11/04/18 Maia Szalavitz

This week on Century: award-winning journalist and NY Times bestselling author Maia Szalavitz discusses effective treatment for opioid use disorder, and we hear from Anton Luf with the Medical University of Vienna and the "Check It" service regarding new psychoactive substances and drug safety testing.

Century of Lies
Sunday, November 4, 2018
Maia Szalavitz
Download: Audio icon col110418.mp3




NOVEMBER 4, 2018

DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century of Lies. I'm your host Doug McVay, editor of DrugWarFacts.org.

Later in the show we're going to hear from Maia Szalavitz, the award-winning journalist and New York Times best-selling author discussing effective treatment for opioid use disorder. First, though, in October, the Commission on Narcotic Drugs held another set of intersessional meetings in preparation for their next annual session, coming up in March of 2019.

One of the topics under discussion was new psychoactive substances, and ways in which to respond. One of the speakers that they heard from was Anton Luf from the Medical University of Vienna, with the Check It! service. Here's Anton to explain more.

ANTON LUF: Thank you very much. Thank you very much for the invitation. It's an honor to be here and to speak about integrated drug checking, or nowadays as we call it analysis based interventions at Check It! in Vienna.

Check It! is a scientific collaboration of the Vienna Addiction Services and the Medical University of Vienna, and is funded by the city of Vienna and the Federal Ministry of Labor, Social Affairs, Health, and Consumer Protection.

It was founded in the year 1997, so more than 20 years ago, to provide consumers of psychoactive substances on electronic musical festivals with addiction prevention and early interventions.

So, basically, Check It! offers substance analysis and individual risk categorization of so-called recreational drugs to users of those substances, like amphetamine, ecstasy, or cocaine, and so on, and many more, actually, and the service users, this is all on-site, we have a mobile laboratory, and users can hand in their substances and get them analyzed before they are consumed. And this is key.

But, those analytical and toxicological measures are never placed alone. They're never offered alone. They're always combined together with psychosocial interventions, such as information, advice, and support, and it's -- that's what we call analysis based interventions.

So, as this graph shows, the substance analysis never comes alone, but it provides the basis for a bunch of other services, and interventions, like information, advice, and support, ongoing support, and in a wider scope, the monitoring of the drug market. And it increases the value of all of those interventions, but it is not -- it's not the center.

From an analytical point of view, there are a few requirements for comprehensive addiction prevention early interventions in that sense, and first of all, the substance analysis has to provide the identity of all pharmacologically active substances in a drug sample that is handed in.

Then, the second, this is getting more and more important, the quantitative composition of the drug has to be determined. And fast analysis and communication of the results at the venue has to be -- is a key requirement, because there's evidence that service users are not likely to wait longer than 15 minutes to an hour to get a screening result, and it is very important that the results are communicated before the substance is consumed.

And I like to use the phrase "potential consumers," because we will see later not everyone who uses the service is a drug consumer.

So, there are current developments and challenges that we're facing in the drug market in, and this is especially for Austria and Vienna. We have an increasing number of different new psychoactive substances on the market. We have a high complexity of samples, which means that the substances are not pure, they're often mixed with other ingredients, which are also very often pharmacologically active.

We have a high variability of dosage, and also increased dosages, especially MDMA and cocaine. And, the most recent and the most severe consequence, or development, is the appearance of highly potent psychoactive substances in this field, in this specific field, which we also refer to sometimes as the party setting, which is not a good term, actually, but it's used like that.

And it is -- it is very surprising that highly potent substances are appearing in this field. So, you can see the development of the analytical equipment that we're using, that Check It! has been using from 1997 on, and it also had to be developed, according to the market, and nowadays, Check It! uses a combination of three approaches, which includes UHPLC DDMS [ultra-high performance liquid chromatography tandem mass spectrometry digital direct mass spectrometer] and multi DMS, direct mass spectrometric approach, I don't want to go into detail, and I will explain why this is necessary.

And now with the focus on the appearance of highly potent psychoactive substances, here we see in this graph the new and reoccurring new psychoactive substances in Vienna, sorted by year and substance group. We see new psychoactive substances appeared on the market in Vienna in 2005, with piperazines, and the fentanyl -- the phenethylamines entered the market, and it was taken over by cathinones, which peaked in the year 2011 and 2012. And a very interesting development that we see is that in 2017, synthetic opioids entered the market.

So, I brought a few examples just to explain our work, and what is happening. Here we see a white powder, bought as 4HMF, a tryptamine derivative. It actually did contain the substance 4HMF, but also methoxyacetylfentanyl, a highly potent synthetic opioid, and in cases like this, we issue a warning, which is indicated by this red piece of paper, and as you can see, it's also anonymous.

