A new study published in Harm Reduction Journal highlights the health risks of this policy. Surveys with over 700 English people who smoke crack cocaine reveal that one-third have been hospitalized for respiratory illness, and the majority have recently experienced respiratory issues. Follow-up interviews indicate that people having to resort to homemade smoking devices contributes greatly to these startling figures.

“It was a bit of a risky study. How do you generate evidence about something that’s not within the law?”

The data come from the Safe Inhalation Pipe Project (SIPP), led by Dr. Magdalena Harris of the London School of Hygiene & Tropical Medicine. SIPP provided safer smoking kits in six locations across England to evaluate their impact on drug-user health.

“It was a bit of a risky study,” Harris told Filter. “How do you generate evidence about something that’s not within the law?”

Harris and her team overcame this “catch-22,” as she described it, by obtaining temporary police approval. They also received a generous donation of pipes from Exchange Supplies, since government research funding could not be used to fund the intervention.

While analysis of SIPP’s impact is still in progress, data from the baseline phase of the study document clear respiratory health issues among people who smoke crack in the UK.

“Looking at the baseline survey data from 733 people, 60 percent of them … had respiratory symptoms within the last 28 days,” Harris said. “In terms of hospitalization, 31 percent had been hospitalized for a respiratory condition ever. And diagnoses are really high—31 percent have been diagnosed with asthma, and 12 percent have been diagnosed with COPD.”

She also warned that even these high figures are likely underestimates, due to this population’s relatively limited access to medical care.

“We know that COPD is really underdiagnosed in this population,” Harris noted. “So if 12 percent have been diagnosed, I’m sure there’s a lot more undiagnosed, particularly given the high [prevalence of] symptoms.”

“People would often start out with tin cans.”

In addition to the survey questions about respiratory harms, Harris and her team also conducted 33 in-depth interviews with participants, asking them to share their strategies for making their own pipes in the absence of safer supplies.

“People would often start out with tin cans,” Harris said. Other common materials included miniature liquor bottles, asthma inhalers, umbrella handles, naloxone syringes and disposable vapes.

A tin can pipe, which Harris noted can be made “in less than a minute”

While these approaches were innovative, they also tended to be dangerous. Plastic containers, for instance, release toxic chemicals when heated or scraped for valuable residue, while certain glass containers cause severe burns and cuts.

“One of the biggest issues in terms of respiratory harm with homemade pipe use is unsafe suspension devices,” Harris said. When smoking out of tin cans, for example, people tend to place their crack on top of ash. “The issue there is that you’re inhaling a lot of ash, which is really bad for your lungs.”

“[People] talk about burns to their lips or their tongue. But … there’s also the impact of inhaling that hot vapor on their lungs or on their esophagus.”

Other popular suspension materials included stainless steel scrubber (also called “steel wool”), which quickly breaks apart into inhalable metal fragments, and small metal bolts, which reach scalding temperatures. Since stimulants like cocaine have numbing effects, the damage caused by these high temperatures is often greater than people are able to perceive.

“[People] talk about burns to their lips or their tongue,” Harris said. “But then what they’re probably not realizing is that there’s also the impact of inhaling that hot vapor on their lungs or on their esophagus.”

A repurposed metal cannabis pipe, which may cause severe burns

To mitigate use of these homemade alternatives, SIPP provided study participants with pipes made of heat-resistant glass and a more robust suspension material. However, not all participants preferred these safer, purpose-built pipes.

“We collated all of that participant information and took it back to Exchange Supplies and … developed a better pipe.”

“[T]he filter was too dense—it was a good, steel filter made specifically for using crack, but it was just too dense for people,” Harris said. “So what we were seeing is that often people might throw it away and go back to using stainless steel scrubber or whatnot.”

Many people were also unhappy with the size of the pipe and its carrying case, preferring a thinner, more discreet option.

“We collated all of that participant information about the pipes and took it back to Exchange Supplies and … developed a better pipe,” Harris said. “That was a really nice output of the study—something practical that reflects the participants [and] their preferences.”

The new pipe kit, redesigned based on SIPP participants’ feedback

While SIPP is based in the UK, the challenges it’s addressing are global. Many countries continue to crack down on pipe distribution, including the United States, where modest efforts to provide safer smoking supplies under the Biden Administration were met with political outcry.

Harris hopes that SIPP will provide an evidence-based perspective on how pipe distribution can impact the health of people who smoke stimulants. The final results—which will compare this baseline data to new surveys collected six months after the intervention—are still in progress, but preliminary evidence suggests positive effects.

“Our impact evaluation has shown reductions in crack pipe sharing, injecting of any drug, use of homemade pipes and use of ash as a suspension device,” Harris said. “This is a very positive outcome, with longer-term implications for reducing respiratory and injecting-related health harms.”

All photographs courtesy of Magdalena Harris

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Effective October 2, the DEA increased the 2025 APQ for d-amphetamine, the primary active ingredient in Adderall, from 21.2 million grams to 26.5 million grams. It also increased the APQ for methylphenidate, better known by brand names Ritalin and Concerta, as it has done once before since the shortage began to affect those medications in late 2022.

“DEA has determined that although [both] APQs are adequate to address both the domestic and foreign medical demand, they are insufficient to accommodate an unexpected rise of quota requests for product development activities,” the agency stated in its October 2 notice. “The proposed increases are to support manufacturers’ product development activities toward obtaining FDA approval.”

Amphetamine is a central nervous system (CNS) stimulant, a category that includes many other commonly used substances like methamphetamine, cocaine, caffeine and nicotine. Its chemical structure is made up of two isomers, d-amphetamine and l-amphetamine, which are mirror images—like a left hand and a right hand. Adderall contains both, but d-amphetamine, short for “dextroamphetamine,” is the more potent of the two. That’s why generic versions of Adderall are often labeled “dextroamphetamine-amphetamine mixed salts,” or some variation along those lines.

