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Frankfort, Ky.–Governor Matt Bevin says first responders in parts of Kentucky are receiving doses of Narcan to help fight drug overdoses.

EKBtv reports

A partnership between state officials and AETNA will give 720 doses of the medication to first responders in northern Kentucky and Appalachian regions in an effort to prevent drug overdose deaths.

Drug overdose deaths in Kentucky soared to unprecedented levels in 2016 .. jumping seven point four percent .. according to a report from the Kentucky Office of Drug Control Policy.

 

A Fredericton man on trial for drug trafficking in connection with a pill containing fentanyl that was found in Esgenoôpetitj First Nation last spring told police a “new breed of Percocet” was causing people to overdose, the courtroom heard  Thursday.

CBC Canada reports

Jesse Joe, 35, admitted during a statement to police that he’d been in possession of blue Percocet pills, said Crown prosecutor Caroline Lirette.

Joe told RCMP “shit started happening” on April 8, the first day he returned to his home community of Esgenoôpetitj, and four people “dropped” after he got back, said Lirette.

On April 11, a woman suffered a fatal overdose in the community east of Miramichi.

Police later seized a blue pill that had “Percocet 5” written on it.

A Health Canada analysis confirmed the pill contained fentanyl, a prescription painkiller the agency has described as being about 100 times more powerful than morphine.

When Joe was charged, police said several people from Esgenoôpetitj had been hospitalized for suspected overdoses of fentanyl.

Police were still awaiting toxicology results in the fatal overdose on April 11 of  Ann Marie Lambert, the 35-year-old mother of a young son, they said at the time.

Drug

An analysis conducted by Health Canada confirmed a blue pill seized by the RCMP on the Esgenoôpetitj First Nation contained fentanyl. (RCMP)

Joe’s statement to police was admitted into evidence on Thursday morning, the second day of his trial at Miramichi provincial court trial.

Judge Geri Mahoney ruled following a voir dire that the statement was admissible. Police neither threatened him to get the statement, nor made promises of a reduced sentence, the judge said.

The trial was scheduled to continue on Aug. 30 and 31, but wrapped up on Thursday.

A date for a decision will be set on Aug. 30 at 9:30 a.m.

Joe is also scheduled to face a bail hearing on Aug. 30 at 3 p.m. on seven new charges. They include trafficking in fentanyl, criminal negligence causing bodily harm, three counts of trafficking in a controlled substance, as well as obstruction of justice and breach of probation.

The Crown has declined to comment on whether those charges are related to the overdoses in Esgenoôpetitj.

 

Prescription drug monitoring programs (PDMPs) are state-based data banks that track opioid and other controlled substances prescribed by healthcare providers and filled by patients at pharmacies. They are supposed to cut down on the abuse and overuse of such substances by reducing the rate at which physicians prescribe opioids. While many policy makers think they’re a great idea, they may be actually contributing to the rise in opioid overdose deaths.

The Hill reports

PDPMs have been operating in most states for several years, and although the number of opioids prescribed are indeed decreasing, the death rate from opioid overdoses keeps climbing at an alarming pace, with a reported 200 percent increase between 2000 and 2014. Indeed, the most recent data from the Centers for Disease Control and Prevention (CDC) is telling; it appears that overdoses from prescription opioids are stabilizing or even waning, while overdoses from heroin are dramatically increasing.

One reason may be that heroin is cheaper than ever on the black market. In 2015 the CDC reported a record high 33,000 opioid overdose deaths, the majority of which were from heroin. But another reason may be that physicians are reticent to prescribe opioids to those who legitimately need them, forcing their patients to turn to the black market.

And PDMPs likely share some of the blame, although they were created with good intentions. California established the first PDMP in 1939, and by 1992 10 states had PDMPs in operation. Different states had different designs in their programs and they varied in their methods of operation, even though they all shared the goal of diminishing drug abuse and diversion, i.e., the movement of prescription drugs from the patient population into the recreational user community.

Today 49 states have PDMPs at various levels of development. The only holdout is Missouri. There, legislators led by State Senator Robert Schaaf, a family physician, have obstructed the legislature’s attempts to establish a monitoring program on the grounds that it might risk patient privacy.

