Needle Exchange in America

AIDS/harm reduction activists press Obama.

First, the good news: After 20 years, the U.S. Congress has voted to remove the funding ban on syringe exchange programs designed to combat AIDS and to bring hard drug users within the orbit of the medical health community.

Now, the bad news: Conservative legislators have managed to insert a provision in the bill prohibiting needle exchange centers within 1,000 feet of schools, day care centers, colleges, playgrounds, youth centers, swimming pools—and just about any other institution you care to come up with. In short, the legislation would make it virtually impossible to operate a viable needle exchange program, even if sufficient levels of federal funding can be obtained. As one harm reduction activist put it in the Seattle Stranger: The only place you could put a federally-funded needle exchange program in the entire city of Chicago... is O’Hare Airport? Gee, it’s almost like Democrats aren’t really serious about allowing funding live-saving needle programs at all.”

Clearly, needle exchange activists are still waiting for an unambiguous sign from the White House that Obama plans to uphold his campaign promises in this regard. Obama’s go-slow policy on needle exchange has frustrated AIDS activists in particular.

Physicians for Human Rights, a group that supports clean syringe exchange programs, made October 14 a National Call-in Day, noting on its web site that “Senators need to hear from President Obama that his Administration supports syringe exchange. Now is the time to urge President Obama to fulfill his campaign promise to end the ban and to urge the Senate to act.”

In a post in January of this year, I wrote: “Obama’s agenda, as spelled out at Whitehouse.gov, calls for rescinding the ban in an effort to save lives by reducing the transmission of HIV/AIDS. ‘The President,’ according to the agenda, ‘supports lifting the federal ban on needle exchange, which could dramatically reduce rates of infection among drug users.’"

Syringe exchange programs, Physicians for Human Rights declares, “do more than provide clean syringes and properly dispose of used ones; they link people into the health care system and drug treatment programs that save lives.”

In short, says the group, “the presence of syringe exchange programs in communities does not increase rates of drug use, nor does it lead to a rise in crime. What it does do: decrease transmission of HIV, Hepatitis C and other diseases.”

Moreover, during his confirmation hearings drug czar Gil Kirlikowske said that “a number of studies conducted in the US have shown needle exchange programs do not increase drug use.”

It’s a confusing picture in the field: Needle exchange programs exist, in San Francisco, Toronto, New York and other major metropolitan areas, because county and other local and regional officials have authorized it, even when funding was precarious. Alongside these programs, a plethora of illegal needle exchange operations is also in place. The Drug War Chronicle quoted the Western director of the Harm Reduction Coalition: “We need to get legislation authorizing syringe exchanges on a statewide level.... Requiring local authorization means we have to deals with 54 jurisdictions instead of just one.”

Back in May, Maia Szalavitz reported in Time that the president was planning to move deliberately as part of a broader HIV/AIDS strategy, even though groups from the World Health Organization (WHO) to the American Medical Association have gone on record with the view that giving clean needles to drug addicts is a successful strategy to reduce the spread of HIV disease. Studies by Don Des Jarlais of Beth Israel Hospital in New York suggest that infection rates in New York’s drug addict population may have dropped more than 75 % over the last few years as clean needle programs became increasingly available.

In a report last month by the Drug Reform Coordination Effort (DRCNet), a spokesperson for the AIDS Action group was determined to remain positive. “I have a pretty good feeling about this,” he said. “I’m hopeful this is the year.”

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The Black Market for Seroquel

Speed freaks, coke heads, and antipsychotics.

Last week, writing on the Daily Beast web site, reporter Jeff Deeney profiled a startling underground market for the antipsychotic medication Seroquel (quetiapine). Deeney described street transactions in North Philadelphia for Quells or Suzie-Qs, as the drug is sometimes called. Seroquel, a drug developed for the treatment of schizophrenia and bipolar disorder, has developed an additional reputation as a “comedown” drug for stimulant abusers.

Seroquel, a so-called atypical antipsychotic, works by altering levels of dopamine. While some addicts have claimed that the drug is perfect for a cocaine or speed comedown, Seroquel has also been studied for its anti-craving properties when used for cocaine abstinence.

