NYT: Pain doc as pusher?
http://www.nytimes.com/2007/06/17/magazine/17pain-t.html
June 17, 2007
Cover Story: When Is a Pain Doctor a Drug Pusher?
By TINA ROSENBERG Correction Appended
Ronald McIver is a prisoner in a medium-security federal compound in Butner, N.C. He is 63 years old, of medium height and overweight, with a white Santa Claus beard, white hair and a calm, direct and intelligent manner. He is serving 30 years for drug trafficking, and so will likely live there the rest of his life. McIver (pronounced mi-KEE-ver) has not been convicted of drug trafficking in the classic sense. He is a doctor who for years treated patients suffering from chronic pain. At the Pain Therapy Center, his small storefront office not far from Main Street in Greenwood, S.C., he cracked backs, gave trigger-point injections and put patients through physical therapy. He administered ultrasound and gravity-inversion therapy and devised exercise regimens. And he wrote prescriptions for high doses of opioid drugs like OxyContin.
McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient\'s pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.\u003cbr /\>\u003cbr /\>Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy\'s death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.\u003cbr /\>\u003cbr /\>McIver\'s case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain - pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time - and that doesn\'t include medical bills.\u003cbr /\>\u003cbr /\>Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body\'s energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.\u003cbr /\>",1]
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McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient's pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy's death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.McIver's case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain - pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time - and that doesn't include medical bills.Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body's energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.
Video\u003cbr /\>More Video »\u003cbr /\>It\'s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction - which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful - occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn\'t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. "Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older," says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.\u003cbr /\>\u003cbr /\>The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)\u003cbr /\>",1]
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VideoMore Video »It's a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction - which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful - occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn't mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. "Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older," says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)
Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren\'t working, that high doses will - opioids don\'t help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug "holidays" or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.\u003cbr /\>\u003cbr /\>But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. "Dose alone says nothing about proper medical practice," Portenoy says. "Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life."\u003cbr /\>\u003cbr /\>All modern pain-management textbooks advocate "titration to effect" - in other words, in cases where opioids are helping, gradually increasing the dosage until either the pain is acceptably controlled or the side effects begin to outweigh the pain-relief benefits. But the vast majority of doctors don\'t practice what the textbooks counsel. In part, this is because of the stigma associated with high-dose opioids, the fear that patients will become addicted and the fact that careful monitoring is very time-consuming. And most doctors have received virtually no training in medical school about managing pain: many hold the same misconceptions about addiction and dosage as the general public.\u003cbr /\>",1]
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Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren't working, that high doses will - opioids don't help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug "holidays" or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. "Dose alone says nothing about proper medical practice," Portenoy says. "Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life."All modern pain-management textbooks advocate "titration to effect" - in other words, in cases where opioids are helping, gradually increasing the dosage until either the pain is acceptably controlled or the side effects begin to outweigh the pain-relief benefits. But the vast majority of doctors don't practice what the textbooks counsel. In part, this is because of the stigma associated with high-dose opioids, the fear that patients will become addicted and the fact that careful monitoring is very time-consuming. And most doctors have received virtually no training in medical school about managing pain: many hold the same misconceptions about addiction and dosage as the general public.
And even pain specialists can be conservative. Sean E. Greenwood died in August at age 50 of a cerebral hemorrhage that his wife, Siobhan Reynolds, attributes to untreated pain. Greenwood was seeing various pain specialists. What makes his undertreatment especially remarkable is that he and his wife founded the Pain Relief Network, an advocacy group that has been the most vocal opponent of prosecutions of doctors and financed part of the legal defense of many pain doctors. "Here I am - I know everyone, and even I couldn\'t get him care that didn\'t first regard him as a potential criminal," Reynolds said.\u003cbr /\>\u003cbr /\>According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.\u003cbr /\>\u003cbr /\>Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily - for oxycodone or OxyContin, that\'s just 80 milligrams per day - without the patient\'s also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. "There are just not enough pain specialists," says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. "Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise," Fishman says.\u003cbr /\>",1]
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And even pain specialists can be conservative. Sean E. Greenwood died in August at age 50 of a cerebral hemorrhage that his wife, Siobhan Reynolds, attributes to untreated pain. Greenwood was seeing various pain specialists. What makes his undertreatment especially remarkable is that he and his wife founded the Pain Relief Network, an advocacy group that has been the most vocal opponent of prosecutions of doctors and financed part of the legal defense of many pain doctors. "Here I am - I know everyone, and even I couldn't get him care that didn't first regard him as a potential criminal," Reynolds said.According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily - for oxycodone or OxyContin, that's just 80 milligrams per day - without the patient's also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. "There are just not enough pain specialists," says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. "Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise," Fishman says.