This is the first time the DEA has ever adjusted the APQ for sales of Adderall and its generic versions. The d-amphetamine cap of 21.2 million hasn’t budged since 2021, the year the agency began assigning APQ by specific isomer rather than a larger lump sum to just “amphetamine.” 

In 2021, the APQ for methylphenidate was 57.4 million grams. The DEA then slashed it to 41.8 million grams, then during the shortage raised it to 53.3 million grams. The October 2 adjustment brings the APQ to 58.3 million grams.

In September the DEA also increased APQ for lisdexamfetamine, the active ingredient in Vyvanse, from 32.7 million grams to 39.9 million grams. Vyvanse is a similar-but-different CNS stimulant approved for treatment of ADHD, as well as for binge-eating disorder. The agency had previously increased its APQ in September 2024. Both of those changes were technically accompanied by increases in APQ for d-amphetamine, but only for use as part of the synthesis process for lisdexamfetamine products—not for sale as an ingredient in Adderall or its generics.

Slide from DEA presentation on its online portal for APQ applicants

Vyvanse went generic in 2023, but this has yet to make much of an impact on the shortage. Generics have gotten off to a rocky start, with issues ranging from the DEA’s failure to assign APQ allotments to numerous reports of inconsistent potency. There are currently two ongoing recalls for lisdexamfetamine products.

All medications designated Schedule I or II under the Controlled Substances Act are assigned APQ, and that sum total is then divvied up between the various DEA-licensed manufacturers that have applied for quota allotments. But APQ are often gravely out of sync with actual demand—they’re set about two years in advance, in a somewhat arbitrary fashion, and are nontransferrable regardless of whether a company has been assigned more or less than it intends to use. Demand itself also tends to be underestimated because those estimates derive in large part from sales data, which of course reflect sales capped by APQ in the first place. The DEA also controls the quantities of medications that can be stocked by individual pharmacies.

Medical demand increased during COVID-19 pandemic-era telemedicine prescribing, but the DEA maintains that “diversion” risk outweighs the benefits of increasing the supply. At publication time at least six companies that manufacture methylphenidate and at least five that manufacture amphetamine salts are reporting shortages of one or more of their formulations.

The agency has blamed overseas manufacturing issues, or pharma companies failing to max out their quotas. But oral formulations are typically pretty straightforward to produce, and not the kinds of medications that get caught up in extended delays at a manufacturing plant. The DEA is avoiding acknowledging that its APQ are the root of the problem, or that barring access to pharmaceutical stimulants increases demand for the methamphetamine-based counterfeit Adderall tablets it keeps warning everyone to avoid.

Top image via International Trade Administration. Inset graphic (cropped) via Drug Enforcement Administration.

The post DEA Raises Adderall Production Quotas for the First Time appeared first on Filter.

But I’ve also experienced a whole lot of harms associated with drugs, and especially with the conditions of drug use under prohibition. I’ve contracted hepatitis C, and suffered injection-related infections and numerous nonfatal overdoses.

About a year ago, I decided that considering everything, I wanted to stop using drugs. So I applied for a sober living facility and started that journey. That doesn’t mean I think it’s the “right” choice for others. It just made sense for me, when by that point in my life, the risks and harms, and the impact on my mental health, had been outweighing the benefits.

Despite that decision, I recently overdosed again. I want to tell you about it because some of the circumstances could be relevant to a lot of people.

Sober living has been a mixed bag of experiences and emotions, and I’ve been in and out of facilities over the past year.

Again, recovery was the goal I chose for myself, despite past experiences with safe supply, and I went into this with my eyes open. The risk in abstinence-based treatment and sober living, as I already knew, is that you lose your opioid tolerance, so if you do use again, it becomes very easy to overdose. Researchers have often flagged this.

In early September, just over a month after I’d last left the sober living house, I got this sudden, strong urge.

Another risk is that if you’ve been in an abstinence-based culture and committed to that, the shame you may feel if you want to get high can make you hide the fact that you’re using, and choose to use alone.

I’d been making progress in my goal, sometimes going months at a time without using anything. But someone in my life started drinking again and experimenting with drugs like cocaine, and I started to partake with her sometimes.

I still felt like I was on a positive journey. Recovery comes in different shapes and sizes, and as author Johann Hari has said, “The opposite of addiction is not sobriety. The opposite of addiction is connection.”

I was keeping it light and not causing havoc. I was also on 20 mg of methadone at the time, a medication proven to reduce risks for people with opioid use disorder. But in early September, just over a month after I’d last left the sober living house, I got this sudden, strong urge.

A friend of mine had just ordered drugs off of the dark web and offered to let me try some for free. So I taxied out to his house to pick them up. I was planning to do a speedball—still commonly defined as cocaine mixed with heroin, but which in 2024, where I live, means cocaine with fentanyl.

I still had harm reduction in mind. We have a lot more harm reduction resources in Nova Scotia than we used to. One notable thing here is that syringe service programs teamed up with pharmacies to offer free “brown bags”—essentially mini using kits with syringes, cookers, cotton filters, sterile water, tourniquets and alcohol swabs. In most cases, if you ask for a “brown bag” at a participating pharmacy, staff will offer you a free naloxone kit as well.

Sometimes, like me that day, you can’t hold off until you are in a safer place, where people are with you with naloxone.

So after I scored the drugs from my friend, I got the taxi to drop me off at a pharmacy close to where I was staying. I knew they offered the brown bags (some pharmacies choose not to, for the usual reasons). I asked the staff for a bag of long tips and went right into the bathroom.

I wasn’t sick but I was still jonesing for a shot. That’s how it works sometimes, for a lot of people. Sometimes, like me that day, you can’t hold off until you are in a safer place, where people are with you with naloxone.

In the bathroom I grabbed a cooker, a syringe and some sterile water. Then I put two little pink shards of fentanyl into the cooker with about 2 points of cocaine. I heated it up with a lighter until it was all dissolved, took a cotton filter and meticulously sucked up my shot into the syringe. Then I tied off my leg and went for my old faithful vein there. I slowly injected, saw the blood flag and pushed the syringe in.