My state’s PDMP has been operated by the Arizona State Board of Pharmacy since 2008. All federally licensed narcotics prescribers must participate. Their prescribing data are kept in the monitoring program, inaccessible to the general public in order to protect patient privacy.

Providers receive quarterly “report cards” comparing them to their peers in their specialty with respect to the number of times per month they prescribe various opioids, benzodiazepines, and other controlled substances. They are classified anywhere from normal to outlier to extreme outlier.

At this point the report cards are for informational and educational purposes only. Starting in October, however, Arizona will join at least 16 other states in requiring providers to first check the PMDP database on their patient in most cases before being allowed to prescribe an opioid for that patient.

Yet, even before this policy takes hold, the PDMP has significant effect on prescribers. Aware that they are under surveillance, no provider wants to be seen as an outlier. There’s no telling what the long-term consequences might be for a provider with that label. I’ve spoken with practicing physicians across my state, and all of them agree that it’s disconcerting to have “big brother” looming over their shoulders in this manner.

The ensuing chilling effect on the prescribing of opioids has led doctors to cut off some of their patients who are honestly in pain — and some of whom may have developed a physical dependence, but not an addiction (there is a difference), leading some of them to seek relief in the illegal drug market. The CDC data showing an increase in the number of heroin overdoses and a slowing in those from prescription drugs appear to bear this out.

This calls into question the value and effectiveness of PDMPs. PDMPs might succeed in making healthcare providers more frugal prescribers of narcotics. But they may also be sending more patients, in desperation, to the illegal drug market where they obtain opioids that may be counterfeit, laced with dangerous and more powerful drugs such as fentanyl and carfentanil, and where they may opt for heroin because it is actually cheaper and easier to obtain than prescription opioids.

study released in May 2017 lends credence to this theory. Researchers at the University of Pennsylvania and Pennsylvania State University used data from all jurisdictions, as well as from the Centers for Disease Control and the US Census Bureau, to examine the effect of all PDMPs from 1999-2014. They concluded that, “PDMPs were not associated with reductions in drug overdose mortality rates and may be related to increased mortality from illicit drugs and other, unspecified drugs.”

To be sure, PDMPs may serve a useful adjunct to the healthcare practitioner. Knowledge of a patient’s prescription drug history can be very helpful not only when deciding whether to prescribe a narcotic, but also whether to have a serious discussion with a patient about that patient’s possible drug dependency. But this should be at the discretion of the doctor.

There are many cases in which the provider knows the patient quite well, and a check of the database amounts to nothing more than a nuisance. And provider report cards that carry the risk of an outlier accusation probably only serve to exacerbate the opioid overdose problem.

 

Mercury News

Everyone knows cigarettes can kill. Yet 36.5 million adults in the U.S. still smoke.

So after the labels and warnings, the restaurant bans and the grisly ad campaigns, the Food and Drug Administration is exploring a radical approach to helping people quit: regulating nicotine in cigarettes. If the FDA follows through — something far from certain — the shift could prompt some to quit or, at least, switch to relatively safer products like electronic cigarettes or vaping.

Peruz Nazli, who sat on a bench near New York’s Central Park with cigarette butts around her feet, said she was delighted when she heard about the agency’s plans.

“It’ll be easier to quit,” said the 59-year-old retail worker, who started when she was 14. “People look at us different.”

The FDA’s initiative may upend the $130 billion American tobacco industry. It’s also likely to set off a ferocious lobbying and legal war in Washington, and push the cigarette industry to develop products that rely less on burning carcinogenic tobacco and more on delivering doses of nicotine through cleaner vapor. Smoking-related illnesses cost $300 billion a year, according to the Centers for Disease Control and Prevention.

Interviews with New York smokers suggested that few had taken notice of the proposal announced last week, but many said they would be more likely to switch to new delivery devices than to smoke diluted cigarette after diluted cigarette. Some have already made the change.

Kevin Cleare, 36, who picked up his first cigarette from a junior-high buddy when he was 13, turned to vaping three years ago on his doctor’s advice.