In addition to medical considerations real or imagined, there is another deterrent to opioid use: fear. According to the D.E.A., 71 doctors were arrested last year for crimes related to "diversion" - the leakage of prescription medicine into illegal drug markets. The D.E.A. also opened 735 investigations of doctors, and an investigation alone can be enough to put a doctor out of business, as doctors can lose their licenses and practices and have their homes, offices and cars seized even if no federal criminal charges are ever filed. Both figures - arrests and investigations - have risen steadily over the last few years.\u003cbr /\>\u003cbr /\>Opioid drugs have been used to treat pain for decades, mostly for acute postsurgical pain or the pain of cancer patients. But in January 1996, Purdue Pharma helped increase the use of these drugs by introducing OxyContin - oxycodone with a time-release mechanism. Oncologists and pain doctors were the principal prescribers of opioids. But Purdue introduced the drug with an aggressive marketing campaign promoting OxyContin to general practitioners and the idea of opioid pain relief to doctors and consumers. The product\'s time-release mechanism, Purdue claimed, allowed steadier pain relief and deterred abuse.\u003cbr /\>\u003cbr /\>Many pain sufferers found that OxyContin gave them better relief than they ever had before. But Purdue misrepresented the drug\'s potential for abuse. Last month, the company and three of its executives pleaded guilty to federal charges that they misled doctors and patients. The company agreed to pay $600 million in fines; and the executives, a total of $34.5 million. The pill\'s time-release mechanism turned out to be easily circumvented by crushing the pill and snorting or injecting the resulting powder. By the late 1990s, OxyContin abuse was devastating small towns throughout Appalachia and rural New England. Pharmaceuticals, mainly opioids, are still widely abused - now more so than any illegal drug except marijuana. In 2005, according to the government\'s National Survey on Drug Use and Health, 6.4 million Americans, many of them teenagers, had abused pharmaceuticals recently. Most got the drug from friends or family - often, in the case of teenagers, from their parents\' medicine cabinets.\u003cbr /\>",1]
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In addition to medical considerations real or imagined, there is another deterrent to opioid use: fear. According to the D.E.A., 71 doctors were arrested last year for crimes related to "diversion" - the leakage of prescription medicine into illegal drug markets. The D.E.A. also opened 735 investigations of doctors, and an investigation alone can be enough to put a doctor out of business, as doctors can lose their licenses and practices and have their homes, offices and cars seized even if no federal criminal charges are ever filed. Both figures - arrests and investigations - have risen steadily over the last few years.Opioid drugs have been used to treat pain for decades, mostly for acute postsurgical pain or the pain of cancer patients. But in January 1996, Purdue Pharma helped increase the use of these drugs by introducing OxyContin - oxycodone with a time-release mechanism. Oncologists and pain doctors were the principal prescribers of opioids. But Purdue introduced the drug with an aggressive marketing campaign promoting OxyContin to general practitioners and the idea of opioid pain relief to doctors and consumers. The product's time-release mechanism, Purdue claimed, allowed steadier pain relief and deterred abuse.Many pain sufferers found that OxyContin gave them better relief than they ever had before. But Purdue misrepresented the drug's potential for abuse. Last month, the company and three of its executives pleaded guilty to federal charges that they misled doctors and patients. The company agreed to pay $600 million in fines; and the executives, a total of $34.5 million. The pill's time-release mechanism turned out to be easily circumvented by crushing the pill and snorting or injecting the resulting powder. By the late 1990s, OxyContin abuse was devastating small towns throughout Appalachia and rural New England. Pharmaceuticals, mainly opioids, are still widely abused - now more so than any illegal drug except marijuana. In 2005, according to the government's National Survey on Drug Use and Health, 6.4 million Americans, many of them teenagers, had abused pharmaceuticals recently. Most got the drug from friends or family - often, in the case of teenagers, from their parents' medicine cabinets.
At the time the OxyContin epidemic emerged, the D.E.A. had far more experience seizing illegal drugs like cocaine and heroin. According to Mark Caverly, the head of the liaison and policy section for the D.E.A.\'s Office of Diversion Control, the OxyContin epidemic, however, required the agency to step up its antidiversion efforts. In 2001 the D.E.A. established the OxyContin Action Plan. The D.E.A. dispatched investigators to the most troubled states and trained local law-enforcement officials.\u003cbr /\>\u003cbr /\>The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician\'s trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts - witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.\u003cbr /\>\u003cbr /\>Identifying the scammers is especially tricky because there is no objective test for pain - it doesn\'t show up on an X-ray. In one British study, half the respondents who complained of lower-back pain had normal M.R.I.\'s. Conversely, a third of those with no pain showed disk degeneration on their M.R.I.\'s. The study suggested there could be a profound disconnection between what an M.R.I. sees and what a patient feels.\u003cbr /\>\u003cbr /\>There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor\'s dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America\'s undertreatment of pain.\u003cbr /\>",1]
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At the time the OxyContin epidemic emerged, the D.E.A. had far more experience seizing illegal drugs like cocaine and heroin. According to Mark Caverly, the head of the liaison and policy section for the D.E.A.'s Office of Diversion Control, the OxyContin epidemic, however, required the agency to step up its antidiversion efforts. In 2001 the D.E.A. established the OxyContin Action Plan. The D.E.A. dispatched investigators to the most troubled states and trained local law-enforcement officials.The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician's trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts - witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.Identifying the scammers is especially tricky because there is no objective test for pain - it doesn't show up on an X-ray. In one British study, half the respondents who complained of lower-back pain had normal M.R.I.'s. Conversely, a third of those with no pain showed disk degeneration on their M.R.I.'s. The study suggested there could be a profound disconnection between what an M.R.I. sees and what a patient feels.There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor's dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America's undertreatment of pain.
