11/06/16 Doug McVay

This week we listen as the New Mexico State Legislature considers heroin treatment as a policy alternative, plus the US government stops the sale of thousands of rifles to the Philippine National Police #BoycottThePhilippines.

Century of Lies
Sunday, November 6, 2016
Doug McVay
Drug War Facts
Download: Audio icon col110616.mp3



NOVEMBER 6, 2016


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

DOUG MCVAY: Hello, and welcome to Century Of Lies. Century Of Lies is a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org.

On Friday October 28, the New Mexico State Legislature's Legislative Health and Human Services Committee and its Courts, Corrections, and Justice Committee, both of which are House-Senate joint committees, met together to talk about opiate policies, including prescription monitoring, alternative healthcare, and addiction treatment, including treatment with heroin.

They heard testimony from Eugenia Oviedo-Joekes, an associate professor at the School of Population and Public Health at the University of British Columbia, Canada; Miriam Suzanne Komaromy, MD, an associate professor of medicine at the University of New Mexico; Andrew Hsi, MD, a professor of family and community medicine at the UNM; and Lindsay LaSalle, a senior staff attorney for the Drug Policy Alliance. Last week, we heard some of their testimony, so this week we're going to listen as they reply to questions from the legislators. Let's just get to it.

NM STATE REP: Okeh, we'll go to -- any, anybody else want to add anything? We'll go to question from committee members, chairman Ortiz y Pino?

NM STATE SENATOR GERALD ORTIZ Y PINO: Thank you, Mister Chairman, and I'll start with some questions for Dr. Oviedo-Joekes. The use of heroin assisted treatment is, I'll tell you how intriguing it is, somebody from US News & World Report called me yesterday to say, I hear you're going to have testimony on heroin assisted treatment. I looked at our agenda, and I didn't know we were going to have testimony on it. But I think he may be listening in, if we didn't lose him over the lunch break.

So, there's a great deal of interest. There's curiosity, I guess. And so I wanted to ask you about the European experience with it, and also the British Columbian experience. Is it time limited, or is the idea that the person who would be in this, in this type of treatment would just continue for the rest of their life? Or is there an effort to gradually taper them off?

PROFESSOR EUGENIA OVIEDO-JOEKES: Thank you, Mister Chair, members of the committee. Thank you for the question, and it's the question that always comes up, and I would like to answer in the way that, what this treatment's meant for is to meet patients where they're at, and start working from there on the many issues they bring to treatment after so many years, to have been left behind by the healthcare system. So, while it's the intention of cessation, as a researcher, as a care provider, always to do the best for our patients, this will depend on each patient, how this best is going to look like.

We had a very interesting discussion this morning, and sometimes I remind people, if we have patients for example that are around our average age in clinical trials in Europe and also in British Columbia is around between 40 and 45. And they haven't been able to work either because they have been sick or because they lack skills, because they have not been able to access them, just starting this treatment is not going to put them back in the workforce. There will have to be a huge deal of reinvestment in social skills, working skills, education. The main priority of this treatment, when we receive a client or a person for the first time is to get this person safe. That's the main priority. Once we have established that the person is going to continue coming, and we start seeing them three times per day, we start working in other areas.

We have extremely successful stories in terms of what other people think success is, for example, leaving the treatment. There are a lot of people, particularly in studies from Switzerland, they have been running this for the last 17, 20 years, where people have come back and then taper out, and stop using any kind of drugs. But also, you will see in these programs, thirty percent of the people that are yearly, are part of this cohort, move to either methadone or buprenorphine. This treatment is, you know, you need to come three times per day to a clinic, so it is a treatment for people that are really either very poor or with very poor social skills, and very, very limited recovery capital, and we try to expand that recovery capital, in a way that they can start moving forward.

It is true, a lot of people stay in this treatment for several years, or move to methadone or to buprenorphine, or become abstinent, but let's not forget that opiate dependency is a chronic illness, so they are going to be back and forth. What we're trying to do is to always have a treatment that a person can access in the moment they need it. In our cohort in British Columbia, we so far most of our clients have been there, in 2011, we're in 2017, in and out, maybe two, three, four years, and we have in particular one case that, she stopped drugs altogether, she never came back for treatment, she finished her nursing degree, and now she is practicing as a nurse. Those cases exist, but the majority of the people we reach is people that are really poor, that they live mostly on disability, that they are homeless, and they live in single hotel room occupancy, so there's a lot that we as a community need to do to catch up in order for them to have something to go, once they reach some stability in their treatment. I hope that answers the question.

