06/24/16 Scott Macdonald

US Senate Homeland Security & Governmental Affairs Committee: America's Insatiable Demand for Drugs - Examining Alternate Approaches with: US Senator Tom Carper, Dr, Scott Macdonald of Vancouver Injection Clinic and Dr. David Murry, former ONDCP official

Program: 
Cultural Baggage Radio Show
Date: 
Friday, June 24, 2016
Guest: 
Scott Macdonald
Organization: 
Doctor
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CULTURAL BAGGAGE

JUNE 24, 2016

TRANSCRIPT

DEAN BECKER: Broadcasting on the Drug Truth Network, this is Cultural Baggage.

UNIDENTIFIED VOICE: It is not only inhumane, it is really fundamentally un-American.

CROWD: No more! Drug war! No More! Drug War! No More! Drug War!

DEAN BECKER: My name is Dean Becker. I don't condone or encourage the use of any drugs, legal or illegal. I report the unvarnished truth about the pharmaceutical, banking, prison, and judicial nightmare that feeds on eternal drug war.

This is Dean Becker. Thank you for being with us on this edition of Cultural Baggage. Last week, we featured a segment with Ethan Nadelmann, the director of the Drug Policy Alliance. He was speaking at the US Senate Homeland Security and Governmental Affairs Committee, America's Insatiable Demand for Drugs Panel: Examining Alternative Approaches. Today, we're going to hear from the other side, some of the cowards who refuse to be guests on this show. I think it only fair, and then I'll comment about what they have to say. Let's get on with it.

SENATOR RON JOHNSON: The reason we're having this hearing, of course, is the scourge of drug abuse is incredibly serious, but also an incredibly difficult problem. The reason we're having it in this committee, there's a somewhat unusual path that really led to today. When I took over the chairmanship, working with ranking member Carper, the first thing we did is we developed a mission statement for the committee, to enhance the economic and national security of America, and then we laid out some priorities. On the homeland security side there's border security, cyber security, protecting our critical infrastructure, countering Islamic terror. We've really focused an awful lot on border security. We've held 18 hearings on different aspects of it, published about a 100 page report. I'm not sure, I think you're at least sympathetic with what I've come up with as the primary reason, the primary root cause of our unsecure border, is America's insatiable demand for drugs.

Now, trust me, I didn't go into those hearings thinking that would be my conclusion, again, many causes, but primary cause. I did a national security swing through Wisconsin early January. Every public safety official I talked to, whether it's state, local, or federal, I just asked them the question, what is the biggest problem you're dealing with here in your communities. You know, large or small. Without exception, drug abuse. Because of the crime it creates, the broken families, the broken lives, the overdoses that we're seeing. So you take a look at the nexus of so many problems facing this nation, our unsecure border, which is a problem now in terms of us being able to try and figure out how to solve the immigration problem, about public health and safety, national security. And then you take a look at, in every city, certainly in Wisconsin, I will say in America, if it's true, and I think it's probably pretty universally true that the number one issue that public safety officials are grappling with is drug abuse, that's a big problem.

Now, we're going to have a pretty broad spectrum of ideas and different approaches and how you address this unbelievably difficult problem. I'll just finish with a little story here and I'll turn it over to Senator Carper. This never came up when I was running in 2010, you know, what my thoughts on legalization of marijuana or decriminalization, never came up during the campaign. About two years into my term, I was in front of a group of couple of hundred seventh grade kids, and one of these seventh graders stood up and said, you know, Senator Johnson, would you support legalization of marijuana? Again, we're holding this hearing because this is a very complex issue, and you know, like prohibition, you know, having prohibition fueled the gangs back then. What we're doing right now is fueling the drug cartels, which is the reason why we have an unsecure border.

So, I'm sympathetic with the broad spectrum of arguments here. But at that moment, I could have punted, I could have, you know, kicked the can down the road, I could have dodged the question, but I decided to make a decision at that point in time in front of that audience and said no, because of the terrible signal it would send kids your age. And there's the dilemma. So again, I'm looking forward to a good discussion here, laying out the realities. I talked a little bit before, I stroked the gavel here. Let's talk about this significant problem, let's talk about what the reality of the situation is, and let's try and move forward with some approaches that make some sense. With that, I'll turn it over to Senator Carper.