In July 2002, an insurance agent was sifting through records in Columbia, S.C., and paused at the file of one Larry Shealy. Shealy was getting OxyContin from a doctor named Ronald McIver - a lot of it. "The amounts were incredible; it jumped out in my face," the agent, who spoke on condition of anonymity, told me. "He was either selling them or taking so much he couldn\'t live." The agent did two things. He recommended to Shealy\'s employers that they exclude OxyContin coverage from their health insurance plan - which they did. And he called the D.E.A. Two days later, a D.E.A. agent showed up in the insurance agent\'s office with an administrative subpoena to collect Shealy\'s file.\u003cbr /\>\u003cbr /\>McIver wanted to be a doctor all his life, two of his daughters told me. But he taught and traveled for years before he finally enrolled at Michigan State University to become a D.O., or doctor of osteopathy, a more holistic alternative to a traditional medical education. (Osteopaths can do everything that traditional M.D.\'s can do, including prescribe opioids.) He began practicing pain medicine in the late 1980s. He had a practice in Florence, S.C., which ended when he declared bankruptcy in 2000. He moved to Greenwood to start over, establishing his new office in a storefront next to a chiropractor.\u003cbr /\>\u003cbr /\>McIver was, by the account of his patients, an unusual doctor in the age of the 10-minute managed-care visit. He usually saw about 6 to 12 patients each day. One patient I spoke with - who never got high-dose opioids - said that his first visit with McIver lasted four hours, and in subsequent visits he spent an hour or more doing various therapies. Many patients said their visits lasted an hour. Patients taking opioids had to sign a pain contract and bring their pills in at each visit to be counted.\u003cbr /\>\u003cbr /\>Many doctors take little interest in the administrative side of their practices, but McIver\'s neglect was epic. To save money, he employed mostly family. His wife, Carolyn, whose only medical training was from her husband, served as his assistant, giving shots and administering therapies. "His doctor\'s office did not resemble my family\'s doctor\'s office," said Sgt. Bobby Grogan, who was the investigator on the case for the Greenwood County Sheriff. While McIver\'s treatment rooms were normal, his and his wife\'s offices - off limits to patients - were a mess, according to pictures presented at McIver\'s trial by Adam Roberson, the D.E.A.\'s principal investigator. Used syringes, for example, overflowed their storage box. "His patient records were manila envelopes stuffed with receipts," Grogan told me.\u003cbr /\>",1]
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In July 2002, an insurance agent was sifting through records in Columbia, S.C., and paused at the file of one Larry Shealy. Shealy was getting OxyContin from a doctor named Ronald McIver - a lot of it. "The amounts were incredible; it jumped out in my face," the agent, who spoke on condition of anonymity, told me. "He was either selling them or taking so much he couldn't live." The agent did two things. He recommended to Shealy's employers that they exclude OxyContin coverage from their health insurance plan - which they did. And he called the D.E.A. Two days later, a D.E.A. agent showed up in the insurance agent's office with an administrative subpoena to collect Shealy's file.McIver wanted to be a doctor all his life, two of his daughters told me. But he taught and traveled for years before he finally enrolled at Michigan State University to become a D.O., or doctor of osteopathy, a more holistic alternative to a traditional medical education. (Osteopaths can do everything that traditional M.D.'s can do, including prescribe opioids.) He began practicing pain medicine in the late 1980s. He had a practice in Florence, S.C., which ended when he declared bankruptcy in 2000. He moved to Greenwood to start over, establishing his new office in a storefront next to a chiropractor.McIver was, by the account of his patients, an unusual doctor in the age of the 10-minute managed-care visit. He usually saw about 6 to 12 patients each day. One patient I spoke with - who never got high-dose opioids - said that his first visit with McIver lasted four hours, and in subsequent visits he spent an hour or more doing various therapies. Many patients said their visits lasted an hour. Patients taking opioids had to sign a pain contract and bring their pills in at each visit to be counted.Many doctors take little interest in the administrative side of their practices, but McIver's neglect was epic. To save money, he employed mostly family. His wife, Carolyn, whose only medical training was from her husband, served as his assistant, giving shots and administering therapies. "His doctor's office did not resemble my family's doctor's office," said Sgt. Bobby Grogan, who was the investigator on the case for the Greenwood County Sheriff. While McIver's treatment rooms were normal, his and his wife's offices - off limits to patients - were a mess, according to pictures presented at McIver's trial by Adam Roberson, the D.E.A.'s principal investigator. Used syringes, for example, overflowed their storage box. "His patient records were manila envelopes stuffed with receipts," Grogan told me.
