A proposal for upgrading these “safe use sites” (if we’re going to have them, might as well have good ones):
The use site has a (24/7 guarded) attached pharmacy with government-produced clean heroin, meth, etc. Users can trade in their drug, the pharmacist runs it through a mass spec analyzer and dispenses back to them an amount of pharmaceutical-grade drug of interest, the amount dispensed being equal to the fraction that is present in whatever cut/mixed drug sample they handed in.
In addition to the obvious safety benefits of only consuming guaranteed-pure drugs, the drug user gets an on-the-spot and very salient piece of information about the quality of the drug they purchased. This creates a lot of precise and accurate drug quality information and feeds it back into the drug abuse cycle. A user buys from a dealer, and right before their first hit they get a purity score to evaluate their dealer with - and maybe some information about what other drugs their dealer just tried to poison them with.
(To avoid some obvious risks: the tested drug sample should be immediately ejected from the analyzer into a denaturing bath and regularly incinerated, so that handed-in drugs are not a theft or recycling target. You probably need to mandate they can trade in only the dose they are about take, and they have to take it on the spot, so that government supplies do not leak back into the streets. There are certainly other failure modes too, a close eye should be kept on this and further processes brought in as needed.)
> dispenses back to them an amount of pharmaceutical-grade drug of interest, the amount dispensed being equal to the fraction that is present in whatever cut/mixed drug sample they handed in
If you're distributing drugs just distribute the drugs. Why cut in the dealers and cartels?
There is no such thing as "a safe supply of drugs". Whether the street drugs are produced in a quality-controlled way or not, it is well-known that use of the substances has negative outcomes in health and occupational functioning.
Direct sale of street narcotics would only be another harm reduction practice, similar to "safe use sites". But no harm reduction practice makes the harm "safe".
The political double-speak around this is very similar to "clean coal"; it implies a strong position ("coal is clean") while offering an escape hatch if challenged ("coal pollution mitigation, otherwise known as clean coal, reduces greenhouse emissions when coal is used as a fuel"). Similarly as there is no "clean coal" in reality, there is no "safe supply of drugs".
When we take deceiving loaded words like "safe" out of the equation, it becomes harder to argue against substance control, even if seen as prohibition. While it is evident that street drug crisis in the US has been mishandled, if restricting the access of these substances (or "prohibition") was done correctly, it would benefit society. Particularly, the prohibition would benefit society more if it was not mainly enforced through criminalization of street drugs, but instead through teaching, rehabilitation, and prevention.
In contrast, "safe" drug harm is an oxymoron. And it's very ineffective to even discuss anything on a double-speak premise. We should instead focus on fixing the root problem of drug use, rather than be distracted by harm reduction, especially when it's been politicized so much.
When I buy a beer from the store that is a "safe" regulated supply of a substance purchased by a government regulated supplier that will ultimately cause liver damage and cancer.
An un-safe supply of alcohol would be the sort of stuff that was common during prohibition, the sort of home brewed moonshine that poisoned people and made them blind.
We already do harm reduction and safe supply of many drugs in our society because we recognize the alternatives of adhoc illegal supply is dramatically worse.
Using opioids like heroin (boy if one could even get heroin at this point) is obviously not "safe."
These sort of concerns around safety are at this point however irrelevant because the reality is that people are chemically addicted to these harmful substances and the issue is how to best get them un-addicted or manage that addiction.
Anyone attempting to get off a chemical drug addiction can be absolutely be expected to relapse at some point (many points most likely!) along the journey to ultimately kicking the addiction for good.
The point of harm reduction is so that when someone relapses they do not die from street drugs that are so incredibly toxic there is no known safe dose and that they have yet another opportunity to try to wean themselves off their harmful addiction.
The context of this discussion around street drugs is about the unregulated street drugs that are so cut with various unknown chemicals that it is impossible to have a dose that yields any sort of expected results. This is what is resulting in an incredible spike in overdose deaths.
There is a clear difference between harm reduction and rehabilitation, although both are beneficial to society. However, we should not use double-speak terms like "safe use", as all efforts to facilitate continuous narcotics use are not safe, and it is counter-productive to imply otherwise. To see my point of view more clearly, consider whether it would be beneficial for any user or potential user to truly believe it is genuinely safe to use narcotics as a part of a harm reduction program.
