly vulnerable to substances, often to the point of powerlessness to cravings and relapse behaviors. Because of this, the abstinence model focuses on building a lifestyle of complete sobriety.

An alternative approach, the harm-reduction model, has emerged as another recovery option. According to this model, recovery from damaging substance abuse requires learning skills and strategies to reduce negative consequences associated with drug use. While abstinence can be an element of harm reduction, so, too, can the conscious use of psychedelic medicines in the context of a safe and structured environment. The goal becomes less about abstinence and more about risk management.
When managed and approached skillfully and with support, psychedelic medicine work can result in powerful transformation for addicts and individuals in recovery.
As a Licensed Addiction Counselor and someone who has worked extensively in the field of addiction counseling for over ten years, I first want to debunk a couple myths.
First, there is absolutely such thing as compulsive and unhealthy psychedelic substance use. While many argue that psychedelics are not subject to dependence or addiction like alcohol, narcotics, and other drugs of abuse, it is very clear that psychedelic substances can do harm. Psychedelic work is not risk-free and does not always provide healing experiences. Put straight, it’s not for everyone and is not a magic bullet.

On the other hand, psychedelic medicine work is not a death wish nor a failure of recovery. I have witnessed countless individuals in recovery utilize psychedelic medicines to do healing work. When managed and approached skillfully and with support, psychedelic medicine work can result in powerful transformation for addicts and individuals in recovery.

This topic is nuanced and is not black and white. Psychedelics can be profoundly healing for individuals in recovery, but can also catalyze relapse behaviors that lead back to a lifestyle of addictive use. We cannot glorify psychedelics as a magic bullet, but we also cannot deny their benefit.

The disease of addiction is cunning and often moves in the shadows. Because of this, pursuit of a psychedelic medicine path first requires contemplation, reflection from peers, and guidance from professionals. The decision should include a fearless exploration of the impulses, wishes, and fantasies associated with this modality. It requires patience, discipline, and accountability.

Below are some of questions to ask yourself before pursuing a psychedelic medicine path:
  • Why should I embark on a psychedelic medicine path?
  • Are there non-substance alternatives that I haven’t tried?
  • Is there a specific medicine I am attracted to? Why?
  • What do I imagine will be the benefits of this work?
  • In what context do I want to begin this medicine work?
  • Have I attempted psychedelic use in the past? How did it go?
  • Am I in a good place to begin this work, or is it something I should consider down the road?
  • If this leads to relapse, is this a risk I am willing to take?
If you identify as an addict or a person in recovery and are exploring the option of a psychedelic medicine path, it is important to weigh the pro’s and con’s of this modality and understand the nuances. While psychedelics are not a magic bullet, they can certainly provide benefit when managed skillfully and intentionally. To ensure you are choosing a safe and intelligent path, start by consulting with a professional and discussing the possible risks and benefits.

 
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