When I interviewed him in prison recently, McIver told me that his records were complete but scattered. He said that he and his wife, distracted by a series of family tragedies, had employed a series of temporary receptionists who had botched the filing. He and his wife were trying to piece them together. "The records were probably half in the office and half at home for me to work on at night," he said. "I kept a box in the back of the car I worked on while Carolyn drove."\u003cbr /\>\u003cbr /\>Leslie Smith first came to see McIver in the fall of 2001. Smith was in his mid-40s and lived in Chapin, a small town near Columbia, a 60-mile drive from Greenwood. He filled out a medical-history form and told McIver that his wrists hurt so badly that he was getting only three or four hours\' sleep a night. He also said that a previous doctor helped him by prescribing OxyContin, and he mentioned the name of a doctor he said referred him. McIver examined Smith\'s wrists. Smith walked out with an opioid prescription and an appointment to come back the next week.\u003cbr /\>\u003cbr /\>Smith\'s wrists did not hurt him, as he testified at McIver\'s trial. He was addicted to OxyContin and Dilaudid, which he injected. He complained of wrist pain because it was plausible: he had injured one wrist previously, requiring an operation that left scars, and he had arthritis in the other. Until June 2002, Smith kept getting prescriptions.\u003cbr /\>\u003cbr /\>Smith saw McIver every few weeks. He testified that he had track marks on his arm at the time but always wore long sleeves to cover them. He said McIver never saw them. McIver put him on an electric nerve stimulator every visit for 15 or 30 minutes on each hand and did osteopathic manipulations. He prescribed exercises. Smith bought a nerve-stimulator machine to use at home and told McIver it was helping. At McIver\'s request he filled out a pain chart and reported that his pain rated a 5 or 6 upon awakening, reached 7 during the day and occasionally hit 9. "I answered all the questions exactly like I thought he\'d want to hear them answered," Smith testified. At one point McIver found a syringe in Smith\'s pocket. Smith told McIver that he was going fishing later that day and that he used the syringe as part of his fishing equipment. That apparently satisfied McIver, who testified that his grandfather kept syringes in his tackle box to pump air into his bait.\u003cbr /\>",1]
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When I interviewed him in prison recently, McIver told me that his records were complete but scattered. He said that he and his wife, distracted by a series of family tragedies, had employed a series of temporary receptionists who had botched the filing. He and his wife were trying to piece them together. "The records were probably half in the office and half at home for me to work on at night," he said. "I kept a box in the back of the car I worked on while Carolyn drove."Leslie Smith first came to see McIver in the fall of 2001. Smith was in his mid-40s and lived in Chapin, a small town near Columbia, a 60-mile drive from Greenwood. He filled out a medical-history form and told McIver that his wrists hurt so badly that he was getting only three or four hours' sleep a night. He also said that a previous doctor helped him by prescribing OxyContin, and he mentioned the name of a doctor he said referred him. McIver examined Smith's wrists. Smith walked out with an opioid prescription and an appointment to come back the next week.Smith's wrists did not hurt him, as he testified at McIver's trial. He was addicted to OxyContin and Dilaudid, which he injected. He complained of wrist pain because it was plausible: he had injured one wrist previously, requiring an operation that left scars, and he had arthritis in the other. Until June 2002, Smith kept getting prescriptions.Smith saw McIver every few weeks. He testified that he had track marks on his arm at the time but always wore long sleeves to cover them. He said McIver never saw them. McIver put him on an electric nerve stimulator every visit for 15 or 30 minutes on each hand and did osteopathic manipulations. He prescribed exercises. Smith bought a nerve-stimulator machine to use at home and told McIver it was helping. At McIver's request he filled out a pain chart and reported that his pain rated a 5 or 6 upon awakening, reached 7 during the day and occasionally hit 9. "I answered all the questions exactly like I thought he'd want to hear them answered," Smith testified. At one point McIver found a syringe in Smith's pocket. Smith told McIver that he was going fishing later that day and that he used the syringe as part of his fishing equipment. That apparently satisfied McIver, who testified that his grandfather kept syringes in his tackle box to pump air into his bait.
Smith filled some of his prescriptions at the Hawthorne Pharmacy in West Columbia. There, Addison Livingston, the pharmacist, got suspicious. He noticed that Smith sometimes came in with other patients of McIver\'s, despite the fact that McIver worked nearly two hours\' drive away. The patients obviously knew each other and would pick up large opioid prescriptions, paying cash and asking for brand-name drugs. Livingston called McIver, who confirmed he had written the prescriptions. At one point, McIver told Livingston that he, too, was suspicious, and that he had sent a letter about Smith to the state\'s Bureau of Drug Control.\u003cbr /\>\u003cbr /\>In February 2002, McIver wrote to Larry McElrath, a B.D.C. inspector, who read the letter at the trial. "Dear Larry," it read, "There are several people out of the Columbia/Chapin area who have aroused my curiosity about their use and possible misuse of medications. Some are referred by [another doctor] and seem legitimate. . . . They all pay cash despite some of them having insurance with prescription cards. . . . When they are in the office, they sometimes make a show of not knowing each other. . . . The situation is made complicated by the fact that each has some real pathology with objective findings that would justify the use of opiates if their pains are as bad as they say. I have given them the benefit of the doubt, but I\'m becoming less inclined to do so. I would appreciate it if you could make some discrete inquiries and let me know whether my concerns are justified. . . . I certainly don\'t want to refuse help to someone who needs it. On the other hand, I want even less to be implicated in diversion or other improprieties." He listed their names and Social Security numbers.\u003cbr /\>\u003cbr /\>McElrath did nothing with the letter. "It\'s incumbent upon the physician to have a trust with his patients," McElrath testified at the trial. "Here there was nothing that I could assume or conclude that any crimes had been committed."\u003cbr /\>\u003cbr /\>Smith was the most damning of the several patients who testified against McIver. (Smith and the other patients mentioned here did not agree to be interviewed for this article, as they are suing McIver for alleged overprescription of addictive drugs. Such suits often prosper after successful criminal convictions, as civil suits are easier to win.) Smith had a confederate in Seth Boyer, who lived in Chapin and followed a similar pattern in his dealings with McIver: he exaggerated pains in his foot, never provided records from a previous doctor and had needle tracks that he later testified McIver never saw. At one point, Boyer told McIver that he had spilled a bottle of liquid OxyFast, another opioid. (In reality, Boyer had injected it.) McIver wrote him a prescription for a replacement - apparently a violation of his standard pain-medication contract, which had a "no early refills" stipulation.\u003cbr /\>",1]