It felt great—exactly what I expected. I got the cocaine high, and then I slowly came down. And that’s all I remember.

I woke up surrounded by paramedics, police officers and pharmacists. They’d cut off my nice Adidas track jacket and given me six vials of naloxone. They saved my life and were like humble heroes. The group acted if they did this everyday. Which they probably do.

I knew my name, where I was, and the fact I didn’t want to go to the hospital.

They’d given me more naloxone than I’d needed, when one dose is usually enough. For a lot of people this can heighten precipitated withdrawal, causing unnecessary suffering and greater risk. I didn’t get that, because I was no longer too physically dependent on opioids.

Surprisingly, I was all there when I woke up. I knew my name, where I was, and the fact I didn’t want to go to the hospital.

The police officer who’d arrived first and found me, after the pharmacy staff called emergency services, said I’d turned blue before I received the naloxone. He urged me to go to the hospital.

But I was dead set on not going. I’ve gone to hospitals after several overdoses, and been treated like a piece of garbage almost every time.

Nova Scotia is a small place, and one of the paramedics who helped save me actually remembered me from a talk I did on harm reduction. He explained to me that they had to have some kind of care plan for me where I wasn’t going to be alone. So I quickly suggested: How about the overdose prevention site?

The paramedic talked to the on-call doctor about my plan, and they were okay with it. Back in the day I probably would have been going to the police station. But that day, the police officer dropped me off at the local overdose prevention site.

This whole experience left me feeling hopeful that some of the work to change minds has finally started to kick in.

Overdose prevention centers (OPC), which have a lot of different names around the world, aren’t just places where people can use drugs without the fear of arrest or fatal overdose. They also offer many other resources, and referrals to health and social services. But my favorite part is the community connection you get there. You’re with compassionate, understanding people, who let you know you’re not alone in this battle against the drug war.

In that environment I recuperated, felt supported and left feeling well. I want to thank everyone there.

This whole experience left me feeling hopeful that some of the work many of us have done to change minds about people who use drugs has finally started to kick in.

I could feel that the people I interacted with weren’t looking down on me the way they used to. Even when I was in the back of the ambulance, before the cop was going to drop me off, the paramedic and a student were with us, and in our conversation they encouraged me to teach the cop a few things about harm reduction, stigma, language and drug use. It turned something extremely scary for me into a learning experience for all of us.

I would choose an OPC over a hospital any day of the week.

There are obvious harm reduction lessons here about vulnerability after abstinence, naloxone, using alone and the way we all treat each other.

For me, it also raises the question of why we can’t routinely offer to take people who have overdosed to an OPC, where they’ll receive the best support and won’t need to take up a hospital bed.

OPC need resources to play that role, of course, and a lot of jurisdictions still need to open them in the first place. But it’s a thought I’ll pursue. We all deserve a choice—it’s a principle of trauma-informed care—and I would choose an OPC over a hospital any day of the week.

September 23 was Medic Monday in Nova Scotia, and I want to acknowledge all the hard work of the province’s 1,300 paramedics, who between them have saved my life on multiple occasions.

Photograph by Nova Scotia Ambulance via Wikimedia Commons/Creative Commons 2.0

The post I Just Overdosed Again. This Time, It Was Different.  appeared first on Filter.

Vyvanse is the brand name for lisdexamfetamine, a central nervous system stimulant that once metabolized converts to dextroamphetamine (AKA D-amphetamine), the same active ingredient in Adderall. Both are Schedule II controlled substances, and as such the DEA decides how much of it pharmaceutical companies are allowed to produce, and how much pharmacies are allowed to carry.

The DEA unveiled the update in the Federal Register on September 5, and the order went into effect the same day. The agency is raising its aggregate production quota (APQ) for lisdexamfetamine by around 24 percent, and raised the APQ for dextroamphetamine by around 18 percent. The latter is only for use as an active ingredient in Vyvanse or generics, not for manufacturing Adderall; the DEA acknowledged that companies wouldn’t really be able to increase lisdexamfetamine production without increased access to the active ingredient.

Though The New York Times and other outlets have characterized the increase as a “potential solution,” only about 25 percent of the expanded quota is for domestic production; the rest will go to international markets where demand has increased at a faster rate. This means that for patients in the United States, the AQP increase is around 6.5 percent for lisdexamfetamine, and around 4.5 percent for dextroamphetamine.

Different pharmaceutical companies’ production methods, as well as the different individual quotas they each receive from the DEA, are all proprietary, so we can’t be sure exactly how this will math out in terms of supply availability. However, given that the FDA estimated the medical need for Vyvanse and equivalent generics increased 6 percent from 2023 to 2024, we can be pretty sure that the impact will be tiny.

Dextroamphetamine and amphetamine, which together comprise Adderall and its generics, went on backorder in October 2022. The Adderall shortage has resolved for some manufacturers—Teva Pharmaceuticals, which makes the brand-name version along with a generic, expects inventory to be fully recovered by the end of September—but not others. Meanwhile, other ADHD medications also began struggling with “low inventory,” as Vyvanse manufacturer Takeda Pharmaceuticals announced in June 2023. The DEA has previously raised the APQ for methylphenidate (brand names Ritalin, Concerta) but hasn’t yet done so for dextroamphetamine.

Manufacturers of generic Vyvanse all attributing their shortages to caps on the active ingredient.

Vyvanse went generic in August 2023 when Takeda’s patent expired, and nearly a dozen companies now manufacture a generic version. But because the DEA also caps dextroamphetamine for those manufacturers, soon they were reporting shortages too. In July 2024, the FDA advised the DEA that all manufacturers of generic Vyvanse were attributing their shortages to a shortage of the active ingredient.

A few weeks before Vyvanse went generic, the FDA and DEA published a joint letter disclosing that Adderall (and generic) manufacturers were only filling about 70 percent of their quotas.