Another sample the same night was submitted as fentanyl. It did not contain fentanyl, but as you can see in the MS trace chromatagram, it contained carfentanyl. Carfentanyl, as many of you know, is a highly potent synthetic opioid many times more potent than morphine, ten-thousand fold, it depends on which literature you consult. And as indicated by the picture next to it, very small amounts, micrograms, can lead to severe intoxications.

And this is a summary of what happened at the same night. This was quite representative for this night, but not for the whole setting. There were several unknown research chemicals handed in, so people -- that indicates that the people who handed in the substances had no idea what the substance was, and we found in three cases U-47700, cyclopentyl fentanyl, furanylfentanyl, which are all powerful and very potent synthetic opioids, and some other cathinones and other derivatives, all at the same night.

So, from an analytical point of view, it is extremely important to know the [unintelligible] substances, because it would create a false sense of safety, so we, in addition to our UHPLC-MS, we use now direct mass spectrometry on site with this very fast and easy approach, and this, our DMS has a very high sensitivity, and it is, as I said, easy to use.

So, at last, it is very important to analyze how the clients, the service users, react towards those warnings, and we, this is preliminary data of our ongoing survey, and one of the questions in this ecstasy survey was, how do you react if the analysis of your tablet yields a warning because of a harmful substance?

And 71 percent stated that they won't -- that they don't consume, 20 percent said that they would at least take less than usual, and only seven percent would consume as usual.

So, in the end, it -- this indicates that consumers or service users have -- show great risk awareness when they are presented with the right information, but without the information, they don't have the risk awareness, so it also indicates, this data, that the analysis based interventions can avoid -- can avoid -- sorry, I got stuck there now -- can avoid severe intoxications and in some cases maybe death cases. Thank you.

CND CHAIR: Thank you very much, Mister Luf, and, for a very interesting presentation. I want to see whether there will be any comments from the floor, any questions from the panelists as well. The UK, you have the floor.

DELEGATE FROM THE UK: Thank you very much, and thank you to the presenter for this very insightful presentation.

I have two quite specific questions, if I may. So, the first is in regards to the demographics of those who use this service. Do you have anything to show the age ranges?

And the second is about the preliminary data that you have, and whether you were able to find what you meant by harmful in the questionnaire. Did that mean that it was a substance that they didn't -- they weren't aware of, or does it mean that it was a highly potent, for example, more MDMA in a tablet of ecstasy, for instance? Thank you.

CND CHAIR: Thank you. Canada?

DELEGATE FROM CANADA: Thank you. I've been wanting to ask, there's a few questions, maybe, that just, a little bit maybe more description around the other parts of the service. So, if you could speak to anything like what percentage of people you think that are aware of the service would choose to use it. Do you give, are you able to identify all of the substances that you find, or is there an unidentifiable? And then what would you do with that?

And, I can't remember. There was supposed to be a third one. But if you could give a little more description around the rest of the service.

CND CHAIR: Angela, you wanted to make a comment?

ANGELA ME, UNODC: I just want to make a comment, if I may, because I think it's interesting what, particularly the last panel, that not everyone actually would not use the drug knowing that it is harmful, and then, it goes back to the issue of fentanyl in the US, and what I heard that some have researched, and I don't know if, you know, if it's true, that it shows that some users indeed, you know, want to avoid fentanyl, but actually what is happening also in the US and Canada have actually created some users who are actually, some want fentanyl.

They are very, maybe, not, you know, the great majority, but in a way, all of this potent substances are also creating niche markets, and I think it's important to understand, because, you know, of course, services to prevent the negative impact of drugs are very useful, but they need also to be targeted by those who really want to avoid the negative impact.

And the other question is, how do you manage with users that actually want to have very potent substances, and very dangerous substances?

CND CHAIR: Any other delegation? The Netherlands, and Slovenia.

DELEGATE FROM THE NETHERLANDS: Thank you, Madame Chair. I thank the presenter for his presentation, and I have a question about drug testing. We have it in the Netherlands as well, and the main purpose of it, of course, is harm reduction, but it has something counterintuitive about it, because people would think that it might stimulate the use of drugs instead of only reducing the harms.

So, can you elaborate a little bit on that issue, and explain to us whether it stimulates the use of drugs, and maybe lure non-users into the use of drugs. Thank you.

CND CHAIR: Let's take the one also Slovenia, please.

DELEGATE FROM SLOVENIA: Thank you very much. When somebody pays money for the drugs, normally you want to use it. It's, and if you will use it, even if it will be tested or not. If we're offering the testing, that is much better.

In Slovenia, we have such network of eleven focus centers in which everybody can bring the drugs on the test, and in a few days, he receives the answer from the laboratory. It is some kind of agreement between the police, medical institute, and the network of these centers. Is it exist also in Austria in such network or not?