);
//-->
Smith filled some of his prescriptions at the Hawthorne Pharmacy in West Columbia. There, Addison Livingston, the pharmacist, got suspicious. He noticed that Smith sometimes came in with other patients of McIver's, despite the fact that McIver worked nearly two hours' drive away. The patients obviously knew each other and would pick up large opioid prescriptions, paying cash and asking for brand-name drugs. Livingston called McIver, who confirmed he had written the prescriptions. At one point, McIver told Livingston that he, too, was suspicious, and that he had sent a letter about Smith to the state's Bureau of Drug Control.In February 2002, McIver wrote to Larry McElrath, a B.D.C. inspector, who read the letter at the trial. "Dear Larry," it read, "There are several people out of the Columbia/Chapin area who have aroused my curiosity about their use and possible misuse of medications. Some are referred by [another doctor] and seem legitimate. . . . They all pay cash despite some of them having insurance with prescription cards. . . . When they are in the office, they sometimes make a show of not knowing each other. . . . The situation is made complicated by the fact that each has some real pathology with objective findings that would justify the use of opiates if their pains are as bad as they say. I have given them the benefit of the doubt, but I'm becoming less inclined to do so. I would appreciate it if you could make some discrete inquiries and let me know whether my concerns are justified. . . . I certainly don't want to refuse help to someone who needs it. On the other hand, I want even less to be implicated in diversion or other improprieties." He listed their names and Social Security numbers.McElrath did nothing with the letter. "It's incumbent upon the physician to have a trust with his patients," McElrath testified at the trial. "Here there was nothing that I could assume or conclude that any crimes had been committed."Smith was the most damning of the several patients who testified against McIver. (Smith and the other patients mentioned here did not agree to be interviewed for this article, as they are suing McIver for alleged overprescription of addictive drugs. Such suits often prosper after successful criminal convictions, as civil suits are easier to win.) Smith had a confederate in Seth Boyer, who lived in Chapin and followed a similar pattern in his dealings with McIver: he exaggerated pains in his foot, never provided records from a previous doctor and had needle tracks that he later testified McIver never saw. At one point, Boyer told McIver that he had spilled a bottle of liquid OxyFast, another opioid. (In reality, Boyer had injected it.) McIver wrote him a prescription for a replacement - apparently a violation of his standard pain-medication contract, which had a "no early refills" stipulation.
But McIver ended up discharging Boyer in June 2002, when Boyer altered a prescription so he could fill it three days early. He wrote McIver three pleading letters of protest, to no avail. "I was looking for an excuse to discharge them, and with Seth I found it," McIver told me. "I needed more than suspicion. With Les, he never actually did anything that allowed me to say, \'O.K., here\'s that concrete piece of evidence.\' "\u003cbr /\>\u003cbr /\>McIver may have felt he needed more proof, but medically he probably had enough. Pain specialists told me that doctors can stop prescribing a drug whenever the risks outweigh the benefits, which includes the risk of abuse.\u003cbr /\>\u003cbr /\>Another drug-dealing patient of McIver\'s was Kyle Barnes. She testified that she suffered from fibromyalgia, a chronic-pain syndrome, but exaggerated her pain to get higher levels of OxyContin and Roxicodone. She was addicted to those drugs before she began seeing McIver in July 2001. She also brought no medical records and drove three hours to each appointment. She got prescriptions on her second visit, during which McIver also did osteopathic manipulations and massage.\u003cbr /\>\u003cbr /\>Barnes was in real pain. McIver did several different therapies at each visit. He set up an appointment for her at a sleep clinic, sent her for X-rays and put a cast on her wrist. He knew she had trouble paying for her medicines, and he contacted Purdue Pharma to see if she qualified for reduced-price drugs. She kept claiming the drugs were not helping enough and was soon taking 16 times the dose of OxyContin she took when she first saw him. One tip-off in her case should have been that she paid thousands of dollars a month in cash for her prescriptions, even though she was on Medicaid. She told McIver that her father and boyfriend were helping her buy them, which she later testified was partly true. But most of her income came from selling some of the drugs he prescribed, she testified. In December 2003, McIver told her that he would stop treating her unless she took a drug screen. She did nothing. Three weeks later he told her again. She never returned.\u003cbr /\>",1]
);
//-->
But McIver ended up discharging Boyer in June 2002, when Boyer altered a prescription so he could fill it three days early. He wrote McIver three pleading letters of protest, to no avail. "I was looking for an excuse to discharge them, and with Seth I found it," McIver told me. "I needed more than suspicion. With Les, he never actually did anything that allowed me to say, 'O.K., here's that concrete piece of evidence.' "McIver may have felt he needed more proof, but medically he probably had enough. Pain specialists told me that doctors can stop prescribing a drug whenever the risks outweigh the benefits, which includes the risk of abuse.Another drug-dealing patient of McIver's was Kyle Barnes. She testified that she suffered from fibromyalgia, a chronic-pain syndrome, but exaggerated her pain to get higher levels of OxyContin and Roxicodone. She was addicted to those drugs before she began seeing McIver in July 2001. She also brought no medical records and drove three hours to each appointment. She got prescriptions on her second visit, during which McIver also did osteopathic manipulations and massage.Barnes was in real pain. McIver did several different therapies at each visit. He set up an appointment for her at a sleep clinic, sent her for X-rays and put a cast on her wrist. He knew she had trouble paying for her medicines, and he contacted Purdue Pharma to see if she qualified for reduced-price drugs. She kept claiming the drugs were not helping enough and was soon taking 16 times the dose of OxyContin she took when she first saw him. One tip-off in her case should have been that she paid thousands of dollars a month in cash for her prescriptions, even though she was on Medicaid. She told McIver that her father and boyfriend were helping her buy them, which she later testified was partly true. But most of her income came from selling some of the drugs he prescribed, she testified. In December 2003, McIver told her that he would stop treating her unless she took a drug screen. She did nothing. Three weeks later he told her again. She never returned.