NM STATE SENATOR GERALD ORTIZ Y PINO: And Mister Chairman, then I guess, I'm intrigued by the possibility of New Mexico engaging in a pilot of this sort. And Dr. Komaromy and Dr. Hsi, is there any interest, or would there be a way for UNM to participate in this, that you could see? Or is there even any talk about it?

MIRIAM SUZANNE KOMAROMY, MD: We have been, there has been some talk about the idea of safe injection facilities, which in some way are sort of a cousin of this concept, so that's where someone who is not being prescribed heroin but is using heroin that they obtained on the street has a place where they can inject safely without risk of dying of an overdose, and also as you were saying, it helps to engage them, and start to talk to them about other options.

NM STATE SENATOR GERALD ORTIZ Y PINO: Yes, social supports or case management.

MIRIAM SUZANNE KOMAROMY, MD: Yeah. I haven't heard anyone at UNM propose heroin assisted treatment, although I agree that the evidence is strong for its benefit. It will certainly be a major lift to introduce this in New Mexico, if we're going to go that route, but, you know, worthwhile. I think it's really true that there people who are not reached by the other therapies that we have, and as long as those people are, you know, they're suffering, they're at risk of early death, they're becoming infected and putting others at risk of infection, they're, you know, committing --

NM STATE SENATOR GERALD ORTIZ Y PINO: They're having to steal to maintain their habit.

MIRIAM SUZANNE KOMAROMY, MD: Yep. And so, and from a public health standpoint, I think both the idea of safe injection facilities and this type of therapy are things that we should consider. Dr. Hsi, did you want to comment?


ANDREW HSI, MD: Mister Chairman, members of the committee, Senator Ortiz y Pino, I can only speak from the perspective of looking at family systems, that the medication part of the treatment is incredibly important in terms of stabilizing individuals. But, I would have a very hard time managing a large population of people on methadone, buprenorphine, or injectable heroin, if I had not built a team that could simultaneously address the social needs and the developmental needs of the children in the families, and it's that relationship with the child that seems to be a large motivator for the next set of things that happen.

I think also that the issue of counseling and access to counseling is a critical problem for any of the program that are providing services, and I would say specifically, the issue of gender specific treatment that's trauma-informed for women who are using, injecting drugs, because their situation is, in my view, very different than the larger population of people who have substance use disorder.

There is good data that says that people have dopamine accentuation, with the anticipation of injecting, and that, while buprenorphine does a good job in blocking opioid receptors, that then prevent craving and withdrawal, that the injecting part of it is a powerful motivator for people to seek drugs. Now, the question would be is whether something like injectable heroin or diluadid, or something else, might be the answer to the dopamine stimulation around the behavior of injection drug use.

NM STATE SENATOR GERALD ORTIZ Y PINO: So, so, Mister Chairman, just to follow that up, that's fascinating because I've often heard that the whole ritual around preparing the stuff, and injecting, that that is a powerful -- at your program, do they inject themselves, or is there a nurse or a physician who does the injection?

PROFESSOR EUGENIA OVIEDO-JOEKES: In British Columbia, in Canada, the nurse does not push the medication, for a matter of liability if anything happens, so, the nurse can help find a vein, because, if you can picture our clients are people that don't look healthy, because they've been in the street and they have many other issues. So many of them have been injecting for so long that they don't find a vein, so sometimes the nurses will help find a vein. In countries like in Spain, there was not a liability issue so sometimes when they're -- to call on the nurse and will help.

But it becomes extremely medicalized, so you see, the ritual, it becomes, it's like one -- in case indeed that the flavor and the ritual itself, the injection is still there, but you are in a place with nurses and lights, and then you are handed a basket with all what you need to inject, you see your physician, so, it becomes for them, when you listen to them, how they express, it's their medication. It's not anymore the drug for them. Now it's my medication. And they take a lot of pride on being able to say that this medication is working for them. And how they look forward to starting improving in other areas of their lives. Such as, sometimes, it's just to have food on their cupboards, and how much they have improved on that, and making plans, or being able to follow up plans with their families, knowing if I say I'm going to be there on Tuesday, I'm actually going to be there on Tuesday, because I have a schedule at the clinic, and after that, I can move. So now they can structure their lives around a medical place where this street drug becomes a medication.