DEAN BECKER: All right, and before I turn it over to Senator Carper, I'd like to respond to some of the thoughts just put forward. We'll go with my usual, that is, this drug war empowers our terrorist enemies if they're brave enough to grow the flowers we forbid, it enriches the barbarous cartels south of our border who killed well over 100,000 people as of this point, it gives reason for these violent gangs to prowl our neighborhoods with high-powered weapons, enticing our children to lives of crime and addiction, and despite the expenditure of well over a trillion US taxpayer dollars, the arrest of more than 50 million of our fellow citizens, one out of every five adults in this country, we have never done anything to dissuade this black market from existing. It's a fraud, it's a sham, scam, it's just -- has no reason to exist. Let's continue with the senator.

SENATOR TOM CARPER: Thanks, Mister Chairman. We're delighted to see you all, thanks so much for coming, thanks for what you do with your lives. I come at this issue with a variety of hats on. I'm a retired Navy captain, spent a lot of time in the military, and we focused a good deal in those years on drugs, and trying to make sure that the folks that are serving us, in my case in airplanes, were not using drugs that are illegal. And, so, we, and if they were, we had a policy that basically, you're doing drugs, you're out of here. So, I come at this as a recovering governor. Focused a fair amount on trying to make sure that kids were born to parents that were ready to raise them and to be good parents, set high expectations, involved in the education of their children, and that kids had good role models, mentors and stuff like that, so, to work I think, one of the reasons why people end up using drugs.

And spent plenty of time in prison, not as a, just as a visitor, but, I've been in every prison in Delaware and talked to inmates in every one of them, how did you end up here, for the most part the stories were similar. I was born, never knew my dad, the, my mom was young when I was born, I started school behind, I started kindergarten behind everybody else who could read, they knew letters, I didn't, and I just fell further and further behind, end up dropping out of school, and I can't support, I want to be happy, want to feel good about myself. How do I do that? Get involved in the drug trade. I get caught, go to prison, that's the way it ended up, again and again and again, that's what happens in my state. People do their time, get out, and they go through maybe work release and eventually they are back in their community, back in their neighborhoods, same influences and then the same problems, so. It's a familiar story and it's not just Delaware, it's across the country.

I've had, I've taken special interest in three countries in Central America: Honduras, Guatemala, El Salvador. Some of us have been down there to gather, to, couple of them, the Chairman and I have been to at least a couple of those countries together, and I started focusing on them when I'd go to the border to see what's going on with respect to all these tens of thousands of folks coming into our country illegally, and what do we need to do to keep them out? And we built walls, we've built fences, we have ten, over twenty thousand border patrol, arrayed along the border. We have drones in the air, we have aerostats, tethered aerostats, we have P-3 airplanes, we have helicopters, we have boats, you name it. We spent a quarter of a trillion dollars to keep people out over the last ten years, keep them from coming, mostly from those three countries into the United States. Quarter of a trillion dollars. We spent less than one percent of that in order to address the root causes of their misery, which we are complicit in creating.

So, I, for me, root cause was really addressing a lack of rule of law in these countries, lack of opportunity, lack of entrepreneurial spirit, lack of work force, you know, so, what my focus was, how do we address those countries, to kind of like Plan Colombia, if you will, for those three countries? And they created something for themselves called Alliance for Prosperity. It's being funded rather significantly with our support, the support of the President and Vice President. And, but it's, as the chairman suggests, that's not really the root cause. The root cause is our insatiable appetite for drugs. And so we're complicit in their misery, how do we reduce that complicity? By reducing our demand for the drugs that transit through those countries. So. The, this is something we've all, everybody on this committee has thought a lot about, and we're interested in finding out what works, do more of that, what doesn't work, do less of that. Thank you so much for being here today and being part of this conversation. It's an important part, this conversation.

DEAN BECKER: All right, again, I would like to just refute some of what was presented by Senator Carper, and that is that, the violence on the border, the tens of thousands of children coming north, seeking shelter from the storm, so to speak, in Guatemala, Honduras, and El Salvador. It is a direct result of the black market, created by this prohibition. It is $375 billion a year, according to Anthony Placido of the DEA. There is no reason, no rational purpose, to this drug war. It's a fairy tale, it's a fable that has gone on for way too long.

SENATOR RON JOHNSON: Our first witness is Dr. Scott McDonald. He's a physician lead at the Providence Crosstown Clinic in downtown Vancouver, British Columbia. Crosstown is the only clinic in North America providing opiate assisted treatment for people with severe opiate use disorders. Dr. McDonald.

D. SCOTT MCDONALD, MD: Thank you. A hundred and forty people are receiving daily treatment with injectable opioids, an intensified form of medication assisted treatment. And I want to thank the government of British Columbia for supporting our clinic, and making the delivery of this treatment possible in Vancouver.