We should be educating people about the dangers of narcotics addiction, and helping those who are already addicted through rehabilitation programs. They should have access to the narcotics for reduction therapy/tapering. But they also need a lot more — counselling, withdrawals management, relapse management, replacement therapy, group support, and other effective measures.
I suppose the core of what I am trying to say is this: harm reduction is not addressing the core issue effectively enough, and calling any part of harm "safe" communicates a wrong message and is damaging. Harm reduction efforts are important, but are not enough alone; continued narcotics use not be sold by politicians as "safe". There is a subtle but distinct difference between "safe" and "safer", the latter of which is appropriate in harm reduction efforts, but not the former.
Coffee in regular amounts, nicotine not by burning, a beer or two now and then... shouldn't be controversial. Less obvious but still true: opiates at maintanance levels under supervision, regular amphetamine in moderate dosages, MDMA or ketamine on occasion. Loads of drugs in loads of usage scenarios really are "safe".
But just because supervised heroin won't kill you doesn't mean it's somehow good, actually. That's a separate judgement.
There's surely no upside. It's overwhelmingly likely to make you less healthy and less happy. But so will too much bacon and sitting.
Chairs are still safe though, by any sane definition.
Alcohol consumption is proven unsafe to health[1], but it's not controversial. Adults have the right to choose risky behaviors, just like they do in fire fighting, coal mining, underwater welding, or mountain climbing. In some cases, we admire those who choose them for their bravery.
Let's not confuse "unsafe" with "controversial" or "unquestionably bad." But let's remember that "safe" has a clear definition, which does not describe current "safe use" narcotics harm reduction programs. Harm reduction by definition means that harm is involved. Someone safe from street narcotics is someone who is not using them, at least in the way that they are generally used recreationally.
The core issue is a series of failed policies originally implemented to address the problem of white women hanging around black and Chinese men. I don’t think the world would end if we sold Vyvanse and Nucynta ER over the counter at CVS. Let the people predisposed to be addicts just be addicts instead of wrecking their lives and the lives of those around them with failed program after failed program.
The most important part is to not get people into substance abuse in the first place.
Many people start with light drugs (weed or subscription drugs) and then go to heavier stuff. If it is easy to get light drugs and easy to get heavy stuff then more people will be doing drugs. If it is legal to carry around drugs for personal use and if it is considered accepted, then more people will be using drugs.
These findings are consistent with the idea of marijuana as a "gateway drug." However, the majority of people who use marijuana do not go on to use other, "harder" substances. Also, cross-sensitization is not unique to marijuana. Alcohol and nicotine also prime the brain for a heightened response to other drugs51 and are, like marijuana, also typically used before a person progresses to other, more harmful substances.
It is important to note that other factors besides biological mechanisms, such as a person’s social environment, are also critical in a person’s risk for drug use. An alternative to the gateway-drug hypothesis is that people who are more vulnerable to drug-taking are simply more likely to start with readily available substances such as marijuana, tobacco, or alcohol, and their subsequent social interactions with others who use drugs increases their chances of trying other drugs. Further research is needed to explore this question.
I think drawing a line between light and heavy drugs (high risk of overdose/harm/very addictive)
If you have to buy your weed from a dealer who also sells other stuff the chances that you might decide to try something more harmful one days are much higher than if you can get your weed in a legal store.
>Whether the street drugs are produced in a quality-controlled way or not, it is well-known that use of the substances has negative outcomes in health and occupational functioning.
No, the problem is that this is an urban myth. There have been drug clinics that let trained staff inject people with clinical heroin and other drugs with no adverse health effects and often the controlled dosage ended up so low that the drug users maintained self awareness and the high wasn't present or extremely weak.
The clinic was shut down after twenty years of success because people were jealous of drug addicts without health consequences.
A single digit number of people died from overdoses on street dugs within a week of closing the clinic. I wouldn't call that harm reduction.
The truth is that most of the drugs that people want to take voluntarily are perfectly safe and it is the illegal distribution system that adds unsafe cutting agents with severe health consequences.