DOUG MCVAY: You're listening to Century of Lies, a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org. We're listening to a hearing before two joint committees of the New Mexico state legislature, they're discussing opiates, medication assisted treatment, and heroin maintenance. Let's get back to it.

NM STATE SENATOR GERALD ORTIZ Y PINO: Thank you, Mister Chairman. I can see that it would take a lot for us to do this. It would really need a staff, we'd need a support team, we would need federal approval, all sorts of stuff that would have to go into it. But that we're talking about it I think is a healthy sign. And I think pretty clearly that there is that resistant population, in our state currently, to our current efforts at reaching them, we're just not reaching all the people that we need to.

One thing about this is, it kind of takes away the, the marketing of black market heroin that goes on. I mean, you know, it kind of robs the, hey kid, come here, I've got some real high for you here, when you can get that at the hospital, in a medication form. So ...

PROFESSOR EUGENIA OVIEDO-JOEKES: Mister Chairman, members of the committee. We have been partnering with Vancouver Police Department and other sections of the police because they're really interested on expanding the treatment, because of the Fentanyl crisis. And they're asking, their minister of health has received a lot of pressure from the police asking for them to start competing with the black market and start prescribing these opioids for people that are already dependent, with severe opiate use dependence. This is not for other, maybe, other people that be -- encounter opiate use through pain. This is a total different group that we're working with. But the big push is because of the black market and bringing medically prescribed medications such as dilaudid or diacetylmorphine.

So that is an important component of the crisis, and I want to talk along what the doctor was saying about the buprenorphine, and the fact that it is true that we need counseling and we need all these services, but people come for the medication. You give placebo, and they leave. So people come to our clinics because of the medication, and what we do is not about the medication, it's about caring for people, and being able to offer all these resources that we know are the ones that are going to bring true change in our lives and enliven our community.


MIRIAM SUZANNE KOMAROMY, MD: Thank you, Mister Chairman and members of the committee. I wanted to just add one more comment, that Senator Ortiz y Pino, when you mentioned that this type of program could undercut the black market, I think a corollary of that is when you think about what goes on in prison, where there's a huge black market for buprenorphine. If you actually provided the people who want buprenorphine and need it as treatment, with buprenorphine in the prison, that would also eradicate that black market, and would stop that illegal trade that goes on.

NM STATE SENATOR GERALD ORTIZ Y PINO: I wish you were here yesterday when the corrections people were here. They, yeah, they're very stubborn about that idea.

MIRIAM SUZANNE KOMAROMY, MD: They certainly don't share my ideas about it, I think that's definitely true. Thank you, sir.

ANDREW HSI, MD: And, Mister Chairman, and members of the committee, and Senator Ortiz y Pino, I think the one other thing though to consider is that most of the overdoses in New Mexico are combined methadone plus other opiate overdoses. And injectable dilaudid or injectable heroin does not block heroin -- opiate receptors, so that the respiratory center of the brain cannot be overwhelmed if an individual were to access other opiates, Fentanyl or anything else, outside of the clinic time that they are being treated.

So, those are additional issues that need to be considered in the overall structure of the therapeutic program, in those kinds of treatment models.

COMMITTEE CHAIR: Thank you. Representative Armstrong?

NM STATE REPRESENTATIVE DEBORAH A. ARMSTRONG: Thank you. Thank you, Mister Chair, thank you panel. I'm, I've got a couple of specific questions for you. It, just to try and get a sense of how it works. How, and I think you said some people take it for many years, maybe a lifetime use, or is, so, that was one question, how long, but how often? I thought I heard you say three times a day they come in.