About half are receiving treatment with hydromorphone, a widely available licensed pain medication. The remainder receive diacetylmorphine. Our patients can come up to three times a day for treatment. Half come twice per day, and the other half come three times a day. About a third take a small dose of methadone with their last session at night.

All these patients have a chronic disease, a medical condition for life that can be successfully managed. Treatment prevents withdrawal, and stabilizes their lives. Here they have an opportunity to deal with underlying psychological and mental health issues. In time, some will step down to less intensive treatments, or gradually wean themselves off.

These patients were all participants in SALOME, the Study to Assess Longer-term Opioid Medication Effectiveness. SALOME was the follow-up to NAOMI, the North American Opioid Medication Initiative, which showed that diacetylmorphine, or prescription heroin, is superior to methadone in that group of patients who continue to use illicit heroin despite attempts at the standard treatments.

A small group of NAOMI folks received hydromorphone, and in a surprise finding, these experienced drug users could not distinguish which treatment they received. And the beneficial treatment effect was preserved in the hydromorphone arm.

Some people suffering from severe opiate use disorder need an intensified treatment like this. While methadone and buprenorphine are effective treatments for many people, and should remain the first line responses, no single treatment is effective for all individuals. Every person left untreated is at high risk for serious illness, and premature death.

Despite positive results for diacetylmorphine published in the New England Journal of Medicine, only Denmark acted on these results and incorporated prescription heroin into their health system. But it did lead to our follow-up study, and testing of hydromorphone or Dilaudid as a potential treatment. And hydromorphone has the advantage over diacetylmorphine of already being a licensed pharmaceutical.

The SALOME group underwent stringent testing and controls to show need for treatment. For them, the standard treatments, suboxone and methadone, had not worked, and most had multiple prior attempts at treatment. They had used injectable opioids for at least five years, and on average 15 years. They had medical and psychological health problems. They had nearly universal involvement in the criminal justice system. In short, we were able to recruit those patients appropriate for an intensified treatment like this.

At the start of the study, they were using illicit opioids every day. And by six months, their use was down to just three to five days per month.

SENATOR TOM CARPER: Excuse me, three to what?

D. SCOTT MCDONALD, MD: Three to five days per month. Nearly 80 percent were retained in care, and that high rate continues to this day. At outset, they were engaged in illegal activities on average 14 days per month, and with treatment, that reduced to less than 4 days.

This study was published this past April in the Journal of the American Medical Association Psychiatry. And I'd like to acknowledge Health Canada for allowing us to investigate this important scientific question, and allowing for a number of our patients to continue on diacetylmorphine, those who need it on a compassionate basis.

Supervised injectable hydromorphone is indicated for the treatment of severe opioid use disorder, and we are using injectable hydromorphone as a medication assisted treatment, an intensified medical intervention as part of the treatment continuum. Severe opioid use disorder is a chronic disease that needs to be managed long-term, just like type 2 diabetes or hypertension. Without our treatment, this group's only option would be illicit opioids through the narco-capitalist networks.

We still have people who use drugs on the street in Vancouver, but we have another option in addition to needle exchanges: supervised consumption rooms.

SENATOR RON JOHNSON: What do you call it, supervised consumption --

D. SCOTT MCDONALD, MD: Supervised consumption rooms, or injection sites. These are legally protected places where drug users consume pre-obtained illicit drugs in a safe, non-judgmental environment. Vancouver has two such sites. These sites provide an important entry point for people into medical care and substance treatment. They also provide value over needle exchanges alone, as needles and equipment are all contained onsite, and needles will not end up in playgrounds or schoolyards, where they could cause injury.

To contrast with these harm reduction interventions, our clinic, Crosstown, we are providing a medical treatment, providing injectable medication in a specialized opioid clinic under supervision of medical professionals, not only ensuring the safety of the patients and the community, but we also provide comprehensive care.

We are able to use hydromorphone off-label in Canada for treatment of substance use disorder, but some jurisdictions restrict its use to pain. I have seen remarkable transformations in our patients. Some of our patients have already returned to work or school.

Supervised injectable hydromorphone is safe, effective, cost-effective. It's a useful tool when the standard treatments are not effective. Treatments are dispensed within our opioid treatment clinic and prescribed on a dispensing basis onsite. In this setting, hydromorphone is not susceptible to diversion, and an exemption for its use could be considered in jurisdictions where its use to treat substance use disorder is prohibited by law.

In British Columbia, we need every tool in the toolkit to rise to this challenge of opioid epidemic. Injectable opioid assisted treatment in a supervised clinic is one effective approach. Supervised consumption rooms, like Insite in Vancouver, are valuable for public health. Of course, we would like to see an end to people dependent on heroin. But, for those already suffering, it is essential to provide care, and care based on evidence.