While I agree that adulteration of street drugs contributes significantly to them being unsafe, it is proven beyond doubt that illicit narcotics cause addiction with negative health and social outcomes:
Even sustained use of quality-controlled narcotics is detrimental and harmful to health and social cohesion. And you do not need to read these studies that prove it, you can simply ask drug users to speak on the topic.
In contrast, actual measures taken to legalize (if not make widely available) and focus on safety actually work to reduce issues and use.
With many drugs, actually quitting via tapering is a valid approach. How the heck do you propose to do that otherwise than having safe use?
By making it legal and say requiring ID to get, you can actually track and find who has a problem and deliver help to them.
That also requires the pharmacy and doctors to not be drug pushers, a tough sell in USA.
That easy. Worked pretty well in one or two countries.
I do not disagree with medication-assisted treatment (MAT) rehabilitation which involves tapering/dose reduction. I do disagree with the implementation of "safe use" Western countries have now, which is ineffective for rehabilitation.
Drug rehab programs regularly go much further to be effective, and include group counselling, individual counselling, substance replacement, medication to reduce withdrawal symptoms, relapse management, and similar.
On the other hand, harm reduction is a completely different effort that does not constitute safe use in my opinion, because it facilitates continuous use, which is very harmful, even if the harm is reduced. Even in rehabilitation centres, the use of controlled substances is not considered safe by all medics. It is rather more agreeable to call it safer use.
By the way, which are the countries that you mention where legalizing narcotics and selling them in pharmacies yielded positive results, and what were the results?
If you are talking about legalizing cannabis in some US states and Canada, it is far too early to see the long-term results, although preliminarily, it seems like the use of cannabis has increased. This might be acceptable as a trade-off, as legalizing cannabis will lead to less social stigma for the users, fewer engagements with law enforcement, and safe access. For the producers and distributors, it will mean safer working conditions and labor protections. All for a 10-15% growth in known cannabis use. And cannabis is a relatively safe narcotic.
If you are talking about Portugal's decriminalization of drug possession about 20 years ago, the distribution there is still not facilitated by pharmacies, and those in possession of hard narcotics are required to seek treatment, education, or other interventions as prescribed by drug commissions case-by-case. Portugal has not decriminalized narcotics fully, it was more of a shift from punitive measures to rehabilitation measures for the users. The laws surrounding distribution remain generally in line with Western countries.
You speak as if you've never read about the US opioid epidemic and how we got here. Do realize, this makes you sound like a religious prohibitionist extremist..
Your proposal is bunk. Someone who became addicted to prescription opiates does not deserve to play roulette with their life by being forced to buy street drugs after their own physician arbitrarily decides not to provide any more.
A prescribed drug, mind you, where one of the known side effects (of opiate consumption) is addiction, but the physicians prescribing aren't responsible for curing the addicts they create. Because <regulations, guidelines, prescribing practices, etc> mandate they cut patients off. This is "Just say No" all over again, but now it's the doctors saying "No."
What utter BS..
And to think that possession of fentanyl testing equipment is illegal in dozens of US States. It's as if the laws are designed to funnel humans to be slaughtered by adulterated product. Under the revenge-ethics banner of "they deserve it".
The US system:
- humans that are too poor to pay an expensive private doctor get to buy street drugs.
- Rich folks get private doctors that will prescribe what they physically depend on.
Ex:
Prince didn't accidentally die from taking Fentanyl-poisoned street drugs. He was adequately supplied with whatever he needed, for years. Years! While also functioning!
Prince was a functioning human, while also being addicted. There, I said it.
What harm to society was he? Why must we eliminate all addicts as you suggest?
I am not only aware of the opioid epidemic, but my family is strongly involved in rehabilitation clinic work in Europe.
My proposal is to reduce use through education, rehabilitation (including tapering/MAT), and not facilitating continued use. I also propose not using language such as "safe use". Please see the approach Portugal took in 2001 where narcotics possession was legalized but interventions such as rehabilitation were enforced — this is my proposal. The approach can be supplemented by harm reduction, but harm reduction alone is ineffective and selling it as a "safe" alternative to rehabilitation programs is malicious, as can be very evidently seen in the US.