He quit smoking cigarettes for the first time three years ago but resumed for a few months amid a stressful breakup before turning to vaping. Now he’s “never going back,” and vaping looks like a long-term option.

“I’m so disgusted with cigarettes — the smell, the taste,” he said. “This is a fair, reasonable compromise.”

Over the past decades, U.S. regulators have banned smoking in many public places, sending smokers outside or into isolated corners. The rate of adult cigarette use has declined by a quarter since 1965 to only 15 percent, according to the CDC. Teens foresee life as a pariah and turn elsewhere, with daily smoking among high school seniors down to 5.5 percent in 2015.

Kids look at smokers and say, “You’re crazy. What are you doing?” said Cleare, who works with teenagers at the New York City health department.

Encouraging the remaining wannabes to suck on vape gizmos that resemble digital tape recorders is a planned inconvenience.

“This is just another way in making it less satisfying,” said Douglas Kamerow, a senior scholar at the Robert Graham Center for Primary Care Policy Studies in Washington.

Those who stick with cigs are an increasingly gray crowd.

After emerging from a Mercedes-Benz onto a Brooklyn curb, Trevor Carter reached for a cigarette. The car belongs to his daughter. In the back seat is his grandson.

Carter, 68, has smoked for 50 years, a habit he says is harder to break than cocaine or booze, both of which he kicked. If the retired businessman doesn’t give up smoking by year-end, he said, his girlfriend will dump him.

“I’m ready, but I can’t break the habit,” said Carter. But he said he won’t try vaping or e-cigarettes, which mimic the traditional item. Instead, he’s “trying to quit the natural way.”

E-cigarettes are about 95 percent safer than smoked tobacco, according to the U.K. Centre for Tobacco and Alcohol Studies. Vaping atomizers and e-cigarettes heat liquid nicotine, which then becomes vapor. They don’t contain carbon monoxide and tar, chemicals in cigarettes that hurt smokers’ health. The FDA plan would encourage the use of the stand-ins by delaying further regulation until August 2022, giving tobacco companies a chance to build up a range of alternatives.

After the FDA’s announcement last month, shares of the two largest cigarette sellers in the U.S., Altria Group Inc. And British American Tobacco Plc, suffered their biggest single-day drop since the recession, reflecting investors’ belief that companies aren’t prepared for the new era.

Vivien Azer, a research analyst with Cowen & Co. who follows the industry, said that despite the sell-off, companies are trying to adapt with new products that take them beyond the simple equation of flame plus leaf.

“Everyone seems to be leaning in heavily into ‘heat not burn,’ ” she said.

In one study published in 2015, cigarettes with lower levels of nicotine reduced not only nicotine exposure and dependence, but the number of cigarettes smoked. The research, conducted over six weeks and published in the New England Journal of Medicine, studied 780 people who regularly smoked with no interest in quitting.

For now, younger smokers are caught between eras.

John Mastbrook, 33, a bearded Brooklyn bike messenger, started smoking at 12 in his native Fairfax, Virginia. He vapes from time to time to wean himself from the cigarettes he rolls himself. “It’s just a good alternative,” he said.

Smoking refugees like Cleare who’ve switched to vaping recognize, though, that they may still spend their lives tethered to a habit they don’t want. He says he’s just “trading one vice for another.”

“I’m still obviously addicted to nicotine,” Cleare said, pausing to cough into his arm.

 

KUNC reports

This spring, 16 state patrol officers from Colorado and Wyoming took a couple days off their usual work schedule to do something special. They assembled in a hotel conference room in Denver. As instructed, they wore street clothes for their first assignment: going shopping at nearby marijuana dispensaries.

“It’s a brave new world,” said instructor Chris Halsor, referring to the years since Colorado legalized recreational marijuana.

There are now more marijuana dispensaries in Colorado than there are Starbucks shops, said Halsor, a Denver lawyer and former prosecutor. And though consuming cannabis is legal across the state, driving under its influence is not.

The cops in that conference room, with their buzz cuts and Mountain Dew, are all part of the force charged with keeping the roads safe. But first, they needed a formal pot education — to learn how to identify various marijuana products and paraphernalia when they pull over a driver they suspect is under the influence.