DEAN BECKER: Well, I don't have much to refute in what Dr. McDonald said. I was lucky enough to be up in Vancouver to tour the Insite injection rooms. I did see the cleanliness, the, I don't know, the healthiness, of what they had going on there. Let's go ahead and continue listening in to this US Senate Homeland Security and Governmental Affairs Committee discussion.

SENATOR RON JOHNSON: Now for a slightly different perspective. Dr. David Murray served nearly 13 years in the Bush and Obama administration as chief scientist and associate director of supply reduction in the White House Office of National Drug Control Policy. He's currently a senior fellow at the Hudson Institute. Dr. Murray.

DAVID W. MURRAY, PhD: Thank you, Senator. And I certainly want to take a moment to give my appreciation for each of you who is persisting in this issue and this problem. It is an urgent issue, and it does not get the attention it deserves, and I want to commend you senators who have persisted in careful attention to this issue, and are probing for answers for what is as you identified the cause of 47,000 deaths of Americans a year and overwhelming morbidity that is an additional toll.

My perspective for having worked inside the government and looking at the biomedical literature is that we need to approach drug policy somewhat differently than we have most recently, but that it can work. That we can save lives, and that we can effectively transition people into more secure and better lives. The underlying role of substance abuse, of drug use, in driving American pathologies, is extraordinary. Homeless to domestic violence to law enforcement difficulties to national security risks, educational failure, to the death of our beloved fellow citizens, and family members. This is an extraordinary cancer that has been eating at us for a long time.

You will hear arguments and have heard some of them already that I will be probably an outlier or resister with regard to certain of the claims. It's not so much I don't share the goals of lower drug use, of a safer, healthier society, it's that I'm not convinced that the evidence is as strong as it is sometimes portrayed, over these methodologies that are sometimes referred to as harm reduction. There are claims made about impact that when you look more carefully, the evidence is actually very weak and relies on self-report and methodological studies that are very difficult to validate, very difficult to see the actual replicability of them. The evidence is much weaker than you might anticipate with regard to moving in the direction that has been counseled.

Number two, I would point out that we have moved in this direction in the last seven and a half years under this administration. It is a direction that has not strongly applied the strategic lessons of a balanced drug strategy approach, that has weakened and undermined the very office responsible for setting that strategy, and that has moved us down a pathway that approaches harm reduction mentalities. It has led to the enabling of legal marijuana, it has led to discussions about distribution of harm reduction activities including supervision injection facilities, and I think we can say that the results that we are seeing are before us, and are really quite appalling. The results are disaster, epidemic, and tragedy.

Does the war on drugs work? Well, I would say it's contingent on two things. Number one, you have to define what is success, and when you have roughly between a tenth and a sixth of the prevalence rates of illicit substances, such as marijuana, the most widely used, compared to alcohol or tobacco, that is a form of success. You are reducing the disease and its morbidity and its impacts. When you have one sixth to one tenth the prevalence rate among young people and adults of the use of the substance, part of that is attributable to the fact that there are social norms against its use, and law enforcement sanctions against its use, and that law enforcement can be a powerful partner in referring people into treatment and recovery, and when we decriminalize or move towards a model of de-regulation and so forth, this really doesn't suffice, it doesn't answer our needs. It undermines the most effective partner for referring people to treatment, it undermines our hold on prevention, on the norms of non-using of drugs, and ultimately it weakens our approach, I believe.

The second contingency is this: drug policy where it has been effective, and there are models of where it has been highly effective, reducing the youth use rates of marijuana 25 percent in the period from 2001 to 2008, that was an achievement. Reducing the use of major drugs including methamphetamine and heroin during that same time period were major achievements.

And they are almost always attributable to having a bipartisan approach that crosses the aisle, so that it's a unified American understanding of American lives and American risk. The same time, you can't be, my famous story of this, that strikes me as so compelling, is Penelope on Ithaca, the wife of Ulysses, and he's sailing for 20 years, and she must marry a suitor when she finally finishes a tapestry in front of her. And when that figure in the tapestry is done, she will be forced to make a decision. Well, what does she do every night as she waits for Ulysses? She unravels it, because she doesn't want it to come to an end. That's a positive model, but unfortunately we've taken the worst of that. We unravel our drug policy almost every four or eight years. We make gains, we have effective strategies, and then we spend the next period of time reversing ourselves. Under that model you cannot achieve long range sustained goals.