Another patient whose story was particularly troubling was Barbee Brown. Brown was not a drug seeker but a genuine pain patient seeking relief from Reflex Sympathetic Dystrophy. McIver gave her very high doses of OxyContin right away, before she produced any records from other doctors. This was especially disturbing, because she had been addicted to crack cocaine for three months in the year before she came to him.\u003cbr /\>\u003cbr /\>Brown saw McIver at least twice a week for six weeks. He did a thorough physical exam and took a complete history. He used many different kinds of therapies. But he also started her - someone who had never taken opioids - on 40-milligram pills of OxyContin and allowed her to control her own dosing schedule. "As long as you are not having side effects, do not be afraid to take the doses you need to get out of pain," he wrote to her. It was the same advice he gave many patients. "The number of milligrams does not matter. What matters is the number on the 0-to-10 scale."\u003cbr /\>\u003cbr /\>The medicine helped. Brown testified that she ranked her pain at 9 or 10 when she first got to McIver. After seeing him, it dropped to a 4. Her pain diary, which appears to be sincere, had various passages giving thanks that she met McIver. Brown did not become addicted. But allowing an opioid-naïve recovering crack addict to start on high-dose pills and control her own dosage, and telling her that her dosage didn\'t matter, seems reckless.\u003cbr /\>\u003cbr /\>McIver\'s 30-year sentence was the result of the death of Larry Shealy, a 56-year-old man who suffered intense back and knee pain, in addition to many other health problems. He first came to see McIver in February 2002, with full referrals and records. He was on OxyContin before seeing McIver but complained that his pain was still terrible, so McIver doubled his dose. This allowed Shealy to go back to work in an auto body shop.\u003cbr /\>\u003cbr /\>Shealy was not a careful patient. A month after he started with McIver, he took 15 OxyContin tablets in one day instead of the 6 he was prescribed. He was not harmed, but McIver testified that he asked Shealy to bring his family in so he could explain the dosing to them. At one point, McIver tried to taper down the OxyContin and replace it with methadone, but Shealy complained that the methadone made him drowsy. Shealy\'s son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated - often sleepy. Once, his father backed his truck into a tree.\u003cbr /\>",1]
);
//-->
Another patient whose story was particularly troubling was Barbee Brown. Brown was not a drug seeker but a genuine pain patient seeking relief from Reflex Sympathetic Dystrophy. McIver gave her very high doses of OxyContin right away, before she produced any records from other doctors. This was especially disturbing, because she had been addicted to crack cocaine for three months in the year before she came to him.Brown saw McIver at least twice a week for six weeks. He did a thorough physical exam and took a complete history. He used many different kinds of therapies. But he also started her - someone who had never taken opioids - on 40-milligram pills of OxyContin and allowed her to control her own dosing schedule. "As long as you are not having side effects, do not be afraid to take the doses you need to get out of pain," he wrote to her. It was the same advice he gave many patients. "The number of milligrams does not matter. What matters is the number on the 0-to-10 scale."The medicine helped. Brown testified that she ranked her pain at 9 or 10 when she first got to McIver. After seeing him, it dropped to a 4. Her pain diary, which appears to be sincere, had various passages giving thanks that she met McIver. Brown did not become addicted. But allowing an opioid-naïve recovering crack addict to start on high-dose pills and control her own dosage, and telling her that her dosage didn't matter, seems reckless.McIver's 30-year sentence was the result of the death of Larry Shealy, a 56-year-old man who suffered intense back and knee pain, in addition to many other health problems. He first came to see McIver in February 2002, with full referrals and records. He was on OxyContin before seeing McIver but complained that his pain was still terrible, so McIver doubled his dose. This allowed Shealy to go back to work in an auto body shop.Shealy was not a careful patient. A month after he started with McIver, he took 15 OxyContin tablets in one day instead of the 6 he was prescribed. He was not harmed, but McIver testified that he asked Shealy to bring his family in so he could explain the dosing to them. At one point, McIver tried to taper down the OxyContin and replace it with methadone, but Shealy complained that the methadone made him drowsy. Shealy's son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated - often sleepy. Once, his father backed his truck into a tree.
Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam - Xanax - as well. The pathologist at McIver\'s trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing - the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution\'s toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy\'s death by respiratory depression. The pathologist testified that she looked up this dosage and found it to be a fatal level.\u003cbr /\>\u003cbr /\>But there is reason for doubt. According to Shealy\'s prescriptions, he had been taking the same dosage for at least two months, and possibly much longer. Pain specialists say that respiratory depression is extremely unlikely when dosage is consistent. In her testimony, Garvin agreed that what would be a toxic level in an opioid-naïve patient would be safe for someone titrated up properly. But she said she could not conclude he had been properly titrated, in part because she had not seen his medical records. Garvin declined to talk about the Shealy case with me because she is a witness for the Shealy family in their planned civil suit against McIver. But in a deposition for that lawsuit, she appeared to back away from blaming the OxyContin. She described her view as: "Hey, there\'s a red flag here. This can certainly be your cause of death, but you need to go further in exploring whether or not it is."\u003cbr /\>\u003cbr /\>There was something else that might have caused Shealy\'s death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.\u003cbr /\>",1]
);
//-->
Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam - Xanax - as well. The pathologist at McIver's trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing - the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution's toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy's death by respiratory depression. The pathologist testified that she looked up this dosage and found it to be a fatal level.But there is reason for doubt. According to Shealy's prescriptions, he had been taking the same dosage for at least two months, and possibly much longer. Pain specialists say that respiratory depression is extremely unlikely when dosage is consistent. In her testimony, Garvin agreed that what would be a toxic level in an opioid-naïve patient would be safe for someone titrated up properly. But she said she could not conclude he had been properly titrated, in part because she had not seen his medical records. Garvin declined to talk about the Shealy case with me because she is a witness for the Shealy family in their planned civil suit against McIver. But in a deposition for that lawsuit, she appeared to back away from blaming the OxyContin. She described her view as: "Hey, there's a red flag here. This can certainly be your cause of death, but you need to go further in exploring whether or not it is."There was something else that might have caused Shealy's death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.
The testimonies of the patients Smith, Boyer and Barnes were the parts of the trial that most directly addressed the question of whether McIver intentionally wrote prescriptions for a nonmedical purpose. This is the relevant legal test for the statute under which he was prosecuted. Several Supreme Court and district court cases have made it clear that under the Controlled Substances Act, a doctor is guilty of a crime if he intentionally acts as a drug pusher.\u003cbr /\>\u003cbr /\>The judge in the McIver case, Henry F. Floyd, told the jurors that bad prescribing is the standard for malpractice, a civil matter. "That is not what we are talking about," he said. "We\'re not talking about this physician acting better or worse than other physicians." If McIver was a bad doctor - but still a doctor, with intent to treat patients - he was innocent. "If you find that a defendant acted in good faith in dispensing the drugs charged in this indictment, then you must find that defendant not guilty," Floyd said. But Floyd also told the jury to take bad doctoring into account in deciding McIver\'s intent.\u003cbr /\>\u003cbr /\>This instruction - that bad doctoring does not prove intent but could be considered when weighing his intent - is subtle and potentially extremely confusing. It apparently confused the jurors. I spoke to two jurors, who told me their own views and characterized the jury discussion. The overwhelming factor, they said, was that McIver prescribed too much - the very red flag that alerted the insurance agent and set the case in motion.\u003cbr /\>\u003cbr /\>The jurors I spoke with said that by far the most important testimony came from Steven Storick, a pain-management doctor in Columbia and the government\'s expert witness. Reviewing the records of patient after patient, Storick consistently testified that there were too many drugs. "This amount of medication is just extremely high in a situation like this," he said of one patient. This is "excessive," he said of another. "That\'s just an extremely high dose of drug," he said of a third. Storick, who declined to be interviewed for this article, testified that if he had a patient who exhibited no objective evidence of pain, he would not prescribe opioids. He would not have titrated patients as rapidly as McIver did or given them discretion. He disagreed with McIver\'s position that a doctor should try to bring a patient\'s chronic pain down to a level of 2. He would stop titrating when a patient reached 5 out of 10.\u003cbr /\>\u003cbr /\>The jurors took Storick\'s caution to heart, in part, they told me, because it resonated with their own experience with opioids and fears of addiction. I asked Jo Handy, a tall, elegant woman who is now 39 and a real estate agent outside Greenville, why McIver was convicted. "It was the excessive prescriptions," she said in a\u003cbr /\>\u003cbr /\>\u003cbr /\>\u003c/div\>",0]
);
//-->