“This is not a problem that the FDA and DEA can solve on our own,” the agencies wrote. “The FDA and DEA do not manufacture drugs and cannot require a pharmaceutical company to make a drug, make more of a drug, or change the distribution of a drug.”

For however long the DEA is allowed to exist, it will never be able to make a claim so far-fetched that news outlets don’t just take it at face value. This is how media has sort of arrived at a narrative that includes the DEA trying its best to increase the nation’s supply of popular stimulants while the pharma companies involved are just like, not interested in the idea.

Each year the DEA assigns unilateral, arbitrary restrictions to controlled substance manufacturers that hinder full-scale production, and incorrectly forecasts how much product pharmacies will need to meed demand. It could solve the problem, on its own, by not doing that.

Top image (cropped) via United Stated Drug Enforcement Administration. Inset graphic via Substance Abuse and Mental Health Services Administration.

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The ONDCP plan had a “Harm Reduction” section alongside a handful of others like “Supply Reduction and Trafficking” and “Treatment.” When the first progress report was published in 2023, the harm reduction updates weren’t particularly interesting but did address the priorities in the original plan. In the 2024 update, harm reduction has been pared down to one paragraph each on fentanyl test strips, naloxone and a CDC page on polysubstance use that doesn’t discuss meth.

Chemsex Pilot

The first harm reduction priority outlined in the 2022 plan was developing a pilot program aimed at “the at-risk group men who have sex with men (MSM) who use methamphetamine or other psychostimulants, but do not yet meet criteria for stimulant use disorder.” It was supposed to “incorporate” people with lived experience—presumably not just as participants—and some form of HIV services.

By 2023, this had turned into one clinical trial which had already wrapped up several years earlier, and two about PrEP and contingency management. Both of those are still ongoing, but the June 2024 update doesn’t mention them. The original pilot program seems forgotten about.

Fentanyl Education

The next priority from 2022 was some sort of “fentanyl awareness effort” aimed at people who use meth. The 2023 update discussed the Centers for Disease Control and Prevention “Stop Overdose” website, and its separate Stimulant Guide.

That guide is probably one of the better government resources on stimulants to date, but none of the CDC’s stimulant-specific materials made the 2024 update. The only thing that remains is the polysubstance use page from CDC’s “Stop Overdose” site, which only mentions meth to state that it’s an example of a stimulant. 

Naloxone

The harm reduction priority that got the most space in the 2023 update was naloxone distribution in regions with higher rates of meth use. But this was essentially filler, cribbed from other federal-level naloxone access efforts, with no mention of how they’d be adapted to meth-use communities or even why they’d be a good fit in the first place. The exception was Indian Health Service “assessing methods of distributing naloxone to impacted regions, especially areas with high concentrations of methamphetamine use.”

In the 2024 update, this has all been condensed to a paragraph about Naloxone Safety Net Pilot Program for Indian/Tribal/Urban health centers.

Meth Antagonists

The 2022 plan directed various federal agencies to support research and development of “an antidote, reversal agent or better means of managing methamphetamine overdose or toxicity.” This translates to something like a meth version of naloxone. But by the 2023 update, this was mostly about the National Institute on Drug Abuse fund meth vaccines that were already under development.

That update did also describe one meth overdose reversal agent that was already in development, but overdose is not the aspect of meth use that could use medications in development—that would be stimulant agonist medications, for something a bit more like a meth equivalent of buprenorphine. Yet the 2024 update continues going in this direction, except it’s moved everything to the “Treatment” section.

Fentanyl Test Strips

The final harm reduction priority in 2022 was to build drug-checking capacity at syringe service programs, mostly through fentanyl test strip (FTS) distribution. 

“SAMHSA is tracking promising practices such as mass spectrometry testing,” the ONDCP stated that year, “which are more sophisticated and sensitive than fentanyl test strips and can also detect the presence of non-opioid threats, such as xylazine.”

Ideally federal agencies would be tracking these practices closely enough to know that “mass spectroscopy” technically does not encompass the drug-checking equipment they’re talking about (Fourier-transform infrared spectroscopy). FTS are actually more sensitive than the fancier forensic drug-checking equipment, not less. And they cannot detect all opioids—only fentanyl and its analogs, so they don’t detect e.g. heroin or nitazenes. But none of those are really the problem here.

What’s more likely to be a problem in real life is that FTS instructions aren’t written for meth, and the water dilution has to be properly adjusted otherwise they’re extremely likely to produce false-positives. The fentanyl awareness efforts could have at least included that.

Image via New York State

The post White House Meth Plan Still Includes Harm Reduction, Just Not for Meth appeared first on Filter.

The CDC projects that 107,543 US residents died of overdose in 2023, down from over 111,000 people in 2022. (The number of confirmed deaths is lower, because death investigations are often ongoing, so the agency uses a method to project a final number.)

A big question is whether this decrease, the first since 2018, is the start of a new downward trend, or just a temporary fluctuation. Either way, it’s still a full-on crisis. In 2015, over 52,000 people died of overdose, and total deaths increased in almost every subsequent year—with a major spike in 2020, as the COVID-19 pandemic took hold. The record high to date came in 2022.

Total projected overdose deaths declined in many states in 2023. The biggest drop by percentage was seen in Nebraska, followed by Indiana, Kansas, Maine, North Carolina and Arkansas. But many states saw increases, especially in the West. The biggest percentage increases were in Alaska, followed by Oregon, Nevada, Washington State, Alabama, Utah and Hawaii. Deaths also increased in Washington, DC.

“What we’re seeing in the regional variation is a response to the shifting drug supply.”

“What we have to remember is the emergence of fentanyl west of the Mississippi is something that started before COVID, and really took off during the early years of COVID,” Dr. Sheila P. Vakharia, deputy director of research and academic engagement at the Drug Policy Alliance, told Filter. “What we’re seeing in the regional variation is a response to the shifting drug supply … Here on the East Coast, we saw that shift unfold between 2014 and 2017. [Western states] are just seeing it now a few years later.”