Here’s the rub: Despite the increasingly legal use of cannabis in many states, cops still don’t have the equivalent of a reliable alcohol breathalyzer or blood test — a chemically based way of estimating what the drug is doing in the brain. Though a blood test exists that can detect some of marijuana’s components, there is no widely accepted, standardized amount in the breath or blood that gives police or courts or anyone else a good sense of who is impaired.

A number of scientists nationally are working hard to create just such a chemical test and standard — something to replace the behavioral indicators that cops have to base their judgments on now.

“We like to know the human error and the limitations of the human opinion,” said Tara Lovestead, a chemical engineer at the National Institute of Standards and Technology in Boulder, Colo., who is working on setting standards for what a marijuana detection test might require.

It’s actually really hard for Lovestead to do this kind of research because she works in a federal lab; federally, cannabis is considered a Schedule 1 substance, “a drug with no currently accepted medical use and a high potential for abuse.” So even though Lovestead is in Colorado, getting hold of a sample for research purposes is just as hard as getting hold of heroin.

“We cannot use the stuff down the street,” she said.

Aside from being a bureaucratic mess, coming up with a standardized blood or breath test is also a really tricky chemistry problem because of the properties of the main psychoactive chemical in cannabis: delta9-tetrahydrocannabinol, or THC.

In states like Colorado, there is a THC blood test that law enforcement can use to show “presumed” impairment. If a person has more than 5 nanograms of delta-9-THC per milliliter of blood, a court or jury can infer that they are impaired, according to Colorado law (this is called “permissible inference” in legalese).

But Lovestead and others maintain that, scientifically speaking, that cutoff doesn’t actually mean anything.

“We just don’t know whether or not that means they’re still intoxicated, or impaired or not,” she said. “There’s no quantitative measure that could stand up in a court of law.”

Turns out it can be a lot harder to chemically determine from a blood or breath test that someone is high than to determine from such a test that they’re drunk.

Ethanol, the chemical in alcoholic drinks that dulls thinking and reflexes is small and dissolves in water. Because humans are mostly water, it gets distributed fairly quickly and easily throughout the body and is usually cleared within a matter of hours. But THC, the main chemical in cannabis that produces some of the same symptoms, dissolves in fat. That means the length of time it lingers in the body can differ from person to person even more than alcohol — influenced by things like gender, amount of body fat, frequency of use, and the method and type of cannabis product consumed.

In one study, researchers had 30 frequent marijuana users stay at a research facility for a month without any access to drugs of any sort and repeatedly tested their blood for evidence of cannabis.

“And it shocked everyone, including ourselves, that we could measure, in some of these individuals, THC in the blood for 30 days,” says Marilyn Huestis, a toxicologist with the University of Maryland School of Medicine who recently retired from leading a lab at the National Institute on Drug Abuse.

The participants’ bodies had built up stores of THC that were continuing to slowly leech out, even though they had abstained from using marijuana for a full month. In some of those who regularly smoked large amounts of pot, researchers could measure blood THC above the 5-nanogram level for several days after they had stopped smoking.

Conversely, another study showed that people who weren’t regular consumers could smoke a joint right in front of researchers and yet show no evidence of cannabis in their blood.

So, in addition to being invasive and cumbersome, the blood test can be misleading and a poor indicator of whatever is happening in the brain.

Recently, some scientists have turned their attention to breath, in hopes of creating something useful.

A number of companies, like Cannabix Technologies and Hound Labs, are in the process of developing breath detection devices. Tara Lovestead is providing the data that will help relate the concentration of THC detected in the breath to what’s in the blood. Even though blood provides an incomplete and indirect inkling of what’s happening in the brain, it’s the measure law enforcement turns to as a benchmark.

That, too, is a chemist’s nightmare. THC and other cannabinoids — the chemicals that cause a high — are really squirrelly. They degrade quickly and appear only in very tiny amounts in the breath.

Luckily, Lovestead’s specialty is detecting tiny amounts of chemicals in the air. She and her colleagues have worked on methods to use tiny air samples to detect evidence of arsonburied bodies and hidden explosives. Marijuana is the next challenge.