CND CHAIR: Yes, please, go ahead.

ANTON LUF: Thank you for the questions. I'd like to start with Canada, and explain some of the other parts of the service.

As I said, the substance analysis is always placed in the center of attention because it is very interesting, and it happens in the public, but all the other services, there's a drop-in shop, for example, that has opening hours two times per week for psychosocial counseling. There are psychologists, there are groups, there are reduction groups, consumption reduction groups. There's referral.

We are very well connected with the whole addiction and prevention services in all of Vienna, and if a client turns into a patient, then we refer him to a good institution to solve that issue.

Also, there's online counseling, there's legal counseling, there's the whole, Addiction Services of Vienna also have needle exchange programs. There is, also is a big institution for IV drug use, so, and also we're well connected with the European monitoring system, the EWS, the Early Warning System, that we provide all of our data to those services, which contributes to the early warning system, and it's very interesting because some substances are not even detected by the police before we actually identify them first.

And so we get first hand information also, and also how a specific tablet or a specific substance is -- how dangerous it was. Also, if we find fentanyl in heroin, which was also the case, it was not only those party drugs. So, that's what we -- that's what I referred to.

And, about the identification of the substances, we have -- we put a lot of effort into identifying the substances as fast as possible. At the moment, at the venue, if we don't -- if we don't, can't identify it completely, we have an idea what it is, we announce a warning that this is an unknown substance.

We screen for approximately 500 substances, five hundred psychoactive substances, and if it is not one of those, the counselors of course tell the person or the client who is using the service that if it's not one of those substances, why would you ever consume it? Please don't, in that case, and we go back to the stationary laboratory, measure it with high resolution mass spectrometry and everything that we have. We identify it and then we train our systems again to recognize that substance.

The question about, in our survey, what the word harmful refers to. There were several more questions, and one of them also was how would you react if you get a warning because of high dosage. So that was very well distinguished between those two terms.

The word 'harmful' in that sense meant it was something like, we gave some examples, like PMA, like fentanyls, something that really -- that really is, like, a imminent health risk, and not just like an overdose, which I don't want to -- it's, that's maybe the bigger problem with the ecstasy tablets at the moment, but we have a different warning system for those, and we also have a threshold that is based on pharmacological data that we put a lot of research in, and this is very well communicated by the psychologists and the counselors.

DOUG MCVAY: That was Anton Luf from the Medical University of Vienna talking to the Commission on Narcotic Drugs in its October intersessional meetings. They were discussing new psychoactive substances and drug safety testing.

You’re listening to Century of Lies. I’m your host Doug McVay.

NGAIO BEALUM: While marijuana's legal on the west coast and Alaska and a lot of different places, it is still illegal in most of the country. Right? So while these cats are out here making millions of dollars and everybody's got a cannabis business and we're all smoking weed in the streets, there are people in other states who are still in jail over a joint, who got fifteen years on two grams, who got arrested for a gram and a half of weed. It's not over. We still need activists. We still need radicals. We still need to be in the streets.

Like, I've updated one of my new jokes about how what we need to do is just roll out from the west coast to all these other states, and just start going door to door like Weedhovah's Witnesses and getting everybody involved. I have some good news about weed, can I share it with you?

DOUG MCVAY: Now, let's talk about opioid use disorder treatment. The National Academies of Sciences, Engineering, and Medicine in their Health and Medicine Division held a public workshop of the Committee on Medication Assisted Treatment for Opioid Use Disorder at the end of October.

One of the people they heard from was my friend, the journalist and New York Times best-selling author Maia Szalavitz. Let's hear what Maia had to tell them.

KATHLEEN CARROLL, PHD: And finally, to bring us home, we're going to hear from Maia Szalavitz, who's an American reporter and author of the New York Times bestseller The Unbroken Brain: A Revolutionary New Way Of Understanding Addiction, to which I recommend you all highly. Thank you, Maia.

MAIA SZALAVITZ: Thank you so much for having me. I'm delighted and rather terrified, but, I just want to start by saying, we should not be calling this MAT. With any other treatment for any other disease or disorder, we don't say I'm on Prozac-assisted treatment for my depression, or I'm on insulin-assisted treatment for my diabetes.

We recognize that medication is appropriate treatment for a disease or a disorder, and so I think we've got to, like, look, starting right there, from the stigma that lives right there in that name. I would propose counseling-assisted treatment for those, because, you know, according to the data, what actually saves lives and cuts the death rate in half is the medication, even if there's no counseling. Plus, I like the acronym CAT.

Now, I'm going to talk a little bit about some of the barriers that patients experience. Now, I am not currently a patient. I was a patient in the '80s, and that was a nightmare. Basically, it is an -- you know, the reason they call it orange handcuffs, for being on methadone, is because the experience is a carceral one. It is one of being controlled and being humiliated.