The CDC data also indicate which drugs are involved in deaths. “Synthetic opioids,” including fentanyl, remains the most frequent drug category involved, with over 74,000 instances. This has been the case for years, with fentanyl-involved deaths rapidly rising since 2015. The next next category is “psychostimulants,” including methamphetamine, which were reportedly involved in about one in three overdose deaths. This continues a trend of steady increase since 2015, though at a slower rate than with synthetic opioids. Cocaine is the next substance most frequently involved in deaths, at over one quarter of the total. Most other substance categories remained flat or declined slightly—like heroin, which was involved in fewer than 4 percent of deaths, continuing a steady decline since 2017.

But these figures are an oversimplification. The CDC doesn’t yet tell us how many people had used two or more drugs at the time of their death. Such information won’t be available for at least several more months as the CDC compiles and cross-references death certificates. It’s a big current blind spot; one North Carolina study published in 2021, for example, found that over a decade, more than half of opioid-involved deaths and one fifth of non-opioid-involved deaths had more than one substance present.

The current US overdose crisis is a polysubstance phenomenon, Dr. Vakharia noted, which complicates perceptions. “Some people interpret these polysubstance deaths as pure contamination deaths,” she said, “[it’s] this fear of fentanyl adulterating cocaine and meth, and these opioid-naive users dying. What the actual data tells us is, when testing seized samples from the street or users, fentanyl contamination is relatively low and it’s likely people are [deliberately] using these drugs together or within a timeframe before the death, so they test positive for both.”

The small decrease in overdose deaths is unlikely to fall equally among all racial and ethnic groups. We don’t yet have a full demographic breakdown in the CDC data, but Vakharia theorized that overdose deaths may have decreased primarily for white people, while increasing for Black, Hispanic and Latino, and Indigenous people. Research indicates a similar phenomenon in 2017-2018, the last time overdose deaths decreased. And in 2022, the most recent year with full CDC overdose data available, fatal overdose rates increased for all racial and ethnic groups except non-Hispanic white, Native Hawaiian and Pacific Islander people.

“Sadly, we still have so many states where paraphernalia laws mean that harm reduction programs can’t give out safer smoking equipment.”

As deaths involving stimulants continue to increase, it’s important that harm reduction efforts don’t focus solely on opioids. But this expansion faces barriers.

“Sadly, we still have so many states where paraphernalia laws mean that harm reduction programs can’t give out safer smoking equipment to engage stimulant users in harm reduction,” Vakharia said. “I think we haven’t seen enough movement to decriminalize safer smoking equipment so we can bring them into programs where they can learn about fentanyl test strips, naloxone, get support and get help.”

There are also currently no medications like buprenorphine or methadone to treat stimulant use disorder. Some progress is being made here, but Vakharia said it must be sped up. Meanwhile, there are many steps state governments should take to facilitate harm reduction for people who use stimulants.

Vakharia also warned of the consequences of widespread actions by state and local lawmakers, both Republicans and Democrats, to shut down or weaken harm reduction programs.

Idaho lawmakers, for example, have advanced a bill to repeal its syringe exchange law; there’s an ongoing political and bureaucratic attack on syringe providers throughout West Virginia; Philadelphia’s mayor is refusing to use opioid settlement dollars to fund syringe service programs; and New York’s governor has rejected the use of opioid settlement funds to roll out overdose prevention centers.

Federal lawmakers, too, continue to implement damaging and misguided policies, at a time when wider access to lifesaving health care and harm reduction services must remain an urgent priority.

Photograph by Nathan Rupert via Flickr/Creative Commons 2.0

Dr. Vakharia is a member of the board of directors of The Influence Foundation, which operates Filter. The Influence Foundation previously received a restricted grant from the Drug Policy Alliance.

The post Overdose Deaths Fell Slightly in 2023, Per CDC, But Emergency Continues appeared first on Filter.

Stimulant overdose doesn’t cause physical harm nearly as often as people think, but it does cause serious harm all the time when law enforcement gets involved. This is why stimulant harm reduction fits synthetic cannabinoids as well as it fits coke or meth.

Synthetic cannabinoid receptor agonists (SCRA) are known by a wide variety of nicknames across the country, but people are often familiar with them as either “K2” or “Spice.” Or “strips,” as they’re often known in prison drug supplies, though the term can describe papers coated with anything from Suboxone to meth to insecticide, or mystery substances that are sold as mysteries. SCRA don’t really have anything to do with the cannabis that comes from the plant; they just share the name because they both interact with your cannabinoid receptors.

In some cases people use SCRA because they have legal access. Even though many SCRA have been progressively banned at federal or state levels, beginning with the Synthetic Drug Abuse Prevention Act of 2012, there are too many ever-evolving chemical compounds to ban them all. This means that SCRA can’t be easily identified with urine drug screens compared to most other banned substances, which is why they’re very often used by people who don’t have legal access to any drugs. People who are under some form of state supervision, such as methadone maintenance programs, drug-sentencing alternative programs, parole/probation and especially incarceration.

Dosing

SCRA have been a mainstay in prison and jail drug supplies for several years. The Iron Law of Prohibition—“as law enforcement becomes more intense, the potency of prohibited substances increases”—often doesn’t apply to synthetic drugs entering the supply, because there are so many new kinds that the potency is all over the place. But the concept definitely applies to strips, and to any drugs being used inside prisons.

“Start low, go slow” is common harm reduction advice because one of the main risks of using any unregulated drug is that people almost never know how much they’re using at a time. But it’s an especially big problem with SCRA strips. For a basic example, a strip that got one coat of SCRA might make someone hallucinate like a psychedelic high, while a strip that got two coats of the exact same thing might make them fall out like an opioid high.

The effects can vary so much from one strip to the next, so it’s natural to assume that different strips contain different kinds of SCRA—especially if they came from different places. And sometimes the difference does have something to do with the chemical compounds themselves. But usually the reason some SCRA strips seem stronger or weaker than others, or act like “uppers” while others act like “downers,” has more to do with how much is on them, rather than what is on them. 