Why would a speed freak or a coke addict want to take a drug that might decrease their desire for their stimulant of choice? For the same reason that ecstasy users often take a morning-after dose of Prozac in a misguided attempt to compensate for possible damage to serotonin receptor arrays. Or because the drug is mildly sedating for some users. However, there may be more to it. Perhaps Seroquel is an effective anti-craving medication for cocaine and methamphetamine addicts, who misuse it as a drug to ease them through enforced periods of detox or lack of availability.

One high-traffic drug discussion site has shut down a long-standing thread on Seroquel with the warning: “Do not use Seroquel for a cocaine comedown.”

The fact that prescription Seroquel is available as a street drug, at least in some parts of the country, demonstrates the likelihood that physicians and psychiatrists are increasingly using it for off-prescription purposes—like drug detox. Deeney strongly suggests that this is the case: “Drug dealers, mandated to treatment as a condition of their probation or parole, are given off-label prescriptions for Seroquel, then sent right back to the street, where the pills can be sold for cash to users and other dealers.”

Increasing its appeal is Seroquel’s reputation for combining well with cocaine in a mixture known as a Q-Ball, or Rosemary’s Dolly—a variation on the heroin/cocaine mix known as a Speedball, to which Seroquel can also be added. An anonymous med student on a medical blog noted that “certain people say they love Seroquel when doing a speed-ball. Makes sense, think about it. It heightens the high of the heroin, it eases the crash of the cocaine.”

Seroquel’s ability to modulate the effect of illegal drugs means that the medication can possibly find a market both as a detox drug for stimulant abusers, and as an ingredient in the very stimulants they abuse.

By itself, Seroquel is not considered addictive. Some addicts told Deeney that the drug simply put them to sleep more quickly after a long meth run. Indeed, Seroquel is considered to be more sedating than similar antipsychotics such as Olanzapine and Aripiprazole. The larger issue, as the Daily Beast post makes clear, is that “Seroquel can have serious side effects including diabetes, a permanent Parkinson’s-like palsy called tardive dyskinesia, and sudden cardiac death.”

All of this confusing and sometimes contradictory input is coming well ahead of the clinical data, although a study in 2001, presented at the 4th International Conference on Bipolar disorder, found that quetiapine caused a significant reduction in cocaine use among a small group of cocaine-dependent subjects who also suffered from bipolar disorder. A report last year in the Journal of Clinical Psychopharmacology also showed positive results with cocaine users. Studies of quetiapine for the reduction of cocaine use are currently being undertaken by the Seattle Institute for Biomedical and Clinical Research.

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To Flush or Not To Flush

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FDA lists meds for trash or toilet.

A recent post here on the subject of illegal bong water in Minnesota—coupled with a perceptive comment by a reader about drugs in the water supply—got me thinking again about what gets thrown in the sink or flushed down the toilet.

I was surprised to discover that, according to the Food and Drug Administration (FDA), consumers are better served by flushing some drugs down the toilet. The FDA has put up a web site dedicated to the proposition that flushing drugs is the preferred method for certain kinds of drugs—but not for every kind of drug.

While noting that “flushing is not recommended for the vast majority of medicines,” the FDA asserts at druginfo@fda.hhs.gov that “certain medicines may be especially harmful and, in some cases, fatal in a single dose...” To dangerous, in other words, to leave around the house or in the trash.

The potential for fatal overdose, particularly with prescription morphine and its derivatives, suggests that flushing will be the preferred method of disposal unless or until communities and pharmaceutical companies get serious about take-back programs and other medicine disposal services.

Specifically, drugs recommended for flushing include:

--Morphine Sulfate (Morphine, Avinza, Embeda, Kadian, MS Contin, and Oramorph).

--Fentanyl Citrate (Actiq, Duragesic, Fentora, Onsolis).

--Meperidine Hydrochloride (Demerol).

--Methylphenidate (Daytrana).

--Hydromorphone Hydrochloride (Dilaudid).

--Methadone Hydrochloride (Methadone, Methadose, Dolophine).

--Oxymorphone Hydrochloride (Opana).

--Oxycodone Hydrochloride (Oxycontin, Percocet, Percodan).