PROFESSOR EUGENIA OVIEDO-JOEKES: So, each clinic in Europe works a bit differently. Because of the opiate receptors, you will like to offer this at least, offer it for three times per day. So people do not go through withdrawal overnight. You will have places like the Netherlands, what we call the Dutch model. They offer two injections and you have to take home a small dose of methadone to pass the night until the next day. Or you have some clinics in Zurich, the biggest clinic, what they have, you can come anytime you want, and you can come eleven times per day if you want. And because the opiate system has a natural ceiling, people do not go up and up and up and up, they will find a comfortable dose and stick to that.

So, yes, the model would be, we offer in British Columbia up to three times per day. It's optional if you want to take oral methadone and the last dose to combine it, so some people, very few people take home prescribed methadone. Most of them rather come the three times per day.

NM STATE REPRESENTATIVE DEBORAH A. ARMSTRONG: And, is it self-injected? So, you give them prescription grade, in a clinic, safe place to inject, but is it, is it a combination of that safe place to inject so that they're self injecting?

PROFESSOR EUGENIA OVIEDO-JOEKES: So, the clinic would work like this. You will meet first with a physician, and have a, you know, a conversation and start a working plan. After that, you will start what we call a titration. When we are going to raise up 50 milligrams every half hour until you feel comfortable. Once, that's between you and the nurse, have figured it out what is your dose, the physician will write that prescription. Then that prescription gets in the database, and then the pharmacy is going to prepare the personalized, individualized file for Deborah, in this case, so Deborah Armstrong will have her own file.

Let's say you have your morning dose, it's 120 milligrams. So you will come that day, you will have a bar scan, we will give you your medication, and then, if you pass the test, like the nurse is going to say, how are you doing, are you fine? You seem fine, do you want your 120 or do you want less? I want a bit less today, so we will pour 20 milligrams in a place that is registered, because we need to report all the medication that is there, and then, we give you everything and you sit in one of the five seats that we have in the Crosstown Clinic. And you might say, can I have some help today? I don't feel I can do this on my own, so a nurse will come and help you find a vein, and then you will inject that on your own.

NM STATE REPRESENTATIVE DEBORAH A. ARMSTRONG: Okeh. Wow. And, Mister Chairman, is it still all within a clinical trial context, or are you out of a clinical trail and just practicing?

PROFESSOR EUGENIA OVIEDO-JOEKES: Mister Chairman, rest of the committee, Representative Deborah Armstrong, right now, Crosstown Clinic operates outside the clinical trial. The last patient leaving the clinical trial was in, one and a half years ago. We have 140 patients, former participants of the SALOME clinical trial, that still receive either diacetylmorphine through SAPs, or hydromorphone.


DOUG MCVAY: That was from a hearing before two joint committees of the New Mexico Legislature, they were discussing opiate use, medication assisted treatment, and heroin maintenance. The speakers included Eugenia Oviedo-Joekes, an associate professor at the School of Population and Public Health at the University of British Columbia, Canada; Miriam Suzanne Komaromy, MD, an associate professor of medicine at the University of New Mexico; Andrew Hsi, MD, a professor of family and community medicine at the UNM, and Lindsay LaSalle, a senior staff attorney for the Drug Policy Alliance.

While we have time, let's listen in on a recent news briefing at the US Department of State. Spokesperson John Kirby was being questioned about the Philippines, and a recent decision by the US government to stop the sale of more than twenty thousand rifles to the Philippine National Police.

REPORTER: Philippines?


REPORTER: So I don’t know if you will have seen Philippine President Duterte’s response to our story about the United States not proceeding with a planned or a possible – a planned sale of 26,000 rifles to the Philippines. Among other things, he has called the people behind the decision not to proceed with the sale fools and, quote, “monkeys.”

I know you addressed this to some degree yesterday, and I know that there are limitations on what you can say about --


REPORTER: -- such a pending or potential sale. But it’s the last in a long series now of angry statements, critical statements, harsh statements from the Philippine president toward the United States. Do you have any response to his comments on this matter, even if you can’t discuss the underlying sale?