I am saying exactly this. Fixing the root problem through rehabilitation can be supplemented by harm reduction efforts. But harm reduction does not by itself eliminate harm, and should not be called "safe". It could be called "safer". A rehabilitated person is safe from drug use. One using hard narcotics through legalized means is not.
It seems like some people are very strong supporters of "safe use" though, it is difficult to argue that there is another more sustainable approach to the narcotics problem.
Arguably the cycle of police aggressively confiscating drugs from users induces more petty theft as the police confiscations become a new sink to drain drug user wealth. Those chemically addicted to drugs need to replace the confiscated drugs, which creates a new need to find something to sell to get enough money to once again buy drugs on the illegal market.
A safe supply of regulated drugs breaks this cycle.
It would be great to destroy the criminal economy. However, I fear the drug trade is too useful to the likes of the CIA to ever be abolished. Those with power who seriously try to fix the drug problem would probably be assassinated. This is why no US leaders have actually tried to end the drug war.
Replacing individual drug doses with clean versions at the point of consumption is not “distributing drugs” in any sense except rhetorical, so I should simply reject that comparison.
But in the spirit of discussion, I will instead say: why compete when you could regulate?
This proposal would essentially introduce a tax on cutting drugs that is exactly proportionate to the amount of cutting done. Further processes could emulate other forms of regulation: if the drug dose contains enough of some adulterant that it would have been acutely lethal (for example, way too much fentanyl accidentally mixed in), you could withhold the dose or otherwise induce the user to give up the dealer to the police - not as hard of a sell as you might think, given that the pharmacist literally just saved the user from dying in the next 30 minutes - and now you have something sort of like safety and QA regulations that impose jail time penalties for improper manufacturing.
> Replacing individual drug doses with clean versions at the point of consumption is not “distributing drugs” in any sense except rhetorical, so I should simply reject that comparison
I pay a dealer for a ticket. I take it to the dispensary. They clip the ticket and give me new drugs. Now replace “ticket” with “tainted drugs.”
The street-purchase requirement is totally performative. The dispensary is selling drugs with extra steps, with the bonus of sending their revenue to the dealers.
The street purchase requirement is not totally performative. It requires dealers to be standing around on the street carrying books of tickets that are highly illegal to possess, thus allowing police intervention. Under the extra step proposal, police can continue to arrest ticket-sellers, hypothetically reducing the ticket availability towards zero. Without the extra steps, there is just the user and the dispensary, there’s nobody for the police to arrest and law enforcement loses their lever for pressuring and reducing the illicit drug trade.
> hypothetically reducing the ticket availability towards zero
This is prohibition with extra steps. Granted, you deal with the problem of tainted drugs. But that isn’t the chief issue, and creating a giant hole in the budget aimed exclusively at that harm seems political suicide.
In case it’s not clear, I am in favor of prohibition! The exact lesson I draw from the failure of alcohol prohibition is that drug harm isn’t a major factor in drug users’ choices; you can’t (ethically) reduce demand by making drugs more harmful, and more modern evidence seems to show that making drugs less harmful doesn’t increase use by much either. I believe that drug distribution should be illegal, and drug consumption should be as safe as practical.
If we’re talking about political feasibility, I think replacing harmful street drugs with their pure versions at the point of consumption is politically much closer to “safe injection sites” than it is to “government agents with the job title of Drug Dealer”.
Because there are other reasons extremely valid reasons why we shouldn't drug dealers and organized crime besides that they drugs they sell are ussually adulterated?
I mean you couldn't even get these legal/clean drugs directly before buying something from a street dealer under this scheme? Why? IMHO that's just beyond absurd we might just as well provide direct cash subsidies to drug cartels instead if that's your goal.
The government also can't compete on potency. We'd be dispensing safe drugs, but the street dealers always win: they're always going to have stronger, riskier stuff. Addicts want the stronger stuff.
An example is the supply arms race with research chemicals/designer drugs (RC). Every month, a new RC hits the streets with greater potency and skirting any previously-established regulations. The drug dealers will always be winning the potency race because they're on the bleeding edge, using the latest formulas and cutting it with experimental/unsafe/word-of-mouth additives.