We need to get back to that model of sustained bipartisan approach. So what am I recommending? We have to acknowledge a couple of things. The urgency before us at the moment is opioid overdose deaths. But we can't let that drive all of our understanding. It's a relatively unique situation, because we have, for opioids, methadone assisted treatment, or medication assisted treatment of various types. We have naloxone, an overdose reversal drug. We have the capacity to do things like injection facilities, if we move in that direction. I would counsel against it. These are not available tools for drugs like methamphetamine or cocaine, or cannabis. We don't have the medications. We don't have the methodologies of approach. A comprehensive drug strategy can't simply focus on the one urgent thing before us.

Second issue. We have overwhelmingly focused in the last little while in this discussion today and the administration's perspective on the consequences of the opioid epidemic, on those who have the disease, those who need treatment, those who are suffering already, how are we going to help them. Compassion requires that we do so, but we have to address the principal urgency if you're thinking medically, thinking epidemiologically, or thinking in terms of sound public policy.

You've got to shut off the entry into that state by protection, prevention. You've got to find the mechanisms of preventing people from falling into the state of addiction and dependency, where we then need to try to rescue them constantly with naloxone overdose treatment facilities. This is too late. We can do things for them, recovery is possible, but if we're not urgently addressing the underlying mechanism that is driving people into this, we're missing our policy opportunity and we're committing a tragedy.

What must we do? Well, one thing would be, don't enable the legalization normative acceptance and reduction in perception of risk regarding drugs, and that's what legalization precisely does. It undermines the fabric of resistance and the capacity to prevent. And I would offer, and we'll have time to discuss so I won't make all -- all the cards on the table at this point.

But I would say that there is a superior means of approaching this, and it is the one piece of public policy that was actually eliminated or neglected in the last seven years. We have to focus on drug supply. The availability of the drugs themselves. The administration recognizes this with regard to prescription opiates, which are the number two drug problem in America in terms of prevalence rates behind marijuana, which should tell you by the way that regulation and legalization and medical practice are not sufficient to make the problem go away, because we have an enormous problem with regulated, formally acceptable, medical practice prescription opiates, they're killing 18,000 people a year according to the last count. So that's not sufficient somehow.

At the same time, we've seen the supply as it's being reduced from medical practice, is slowing up as this rate is starting to slow. What about cocaine? Cocaine from South America, from Colombia, was reduced 76 percent between about 2003 through around 2010, 2011, the consequences were major in the United States. People got better, people got into recovery. Overdose deaths from cocaine dropped significantly. Well guess what's happened in the last two years in Colombia? Cocaine is taking off again, and it's coming right back at us and will soon be right back at our throat, as the supply increased, overdose deaths are starting to climb once again.

Third example, and the one I think that we're not sufficiently paying attention to, is heroin. The illicit opiate. Twenty six metric tons was the production out of Mexico, our primary source, back in 2013. The assumed need for use of heroin in the United States was never more than 18 metric tons. What were they doing with this abundance? A year later, it rose to 40 metric tons, that's an extraordinary amount of deadly substance being manufactured and sent across the border, and as of 2015, it has now skyrocketed up to 70 metric tons. Where's it going? Who's it infecting? Why aren't we doing more in international partnerships and interdiction and border protection? If you're thinking epidemiologically, and this is a disease, you've got to drive down the presence of the pathogen, the thing that infects people. It's a behavioral disease, and the pathogen in this instance is the illicit market of heroin.

DEAN BECKER: Of course, Dr. Murray is very concerned about the prevalence, the supply, of drugs, little realizing or wanting to investigate the fact that it is the black market which makes these drugs impure, which then allows them to be cut with all kinds of, well, cuts from everything from baby powder to rat poison, before it's sold to our children. Nobody knows what's in the bag, the phrase I use to close this show every week. It entices kids to get involved in the trade and to sell to their friends, and make some money. The black market is the reason for most of the horrors of this drug war.

It's time to play Name That Drug By Its Side Effects! Swelling of hands and feet. Rash. Hives. Blisters. Swelling of the face, lips, tongue, and neck. Trouble breathing. Changes in eyesight. Muscle pain. Fever. Skin sores. Dizziness. Sleepiness. Weight gain. Feeling high. Time's up! The answer, from Pfizer: Lyrica, for fibromyalgia.

All right, folks, that's about it for this week. Next week I'll be reporting live from Colorado and some of the dispensaries there in Denver. As always I remind you, because of prohibition you don't know what's in that bag, please be careful.

To the Drug Truth Network listeners around the world, this is Dean Becker for Cultural Baggage and the unvarnished truth. This show produced at the Pacifica studios of KPFT Houston.

Tap dancin on the edge of an abyss ......