-- Sodium Oxybate (Xyrem).

The FDA says that the disposal of “these select, few medicines by flushing contributes only a small fraction of the total amount of medicine found in the water. FDA believes that any potential risk to people and the environment from flushing this small, select list of medicines is outweighed by the real possibility of life-threatening risks from accidental ingestion of these medicines.”

The preferred disposal method for all other drugs, says the FDA, is to mix them with kitty litter or coffee grounds, place the mixture in a sealed plastic bag, and throw the container in your household trash.

Photo Credit: www.pri.org

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Alcohol and In Vitro Fertilization

Do drinking women face tougher odds?

Everybody knows by now that it’s not safe to drink while pregnant. However, a new study of more than 2,500 couples enrolled in a course of in vitro fertilization (IVF) treatment at a fertility clinic found that women who drank more than a single drink per day significantly reduced their likelihood of pregnancy, according to a report by doctors at the Harvard Medical School in Boston.

Now, it may not even be a good idea for women to drink while trying to get pregnant. And that includes you men out there as well.

Dr. Brooke Rossi presented the findings last week to a meeting of the American Society of Reproductive Medicine. In the study cohort, half the women and a third of the men had less than one drink per week, while about 5% of men and women had at least one drink per day. According to Dr. Rossi, women were 18% less likely to have a successful IVF baby if they drank at the higher level. Men who had more than six drinks per week reduced the rate of successful in-vitro fertilization by 14 %.

The average age of women taking part in the study was 34, and for men, the average age was 37. Tony Rutherford, chairman of the British Fertility Society, told the UK Guardian that “this is further evidence to suggest that alcohol does have an impact.” Rutherford agreed with the study authors at Harvard that women who wish to become pregnant should stop drinking.

In 1998, the British Medical Journal published a Danish study of more than 400 couples that concluded: “A woman's alcohol intake is associated with decreased fecundability even among women with a weekly alcohol intake corresponding to five or fewer drinks.” The authors conceded, however, that other studies have found little evidence of an alcohol effect on conception rates.

“It may well be that couples who are already subfertile are more affected by alcohol than those who are perfectly fertile,” Rutherford speculated. “Eggs and sperm take at least three months to develop so women have got to stop smoking, reduce alcohol consumption, or, if you are overweight, correct that weight, that far ahead if you want to maximize your chances of conception.”

Photo Credit: www.babble.com


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Bong Water Illegal in Minnesota

State Supreme Court calls it a “drug mixture.”

The lesson is clear: If you live in Minnesota, and you happen to own a bong, be sure to pour out the water after each use.

Bong water is now officially a controlled substance in Minnesota, according to a state Supreme Court ruling last week. An Associated Press report by Steve Karnowski in the Minneapolis Star Tribune said the decision “raises the threat of longer sentences for drug smokers who fail to dump the water out of their pipes.”

The decision (PDF HERE) reverses two lower court rulings, which dropped charges in a case where a search of a Minnesota home included the discovery of a glass bong with 37 grams of liquid that tested positive for methamphetamine. Rice County authorities charged the homeowner with a first-degree drug offense for possession of a “drug mixture.”

The Minnesota Supreme Court ordered the case back to Rice County District Court prosecutors. The 4-3 decision, authored by Justice G. Barry Anderson, said that the bong water was clearly a drug “mixture” and therefore subject to state drug statutes. Anderson also wrote that a narcotics officer had alleged that drug users sometimes drink or inject bong water.

Justice Paul Anderson, writing in dissent, claimed the majority decision “borders on the absurd.” Bong water as a drug mixture carries a penalty of up to seven years in prison. However, when defined as drug paraphernalia, which is conventionally the case, the offense is a misdemeanor carrying a $300 fine and no jail time.

An attorney for the woman arrested and charged in the case said that officials were treating his client, “who had two tablespoons of bong water, as if she were a major drug wholesaler.”

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How Pure Is Ecstasy?

Dutch study of street MDMA.