You know, I could have told them I was still using coke, but no, I had to sit there and, you know, try to eke out some pee in front of somebody, because I was so dehydrated from shooting the coke. But that would not have been acceptable, I would have not had the urine.

So, the humiliating and literally ghettoized nature of methadone clinics is deeply problematic, and we really need to -- we can prescribe Oxycontin to as many patients we want to do, so why can't we prescribe methadone or suboxone to however many patients we want to do?

If we are actually considering addiction to be a medical disease, we should not be treating these patients as somehow different, and as somehow requiring of more surveillance because we are somehow evil, bad, scummy people that are going to lie to you.

The stigma of addiction is often spread by people talking about how people with addiction, oh, when do they lie? When their lips are moving. Now, if you actually look at self-report data from people with addiction compared to people without addiction, if they don't have a reason to lie, like any other human being, they won't lie.

So, it's really, again, we really need to stop, you know, having these barriers, and so I just talked to a bunch of people who are actively patients about what kind of barriers they are currently experiencing. So, this is from a woman, she's on buprenorphine. "My symptoms are dismissed as simply pill-seeking behavior, leading doctors to miss a giant tumor in my ovary that almost left me infertile."

Our courts don't recognize suboxone as being clean, their stigmatizing word. It's holding up the visitation of my children, in this person, this is the mom of the patient, so, she can't see her grandchildren because the mom can't see her children, because suboxone isn't "clean."

We get people, I have tons of stories of people thrown off of methadone or suboxone for positive marijuana tests. Now, let me just say, a study came out a couple of weeks ago showing that daily marijuana use was actually associated with better outcomes in medication assisted treatment, oops, I didn't mean to use that phrase, but, yes, there -- but also, do we throw people who have diabetes off of their insulin because they smoke pot? No, we do not, we recognize that a life saving medication is a life saving medication and people should be on it.

I know that one of the federal agencies has warned that we shouldn't be throwing people off of opioids for benzodiazepines, either. The main thing that we do in our system of providing methadone or buprenorphine is to create these barriers.

So, we don't require counseling for anything else. I have a lot of stories here about people, I want to do my job, I want to go to work, but I have to go to counseling three times a week and it's in the middle of the day, and otherwise they're going to cut me off my medication.

I have heard from a woman whose husband suffers from psychosis. He was on I think 120 milligrams of methadone. He went into the hospital. They took him down to 20 just because. And we also probably know that actually opioids are kind of good at reducing psychosis, so that was completely -- there was no reason to do that to this person, other than to make him suffer.

We also have a problem with drug courts, that two thirds of drug courts say that you're not allowed to use methadone or suboxone, and that this does not count as treatment.

So, that -- they're basically, I reported a case a few years ago where a young man was doing well on methadone. He, some old warrant came back to haunt him, and the judge insisted that he come off methadone, and he was dead of an overdose a few days later.

He can't sue, because you can't sue the justice system, but the -- that kind of malpractice, and that kind of practicing medicine by judges, should not be happening.

I've heard stories from women who, oh, you gave birth? No more methadone for you. I've heard stories, oh, you miscarried? We're going to cut your Subutex down. There is also just the ongoing intense stigma that people experience when they seek any kind of other medical care. As soon as they hear that you are a person with addiction, you get, oh, you're just here to fool me kind of thing, and that's the nicer version of it.

There are also detoxes that have killed people because they couldn't pay for treatment anymore, and I haven't even gotten into the financial barriers.

I know I'm towards the end of my time but there's one more thing I want to say, which is, one of the key things that we do in the medication treatment world is we require people to attend twelve step programs. Narcotics Anonymous, which is the primary twelve step program for people with opioid addiction, does not consider being on medication to be being clean or in recovery.

So basically this means that we're sending people to a place that will stigmatize them. We're sending people to a place that will tell them to stop those evil meds, they're bad for you, you don't need them. If we really want to provide social support for people on medication, we should not be requiring them to attend programs that tell them that medication is bad, and I will be happy to take questions later. Thank you.

DOUG MCVAY: That was Maia Szalavitz, award-winning journalist and New York Times bestselling author, speaking to the Committee on Medication Assisted Treatment for Opioid Use Disorder at the National Academy of Sciences, Engineering, and Medicine, on October Thirtieth.

And for now, that's it. I want to thank you for joining us. You have been listening to Century of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I’m your host Doug McVay, editor of DrugWarFacts.org.

The executive producer of the Drug Truth Network is Dean Becker. Drug Truth Network programs are available by podcast, the URLs to subscribe are on the network home page at DrugTruth.net.

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We'll be back in a week with thirty more minutes of news and information about drug policy reform and the failed war on drugs. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.