The only way to win is making them free. And even then, the potency race continues. It's a ginormous value edge that the dealers have, and sadly, it preys on the most vulnerable sufferers.
Potency only means that you need a smaller quantity of a substance to attain the same effect. It has nothing to do with the maximum attainable effect. Users don't care about potency.
If anything, users care about speed of crossing the blood-brain barrier, which causes the pleasurable "rush" of rapidly increasing effects. The major drugs like heroin and methamphetamine are already pretty optimal in this regard.
On the other hand, drug suppliers care about potency because they can transport more doses in the same weight.
The only people who care about RCs are people trying to skirt the law, and drug nerds.
https://en.m.wikipedia.org/wiki/Potency_(pharmacology)
> Potency only means that you need a smaller quantity of a substance to attain the same effect.
Semantics, misused a term there.
> The major drugs like heroin and methamphetamine are already pretty optimal in this regard.
In a world where this was true, cutting drugs with fentanyl wouldn’t be a thing. It’s not just a cost optimization, it’s also because it gets you the best high on the block.
> The only people who care about RCs are people trying to skirt the law, and drug nerds.
“Spice”, as one example, has destroyed many communities. Legal highs and designer drugs are everywhere as of the past decade. “Bath salts” (cathinones), synthetic cannabinoids, etc.
Not exactly designer, but the isomerization process to extract delta-8 from hemp is a novel technique that’s being done underground by labs everywhere and distributed widely across America. We have no idea what’s in this stuff, even testing labs usually report XX% of unknown substances, reaction residues and cannabinoids in samples.
Research chemicals are everywhere. This arms race has touched millions.
You have it backwards. The only reason for novel compounds is their lack of regulation or that their potency makes smuggling easier. It's definitely not a demand-side thing.
If the government is going to give out drugs, then they should just run some pharmacies similar to state run liquor stores. No need to force users to buy from dealers, that makes no sense at all.
I'm not sure I understand completely or agree with it, but if the drugs could be reliably tested to avoid gaming the system, then in theory we could continue to try to curtail the illegal drug trade on one end while replacing adulterated drugs with clean ones on the other, net zero increase of availability.
If it worked well. There are probably many problems with this idea.
I've always said anyone who likes should be offered the choice of a free ticket to Swain's Island, which could be stocked with barrel fulls of absolutely pure and pharmaceutical grade hard drugs to the heart's delight of the new resident.
Let anyone who wants it buy fentanyl, and let natural selection do its work.
This is suggested semi-facetiously, but at the same time, feels like there's something to it.
Decriminalize, tax, regulate, and focus enforcement efforts on black market dealers.
The waste of human effort and life that has gone into the last 60 years of drug policy is insane to consider. We have got to try _something_ other than what we're doing now with prohibition.
I think the framing of "let natural selection do the work" is self sabotaging if you're really trying to make the argument persuasive. It makes your position sound on some level likes it's casually dismissing the loss of life when what is really being argued, to me when I read your post at least, is that we need to accept that in dealing with this kind of topic lives are going to be ruined/lost either way and that when we/governments take responsibility as distributors that at least allows us more control over the situation and from that position we might at least be able to diminish the risk/harm to addicts even if we can't actually convert them into non-addicts.
I'd add that I think more explanation around the black market angle could probably help the argument further since atm the state of legalization advocacy in the US tends to be "But think about the tax revenue!" which is fine for less problematic drugs like weed but which is going to stall fast when you get to things like heroine. Emphasizing legalization and government regulation/distribution as a way to take money out of the hands of gangs and street dealers would be compelling to a lot of people imo if framed in the right way.
100% fair, and also right. I started writing that as a kind of dismissive jokey, maybe slightly trolling, thing and then ended up a little more serious as I continued thinking - probably not my most well-argued or empathetic post.
If you follow that line of thought then allowing fentanyl is equivalent to the capital punishment. You can't consciously rely on this to manage society.
The problem with this approach is that it is impossible. There is no "general chemical analyzer" that can consistently detect the quantity of a substance in any sample. You may as well suggest that a wizard uses his magic wand to purify the heroin.