For 16 years, the Drugs Information Monitoring System (DIMS) in The Netherlands has gathered and analyzed tablets of purported MDMA sold on the street as Ecstasy. In a research report published in Addiction, Neeltje Vogels and others at the Netherlands Institute for Mental Health and Addiction in Utrecht found that between 70 to 90 % of the samples submitted as MDMA were pure. The most common non-MDMA adulterant was found to be caffeine.

The study covered the years from 1993 to 2008. In the mid to late 1990s, researchers saw an increase in ephedra and methamphetamine in the samples, and sample purity hit an all-time low of 60% in 1997. The years from 2000 to 2004 were the golden era, so to speak, for MDMA purity. “After 2004,” the study authors write, “the purity of ecstasy tables decreased again, caused mainly by a growing proportion of tablets containing meta-chlorophenylpiperazine (mCPP).” mCPP belongs to a class of stimulants, the so-called piperazines, that have been banned in several countries (See my post).

As noted on the DrugMonkey science blog, a lack of consistent published data has hampered efforts at studying street MDMA. Tablets for analysis are obtained either from law enforcement—which seizes drugs that may or may not be for sale at the club level--or drug analysis and harm reduction sites. The problem, DrugMonkey writes, is that “perhaps Ecstasy found to result in suspicious subjective effects on the user are submitted to harm reduction sites preferentially.” In other words, people only submit the brown acid.

The Dutch study, on the other hand, obtained samples for testing from capsules seized by club owners and given to the police, who then passed them on to DIMS for analysis. This system helped eliminate the possible bias effect of voluntary submissions.

The study also found that larger tablets, containing 100 mgs or more of MDMA, became increasingly popular starting in 2001.

DrugMonkey, an anonymous NIH-funded biomedical researcher, calls the study “an impressive longitudinal dataset.” The data, he wrote, give us “a good picture of the percentages of MDMA-only across time (higher than certain MDMA fans seem to acknowledge when it comes time to assess medical emergency cases) and the relative proportions of specific contaminants (certain baddies are quite rare.)”

Specifically missing in action most years is the baddy known as PMA, or para-methoxy-amphetamine, which has been implicated in many of the alleged Ecstasy deaths by overheating--a condition known as hyperthermia.

Graphics Credit: National Institute on Drug Abuse


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Moderate Drinking: The Debate Continues

New study says it’s the lifestyle, not the alcohol.

Ever since the first studies showed modest statistical health benefits for people who drank a light to moderate amount of alcohol, the debate has bounced back and forth among researchers. Now an Italian study of more than 3,000 older adults, published in the Journal of the American Geriatrics Society, claims that it is the moderate lifestyle of drinkers, and not the alcohol itself, which helps prevent functional decline as we age.

After controlling for body weight, level of physical activity, education, and income, Cinzia Maraldi and coworkers in the Department of Clinical and Experimental Internal Medicine at the University of Ferrara pointed the finger at lifestyle characteristics—primarily weight control and exercise.

The researchers did not dispute the finding that moderate levels of alcohol intake can lower the risk of cardiovascular disease--but lead author Maraldi said in a press release that “the benefit of alcohol intake on other health-related outcomes is less convincing.”

Maraldi said the positive effects of moderate alcohol on physical aging and cognitive impairment in the elderly may be only apparent, “because life-style related characteristics seem to be the real determinant of the reported association.”

The research follows earlier U.S. studies suggesting much the same thing. A finding that had become common folk wisdom—with perhaps a little nudge from the alcoholic beverage industry--is now openly disputed by scientists.

“The moderate drinkers tend to do everything right,” said sociologist Kaye Middleton Fillmore, in a New York Times article by Roni Caryn Rabin. “They exercise, they don’t smoke, they eat right and they drink moderately.” In the same article, an Oakland cardiologist said: “It’s very difficult to form a single-bullet message because one size doesn’t fit all here, and the public health message has to be very conservative.”

In the New York Times article, Dr. Tim Naimi of the Centers for Disease Control and Prevention said: “The bottom line is there has not been a single study done on moderate alcohol consumption and mortality outcomes that is a ‘gold standard’ kind of study—the kind of randomized controlled clinical trial that we would be required to have in order to approve a new pharmaceutical agent in this country.”

Photo Credit: Rhodes University


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