Seizures and Passing Out

SCRA can sometimes cause seizures. The important thing to know is that these almost always resolve on their own within a couple of minutes. It helps to stabilize the person’s head, and get any sharp objects out of the way.

Seizures from meth or cocaine don’t cause any physical damage to the person experiencing them, and this generally appears to be the case with SCRA. But there is a lot more room for the unknown, since the effects of SCRA aren’t as well-established as they are with the drugs we typically think of as stimulants.

Respiratory depression from using SCRA isn’t nearly as likely as it with opioids, but it is possible. A lot of substances that work as uppers, including stimulants, turn into downers when taken at higher doses. If someone falls out after using what they believed to be SCRA, the important thing is to monitor their breathing. If they’re breathing on their own, at least eight-ish breaths per minute, they’ll be alright to just sleep it off. Put them in the recovery position; SCRA toxicity does make people puke sometimes.

“Bugging Out”

The way “overdose” usually refers to opioids, and the slightly more niche “overamp” refers to stimulants, in prisons the term for SCRA toxicity is often “bug-outs,” or “epees” (short for “episode”). These often involve hallucinations and a break with reality, but only for relatively short periods—maybe 10 minutes or so.

In both prison culture and outside culture, any kind of overdose is assumed to be a sign of addiction. But opioid overdose still prompts a certain amount of sympathy, even from those who view drug use as a moral failing. Stimulant overdose, including from SCRA, is where things diverge.

Because the principal harms of these overdoses come from criminalization, harm reduction on the outside involves the fairly straightforward step of not calling the cops. In prisons, where people are already surrounded by cops all the time, there’s the potential for harm no matter what you do.

If someone uses SCRA and starts loudly hallucinating, they’re likely to get beat up later by other prisoners in their living unit. Attracting the attention of corrections officers often gets others in the vicinity punished too, so it isn’t tolerated regardless of the outcome of an individual incident. 

If someone’s cellie uses SCRA and starts puking or having a seizure, and they call an officer for help, they’re likely to get beat up for the exact same reason. It’s not uncommon for various groups in prisons, including gangs, to have explicit rules against calling officers for help when the situation involves drugs. Meanwhile, corrections departments often have rules that if someone is found to be using drugs, their cellie is guilty by association, unless the cellie was the one to report it.

The best way to navigate this aspect depends entirely on the specifics of the facility and individual people involved. But it’s often just a no-win situation.

Photograph via Pennsylvania Department of Corrections

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CM is based in the idea of positive behavioral reinforcement. Two or three a week you go to a clinic and pee in a cup, and if the results are negative for cocaine and methamphetamine you get some small incentive like a $10 gift card. Some programs use different structures, but generally if the urine sample is negative for stimulants at consecutive appointments, then the incentive value goes up a teeny increment. If the results are positive for stimulants, or you have an unexcused absence, the value resets.

Some programs offer peer support and don’t require participants produce stimulant-negative urine drug screens (UDS) if they want to keep showing up even without the incentives. But often CM is pretty infantilizing, what with the baked-in premise that drug users are not to be trusted with money.

Everything about CM is designed around abstinence. Some CM programs for other behaviors, like cigarette smoking, use tests that can measure decrease in use. But cocaine and methamphetamine programs all hinge on UDS, which only measure use as “Yes” or “No.” In a paper published April 16 in the journal Addiction, researchers argue that it’s time to modify stimulant CM for harm reduction.

“Given rising prevalence and lethality of stimulant use, the preference for harm reduction versus abstinence-only approaches and substantial research showing the efficacy of CM, we propose that it is time to consider updating CM protocols,” the paper states. “Additionally, rising and more lethal stimulant use lends urgency to the need to make CM widely accessible.”

The proposed changes include making UDS easier for providers to access, developing new ways to monitor changes in use, not resetting the incentives as low in the event of “relapse,” and a robust marketing campaign—commercials, infographics—to increase demand.

Urine drug screens aren’t conducive to measuring changes in drug use.

The main barrier to CM being widely accessible is bureaucratic, and it’s unclear whether a harm reduction version would move things along any faster. A lot of providers rely on State Opioid Response funding, and while SAMHSA allows those grantees to put the funds toward CM it also caps the incentives at $75 per participant. CM programs are time- and labor-intensive to complete, and don’t really produce results when they can’t offer participants at least a few hundred dollars. Medicaid doesn’t cover CM, and so far the Centers for Medicaid & Medicare Services has only approved reimbursements for programs in California, Washington and Montana.

A lot of the other barriers are related to the UDS. CM involves much more frequent testing than what Medicaid would cover. Even as more states get CM approved for Medicaid coverage, providers have to apply for a FDA laboratory waiver in order to get reimbursements for administering the tests.

Beyond that, UDS themselves just aren’t conducive to measuring changes in someone’s drug use over time. Urine testing is qualitative, not quantitative—the results don’t indicate how much of a substance is detected, just whether it’s there or not.

A harm reduction CM program wouldn’t need harm-reduction versions of drug tests. It would get rid of them.

The authors noted that in some CM programs for cigarette smoking, reduction in use had been measured through carbon monoxide detection during breath sampling. They called for “investing in research to develop rapid point-of-care tests that can detect reductions in stimulant use in addition to abstinence, which would allow CM protocols to incentivize both, albeit to differing degrees.”

Aligning with harm reduction principles doesn’t mean lowering barriers to UDS so they’re more accessible to providers, or developing oral fluid tests to monitor changes in use. A harm reduction CM program wouldn’t need harm-reduction versions of drug tests. It would get rid of them.

A CM program modified for harm reduction would probably incentivize appointment retention, then give people transportation vouchers and not penalize them for appointments they miss. It would include education on safer stimulant use, or how to respond to overamps, or how to properly dilute stimulants when using fentanyl test strips to avoid the false positives issue. It would also ask participants their goals, rather than assign them.