In the future, she said, an accurate breath test would likely involve looking at a lot more than just THC — probably a whole combination of chemicals.

“One thing to look for would be metabolites — something that comes out of the breath that shows it actually went through your system,” she said. Such a test would greatly reduce the possibility that someone might test positive from inhaling secondhand smoke, she said.

In the meantime, it’s up to law enforcement officers like the ones in Chris Halsor’s class to make the call, based on circumstantial evidence and their best guess.

“The whole point of this class is to get the officers to make correct decisions,” said Halsor.

Many officers in his courses have never used marijuana — or haven’t since some exploratory puffs in high school. These officers need training, he said, to boost their confidence — “confidence that they’re making the right arrest decision and confidence that they’re letting people go who really aren’t impaired.”

The cops attending his seminar in the spring paged through Dope Magazine, chuckled at a photo of an edible called “reef jerky” and watched a video together on how to dab — heating concentrated marijuana and inhaling the vapors. In their visit to a local marijuana dispensary, they examined gold-plated blunts — hollowed-out cigars filled with marijuana.

But the real test of these officers’ ability to identify the signs of cannabis impairment faced them outside the hotel, in a parked RV that was plastered with bumper stickers.

Four volunteers for the project were inside the RV, legally getting as high as they wanted to, from a big plastic tub full of pot products.

“Good music, good company, good weed. It all goes together,” said Eugene Butler, one of the four volunteers.

Butler and the three others had never met before. They had volunteered to get high and then interact with cops to help the officers learn the signs of cannabis impairment.

“We’re going to willfully smell like pot around a bunch of cops,” said Sharica Clark, laughing.

Inside the hotel, the officers practiced roadside sobriety tests on the four volunteers — determining each time if, in real life, they would have arrested these people for a DUI.

All the volunteers had smoked a lot of pot inside the RV. But in the sobriety tests, they performed differently.

A volunteer named Christine, for example, did well on math, quickly calculating how many quarters are in $1.75. But she didn’t do well on other things, like balancing, remembering instructions and estimating time. (She was concerned about recrimination at work, and NPR agreed to use only her first name).

Christine, the officers all decided, would be a danger behind the wheel. In real life, they would have arrested her.

“Yeah, she’d be going to jail,” said Rich Armstrong, an officer with Colorado State Patrol.

But things weren’t so clear with the other volunteers. A lot of the officers had decided they wouldn’t arrest Eugene Butler or a volunteer named John (who also asked that we not use his last name); both men aced the same roadside tests Christine flunked, even though they, too, had just smoked a lot in the RV.

And when it came to Sharica Clark, the officers decided it was essentially a toss-up as to whether they would have arrested her, based on her performance on the roadside tests. Yes, her pupils were huge, and she had a tough time touching her finger to the tip of her nose while her eyes were closed. But her balance, counting and recitation of the alphabet were, as Colorado State Patrol Officer Philip Gurley put it, “spot on.”

“It was a tough one,” said Tom Davis, another officer with Colorado State Patrol.

Right now, these officer’s opinions loom large. If they decide you’re driving high, you’re going to jail. But at the end of the day, they’re just making educated guesses. Two different officers could watch the same person doing the same sobriety test and make different decisions on whether to arrest. In previous courses, officers had decided that a volunteer was impaired when in fact the volunteer hadn’t smoked at all.

So, just like the THC blood test, the judgments officers make can also yield false positives and negatives.

“This is one of those subjective areas,” said Armstrong.

“It’s too subjective,” said Lovestead.

She recently published a paper in the journal Forensic Chemistry where she found the vapor pressure of THC — one of its fundamental physical properties. Lovestead believes finding and standardizing that measurement is a small but significant steptoward a more objective route for evaluating intoxicated drivers.

In the meantime, courses like Halsor’s are the best resource for officers. And at least now the class participants know what pot strains like Skunk Dawg, Hippie Chicken and Chunky Diesel actually smell like.

“Yeah,” said Gurley. “It smells like the bottom side of a rock.”

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