JOHN KIRBY: No, actually, I don’t, Arshad. I have seen those comments through press reporting, and again, I would say what we’ve said so many times before, that that kind of rhetoric is really at odds, and I think the word that I’ve used before is inexplicably at odds, with the close relationship that we continue to have with not just the Filipino people but the Filipino Government. But I can’t account for the sentiments expressed in those comments. All I can do is – and as you rightly noted, I can’t comment about potential commercial licenses in advance either – the decisions that affect them. But I – all I can do is reaffirm again how dedicated we are to our bilateral relationship with the Philippines, to our people-to-people ties with the Filipino people, and in fact how seriously we take our commitments from a security perspective through the defense treaty that we share.

REPORTER: And you said that you – you talked about how his remarks were inexplicably at odds with the close relationship that you have, not just --


REPORTER: -- people-to-people, but also with the government. Do you mean the government excluding Mr. Duterte, or would you say that you have --

JOHN KIRBY: Well, he’s the head of state. He’s the head of the government, but --

REPORTER: Do you feel like you have a close relationship with him?

JOHN KIRBY: Absolutely. Well, we have a close relationship with the Government of the Philippines.

REPORTER: Including him, the head of --

JOHN KIRBY: Well, he’s newly elected, and I don’t know the depth to which we’ve had opportunities to engage on a personal level with him. I know Secretary Kerry met with him and came away from that meeting, as he said he did, feeling positive about where things were going to be going with the Philippines. I don’t know about our ambassador and the personal relationship that he might have been able to develop in this short period of time, but he is the head of state, and our government-to-government relations are very strong.

REPORTER: But how can you say that you have a close relationship with the government when you can’t say that you have a close relationship with the head of state?

JOHN KIRBY: Well, because the government isn’t – doesn’t rest – especially in a democracy, it doesn’t rest on the shoulders of just one individual. Yes, he’s the head of state, but there are many agencies in his government, there are many cabinet officials, there are longstanding relationships that we have nurtured over the years with figures in his government, and those relationships are still there and they’re still vibrant.

REPORTER: And last one on this: Do you remain open to – well, two things. One, by saying that the government doesn’t rest on the shoulders of one individual, you’re – are you trying to suggest that you would try to circumvent him or deal with others or --

JOHN KIRBY: Not at all.


JOHN KIRBY: No, no, no.

REPORTER: And then second --

JOHN KIRBY: No, I was simply referring to the fact that in a democratic government such as the Philippines, that tasks are delegated to various agencies and that we have relationships with these institutions and agencies. Those are solid. They remain. Obviously, you also need to develop a good working relationship with the head of state. And I can tell you, as I’ve said before from this podium, we’re committed to doing that.

REPORTER: Thank you.

REPORTER: I want to very – sure, I get that what you’re – are you trying to suggest something here?


REPORTER: I mean, the head of state determines the foreign policy of the government, much in – in the Philippines as in the United States.

JOHN KIRBY: That’s correct. Right. What’s your point?

REPORTER: Well – so – but you’re saying that the U.S. – that you’ve built up relationships with other parts of the government, so it doesn’t matter what the president thinks?

JOHN KIRBY: That’s not at all what I said, Matt.

REPORTER: Okay. I thought --

JOHN KIRBY: And it wasn’t at all what I implied. I mean, look, he’s the head of state. We recognize he’s the duly elected leader of the Philippine Government and we respect that. And we respect the fact that as the head of state, he determines foreign policy. We totally understand. What I was – the point I was trying to make is that there are institutions in the government that we have good relationships with and we’re going to try to continue those relationships, as well as try to develop a good working relationship with him himself. That’s all I meant.

REPORTER: All right.

JOHN KIRBY: That’s all I meant.

DOUG MCVAY: Those rifles would have been used to slaughter innocent people. Stopping that sale was the only option. Thousands of innocent lives have been lost in the Philippines because of Duterte's death squads. He has other people pulling the triggers yet the dictator of the Philippines, President Rodrigo Duterte, is ultimately responsible for the extrajudicial murders that continue to be carried out in that country. Duterte has to go. Until then, remember, it's hashtag #BoycottThePhilippines.

And well, that's all the time we have. Thank you for joining us. You've been listening to Century Of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org. Drug Truth Network is on Facebook, please give its page a like. Drug War Facts is on Facebook too, give it a like and share it with friends. You can follow me on Twitter, I'm @DougMcVay and of course also @DrugPolicyFacts.

We'll be back next week with thirty minutes of news and information about the drug war and this Century Of Lies. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

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