“Incentivizing outcomes such as attendance or harm reduction activities in addition to abstinence also has downsides,” the authors state in the paper. “Specifically, incentivizing multiple behaviors at the same time can decrease CM efficacy and increase both incentive costs and protocol complexity, such that CM is more challenging to implement and requires additional clinician training and supervision.” They conclude more research is needed.

Nothing about CM actually requires UDS. Its basic principles are about positive reinforcement. The reason it’s difficult to conceive of a program incentivizing anything other than abstinence is that ideologically, stimulant CM is rooted in the drug-testing more than in the incentives.

Abstinence frameworks are often friendly toward harm reduction because they confuse it with use reduction.

Many people do have good experiences with CM, but broadly speaking there’s a lot more enthusiasm for these programs in academia and public policy than there is among participants. Can we take a treatment structured entirely around abstinence and, with enough research and labor and advertising, contort it into something slightly closer to harm reduction? Sure. But … why.

Despite the narrative of an increasingly lethal stimulant supply, it’s a shaky conclusion to draw from overdose mortality data. “Stimulant-related” or “stimulant-involved” deaths don’t mean stimulants were the underlying cause. More people are using stimulants than they were a few years ago, so more people have stimulants in their system at the time they die. There are definitely some people dying as a direct result of stimulant use, but not the way academia and media and law enforcement make it sound.

Some of the opening statistics from the Addiction paper, for example, cite data on the growing subset of overdose deaths that involve fentanyl. In 2021, 47-ish percent of fentanyl deaths also involved stimulants. Overdose from stimulants alone, meanwhile, had “remained relatively more stable, from 14.8 percent in 2010 to 17.9 percent in 2021.”

The Addiction paper characterizes this by saying the “mortality rate associated with stimulant use has increased 50-fold,” and that “stimulants alone or in combination with fentanyl” were involved in nearly half the overdose deaths recorded in 2021.

Tere’s not much appetite for stimulant agonist medications because the broader public does not like the idea of stimulant users having stimulants.

A lot of the claims, both about the lethality of stimulants and the efficacy of CM, present the data similarly. The authors told Filter that they “believe that these are accurate statements given the evidence presented.” This isn’t egregious, because it’s the norm to cite stimulant data this way.

There are a bunch of reasons the Food and Drug Administration hasn’t approved any SUD medication equivalent to methadone or buprenorphine—stimulants are pharmacologically more complex than opioids, their withdrawal process less visible—but one reason is the level of hate and fear is stoked around cocaine, and especially meth. There’s not much appetite for stimulant agonist medications because the broader public does not like the idea of stimulant users having stimulants. So now the public thinks that fentanyl is in everything, but that just as many people are dropping dead from stimulants alone, and that the most promising thing we can offer them is a short-term abstinence intervention that doesn’t address anything else going on in their life.

Abstinence frameworks are often friendly toward harm reduction because they confuse it with use reduction. But harm reduction is effective because it’s premised in safer use, and the understanding that people need more than one thing at a time, especially if their use has increased. Which is different than collecting bodily fluids and telling anyone whose use has gone up that they don’t get a prize.

Photograph via Kastalia Medrano

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This is partly because the Food and Drug Administration has not yet approved any medications for stimulant use disorder (SUD), so the binary of abstinence versus use is more intact compared to opioid use disorder. It’s also because stimulant withdrawal is so poorly understood by researchers and clinicians. And it’s because SUD treatment is mostly housed inside the criminal-legal system, where its success is determined with urinalysis results that are binary by design. No one in a position to strip bodily autonomy from stimulant users is going to factor in whether they’re using less than before, and it’s unheard of if the stimulant is meth.

An analysis of 13 studies on pharmacological interventions for SUD, at a “wide range of treatment facilities,” is one of very few where researchers looked at reduction in addition to abstinence. They found that while abstinence is associated with the greatest clinical improvements, reduction in use is associated with enough improvement to be considered a valid outcome. The new study, funded by National Institute on Drug Abuse, was published in Addiction on January 10.

“If somebody is working towards trying to be abstinent, but they’re struggling with that, this is a hopeful sign that we can see meaningful improvement along the way,” NIDA Deputy Director Dr. Wilson Compton told Filter. “Because the study also clearly shows that abstinence has more clear association with the positive outcomes than reduced use. But the real new information is that reduced use was so strongly associated with the improved outcomes as well.”

If you’ve been using meth or cocaine less than four days a month, it isn’t necessarily a big jump to go a month without it.

Abstinence has always been the treatment goal assigned to stimulant users whether they want it or not, but belief that it represents a bigger change than reduction in use isn’t necessarily true. The Addiction research, for example, quantified reduction as moving from high-frequency use (5-plus days per month) to low-frequency use (1-4 days per month) over a 30-day period, which makes the results a bit complicated.

If you’ve been using meth or cocaine less than four days a month, it isn’t necessarily a big jump to go a month without it. This means that the people who made it into the “abstinence” category were likelier to be people whose SUD complications weren’t as severe as those who landed in the “reduced use” category. Meanwhile, you could have gone from injecting an eight-ball of meth every day to just stirring a teensy bit into your coffee on the weekends and not even have made it into the reduced use category in the first place; the data would show you’d made no change.

“Abstinence is an easier thing to quantify,” Compton said. “Because when you say ‘reduced use,’ the question is always, ‘Well, how much does the reduction have to be before you see an improvement?’ And abstinence is pretty straightforward. So I understand the appeal of an abstinence measure.”

The researchers evaluated improvement according to clinical indicators drawn from the Addiction Severity Index. These include other illicit drug use; alcohol use; legal status; psychiatric status; and status of interpersonal relationships. The original ASI also has medical status and employment/financial support status, but the authors didn’t include those on the grounds that they “tend to stay stable over a short period of time.”

Short data-collection periods are the universal downfall of research on SUD treatment outcomes. A 30-day window probably isn’t representative no matter which part of your life you’re looking at, but employment status is something drug users do tend to find subject to sudden changes. The study authors did not respond to Filter’s request for comment.