Not to mention that users will begin to bring in all kinds of crap to see if they can get heroin from it — notably, their own excrement. Drug sellers likewise may decide it is unnecessary to recrystallize their products to remove solvents, since your suggestion makes no distinction between the sample contaminated with acetic anhydride and the one that was cut with mannitol. So there is still plenty of moral hazard.
I’m pretty sure a mass spectrometer will actually do what we want here, we don’t need a magic wand.
Drug dealers leaving solvents in because this suggestion makes no distinction between different cutting compounds? I propose that we do draw a distinction, then.
Drug users trying to hand us a baggie of their shit and call it heroin? I propose that, uh, we say no?
To be frank, none of your objections seem like very difficult obstacles to overcome.
This was debated when Vancouver first introduced safe injection sites, but was not put into place, as I understand it, because the government didn't want to become the drug dealer.
According to https://harmreductionjournal.biomedcentral.com/articles/10.1... mass spec machines are between $5000 and $1m, and commercial labs offer services for between $5 and $100 per sample. Presumably the capital investment of buying a mass spec machine and hiring a technician drop the cost per sample drop lower than $5, as it seems businesses are able to stay profitable charging that amount.
According to Wikipedia, the budget for the safe injection site in the article is $1.2m initial investment and $500k/year operating cost to handle 175k injections per year. Even at $5 a sample that’s $875k a year. So mass spec is actually completely plausible, in both capital investment and operating cost, for the budget of a single injection site at the volume that injection site handles. https://en.m.wikipedia.org/wiki/Insite
That the conservative estimates and some upper bounds for gold standard mass spec are within the actual budgets of individual injection sites is, I feel, justification enough for my glib “cheap enough!” quip above. Of course, we may not need the gold standard. For the limited scope of identifying pharmaceutical chemicals in small doses, there may be cheaper processes that function just as effectively.
Significantly depends on what kind of MS we are talking. Single quad can be had for well under $100k. Top of the line Orbitrap is ~$1.2 million. Depending on the analytical constraints, I think you could get by with a mid-range triple quad for $200-300k. Although, if you need to do exploratory work, I think everyone should just buy a QE as it is a solid workhorse that can fit most any role.
When a lot of that equipment gets aged out from industrial uses it will be given to universities in still-working order. Biotechs going bust can also be a boon to the second-hand market where state of the art equipment can be had for a song. I know one lab which acquired a piece of equipment that had been used in a background shot of a Jurassic Park movie.
I mean sure, but does it makes sense that a high school would have $1-2M worth of mass spectrometers?
Keep in mind there is significant expense in their upkeep as well.
That's why I guessed they were probably gas chromatographers with wavelength or FID detectors. Those are pretty cheap (gas source, injector and column).
(In case it’s not clear, I’m not actually a fan of illicit drug use. I view this proposal as roughly about as dystopian as the current practice of safe injection sites where trained professionals watch users inject whatever tainted drugs they bring with them, and try to treat overdoses without knowing what the person put in their system. I see it as proposing Brave New World vs the current 1984.)
The use site has a (24/7 guarded) attached pharmacy with government-produced clean heroin, meth, etc. Users can trade in their drug, the pharmacist runs it through a mass spec analyzer and dispenses back to them an amount of pharmaceutical-grade drug of interest, the amount dispensed being equal to the fraction that is present in whatever cut/mixed drug sample they handed in.
In addition to the obvious safety benefits of only consuming guaranteed-pure drugs, the drug user gets an on-the-spot and very salient piece of information about the quality of the drug they purchased. This creates a lot of precise and accurate drug quality information and feeds it back into the drug abuse cycle. A user buys from a dealer, and right before their first hit they get a purity score to evaluate their dealer with - and maybe some information about what other drugs their dealer just tried to poison them with.
(To avoid some obvious risks: the tested drug sample should be immediately ejected from the analyzer into a denaturing bath and regularly incinerated, so that handed-in drugs are not a theft or recycling target. You probably need to mandate they can trade in only the dose they are about take, and they have to take it on the spot, so that government supplies do not leak back into the streets. There are certainly other failure modes too, a close eye should be kept on this and further processes brought in as needed.)