If people wanted something even easier to measure than abstinence, and also more relevant to stimulant users specifically, there is an obvious one.

A recurring argument against using reduction as a research metric is that it’s is a difficult thing to measure. People lean on this argument both because it’s true and because it tends to preempt questions about how difficult, exactly, but nothing’s easier to measure than abstinence and so none of the rest really matters. Urine drug screens will always be quick and easy to read.

“If you cut back from smoking two packs a day to smoking one-and-three-quarters packs a day, obviously that’s a reduction,” Compton said. “But is that enough to see your risk of lung cancer or your risk of heart disease or your asthma problems or all the other issues related to tobacco use to be reduced?”

If people wanted an objective metric that was even easier to measure, and also more relevant to stimulant users specifically, the obvious one would be criminal-legal system involvement—especially if measured on the scale of years rather than weeks. Instead we keep saying the harms of stimulant use are medical, and cite the death data that’s deeply mischaracterized or cardiac strain that wouldn’t be statistically significant if we weren’t looking for ways to present cocaine and meth use as bad.

The publication years of the 13 studies selected average out to around 2010, and don’t include anything more recent than 2017. The “wide range of treatment facilities” doesn’t refer to the environments most drug users probably call to mind, but to clinical trials treating SUD with various psychiatric medications or muscle relaxants. But none of this is unusual, nor will it prevent the research from hopefully having a positive impact.

It’s worth pointing out the places where SUD research could be a bit more representative, because almost no one ever does it, but this doesn’t mean the Addiction research isn’t very good news for stimulant users. It is. So is the fact that NIDA is actively supportive. The utility of research like this is that it’ll be a supporting citation for eventual change at the policy level, rather than something that impacts present-day stimulant users one way or the other.

Photograph courtesy of Kastalia Medrano

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Due to numerous factors which they could only control for to some extent, the researchers warn that their work mustn’t be read as a definitive measure of stimulant purity in the United States. What they can say is that their findings run counter to the narrative that “fentanyl is in everything,” Colin Miller, community liaison with the University of North Carolina’s Street Drug Analysis Lab and a coauthor of the paper, told Filter.

Fentanyl appeared in 8.9 percent of meth samples, and 21.5 percent of cocaine samples. However, there were many caveats.

The researchers tested 718 samples of cocaine and methamphetamine from 77 harm reduction organizations and clinics in 25 states between May 2021 and June 2023. The samples were initially sent to the UNC Street Drug Analysis Lab, where gas chromatography-mass spectrometry was used to check for the presence of fentanyl.

Fentanyl appeared in 8.9 percent of meth samples, and 21.5 percent of cocaine samples. However, there were many caveats to these numbers. Deploying statistical adjustments to account for them, the team then arrived at 6.2 percent for meth and 12.6 percent for cocaine—or roughly one in 10 overall.

Karla Wagner, a professor at the University of Nevada, Reno’s School of Public Health and a coauthor of the paper, explained to Filter that the team adjusted the numbers to account for various confounding issues that could have made fentanyl appear more frequently. (Again, she cautioned, even after these adjustments, the numbers are not meant to be representative.)

Some of these confounding issues are fairly simple. For instance, people would probably be more likely to send in samples for testing if they suspect they contain fentanyl. This might be because they used a fentanyl test strip—which has a chance of producing a false positive—or, in some cases, because after using some of a batch of a stimulant, they felt tired or passed out.

However, the nature of different meth batches, in the absence of fentanyl, might sometimes explain this, described Phillip Fiuty, another coauthor of the paper and technical advisor for adulterant checking programs in New Mexico for the global public health organization Vital Strategies.

“I think there’s a whole confluence of things kind of feeding the situation.”

Other confounding factors the researchers tried to account for include, for instance, the fact that samples only came from around half of all US states.

“I think there’s a whole confluence of things kind of feeding the situation,” Fiuty, who has lived experience of drug use, told Filter.

Miller, who also has living experience with drug use, noted that the number of organizations sending drugs in for checking has grown to more than 160 across more than 30 states since the team performed the research, which should bolster future understanding. He added that there are, of course, cases in which fentanyl appears in batches of stimulants, but that the belief it’s extremely common isn’t necessarily justified.

Parts of the country are seeing more deaths where both stimulants and opioids were present. But Miller pointed out that this doesn’t demonstrate the opioids are appearing as adulterants in meth and coke, when polydrug use is the norm.

“You always have your sort of opiate purists, and sometimes your methamphetamine purists,” he said. “But for the most part, people are going to be using different substances simultaneously.”

At the same time, observers have argued, while accidental cross-contamination from sources selling more than one substance can happen, there’s no incentive for trafficking organizations to deliberately add fentanyl to stimulants. That won’t give the stimulant effects that some buyers solely want, wrote Jonathan Kirkpatrick for Filter, and most polydrug users prefer to measure their own combinations.

The narrative of deliberate contamination is “distorting the actual facts and our ability to respond sensibly with data-driven policies.”

Wagner said that the narrative of deliberate contamination is driving some parts of the US to implement harsher drug laws, such as increased penalties for fentanyl possession and drug-induced homicide laws.

This narrative is “distorting the actual facts and our ability to respond sensibly with data-driven policies,” she told Filter. She added that incarceration, and a drop in tolerance, can lead to more fatal and non-fatal overdoses—and that when drug markets can shift extremely quickly, regulations and policies that target specific drugs will end up obsolete.

Wagner acknowledged that a figure of roughly one in 10 stimulant samples containing fentanyl—while not representative—is concerning.

But taking a harm reduction approach which prioritizes safer supply programs, real-time drug checking services and overdose prevention centers is far better than crackdowns, she said. She recommended that people who use drugs test their batches as much as possible, and that they, their friends and family, and other members of the public get trained to recognize opioid-involved overdoses and to use naloxone.

Correction, December 20: This article has been edited to correct the description of Phillip Fiuty’s role with Vital Strategies.

Photograph of cocaine by Marco Verch Professional Photographer via Flickr/Creative Commons 2.0

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