The testimonies of the patients Smith, Boyer and Barnes were the parts of the trial that most directly addressed the question of whether McIver intentionally wrote prescriptions for a nonmedical purpose. This is the relevant legal test for the statute under which he was prosecuted. Several Supreme Court and district court cases have made it clear that under the Controlled Substances Act, a doctor is guilty of a crime if he intentionally acts as a drug pusher.The judge in the McIver case, Henry F. Floyd, told the jurors that bad prescribing is the standard for malpractice, a civil matter. "That is not what we are talking about," he said. "We're not talking about this physician acting better or worse than other physicians." If McIver was a bad doctor - but still a doctor, with intent to treat patients - he was innocent. "If you find that a defendant acted in good faith in dispensing the drugs charged in this indictment, then you must find that defendant not guilty," Floyd said. But Floyd also told the jury to take bad doctoring into account in deciding McIver's intent.This instruction - that bad doctoring does not prove intent but could be considered when weighing his intent - is subtle and potentially extremely confusing. It apparently confused the jurors. I spoke to two jurors, who told me their own views and characterized the jury discussion. The overwhelming factor, they said, was that McIver prescribed too much - the very red flag that alerted the insurance agent and set the case in motion.The jurors I spoke with said that by far the most important testimony came from Steven Storick, a pain-management doctor in Columbia and the government's expert witness. Reviewing the records of patient after patient, Storick consistently testified that there were too many drugs. "This amount of medication is just extremely high in a situation like this," he said of one patient. This is "excessive," he said of another. "That's just an extremely high dose of drug," he said of a third. Storick, who declined to be interviewed for this article, testified that if he had a patient who exhibited no objective evidence of pain, he would not prescribe opioids. He would not have titrated patients as rapidly as McIver did or given them discretion. He disagreed with McIver's position that a doctor should try to bring a patient's chronic pain down to a level of 2. He would stop titrating when a patient reached 5 out of 10.The jurors took Storick's caution to heart, in part, they told me, because it resonated with their own experience with opioids and fears of addiction. I asked Jo Handy, a tall, elegant woman who is now 39 and a real estate agent outside Greenville, why McIver was convicted. "It was the excessive prescriptions," she said in a
Sunday
Grey Literature Report (Vol. 9, No. 3, May 2007)
The most recent Grey Literature Report (Vol. 9, No. 3, May 2007) is now available at http://www.nyam.org/library/pages/current_grey_literature_report
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We hope you will find this report useful!
The Grey Literature Team
The New York Academy of Medicine
NGA Center for Best Practices
Integrating schools into healthy community design - 2007
Office of Applied Studies, Substance Abuse and Mental Health Service Administration, Dept. of Health & Human Services
Depression and the initiation of alcohol and other drug use among youths aged 12 to 17 - 2007
Heroin, changes in how it is used : 1995-2005 - 2007
Hispanic female admissions in substance abuse treatment : 2005 - 2007
Patterns and trends in inhalant use by adolescent males and females : 2002-2005 - 2007
Patterns and trends in nonmedical prescription pain reliever use : 2002 to 2005 - 2007
Primary alcohol admissions aged 21 or older : alcohol only vs alcohol plus a secondary drug : 2005 - 2007
Religious involvement and substance use among adults - 2007
Sexually transmitted diseases and substance use - 2007
Use of marijuana and blunts among adolescents : 2005 - 2007
Youth activities, substance use, and family income - 2007
Older Women's League
best optical illusions of 2007
http://illusioncontest.neuralcorrelate.com/index.php?module=pagemaster&PAGE_user_op=view_page&PAGE_id=114
Wednesday
New Research Shows Supervised Drug Injection Sites Work
http://www.drugpolicy.org/news/053107vancouver.cfm
New Research Shows Supervised Drug Injection Sites Work
Thursday, May 31, 2007
New research indicates that Vancouver's safe injection site, Insite,
is getting more people into treatment without increasing drug use.
Tony Newman, communications director for the Drug Policy Alliance,
offers his thoughts.
What should be done about the millions of people in the United States
and around the world who inject heroin and other drugs? For 30-plus
years, the U.S. has pushed a war on drugs that is more accurately a
war on drug users. This war on drugs has not delivered on its promise
to keep drugs off our streets or prevent people from using, but it has
filled our prisons beyond capacity and led to far too many cases of
HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their
city’s problems associated with injection drug use. In 2003, the city
established a clean injection site where users can take their drugs in
a sterile environment, and under the supervision of clinical staff.
The rationale is that as much as we don’t want people shooting up
drugs, some—-often society’s most marginalized—-inevitably will.
There are three likely settings for injection drug use: 1) public
places like parks and street corners; 2) "shooting galleries" that are
often dirty, violent, controlled by drug dealers, and conducive to the
sharing of dirty needles; and 3) safe, clean facilities under the
supervision of nurses and public health officials. Aside from making
sure people are using clean needles and are not overdosing, health
professionals can use the opportunity to provide treatment options
designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver’s strategy? A study released on
Friday in the esteemed British journal Addiction found that not only
is the Vancouver injection site accomplishing the goals of reducing
public drug use, cutting down on the spread of HIV/AIDS and overdose
deaths, but is also a bridge helping people get into treatment. The
study found that the city’s supervised injection site increased the
rate of addicts entering detox by 30 percent. The study confirmed that
all of these concrete benefits are happening without increasing drug
use. Similar findings were reported in studies of safer injection
rooms in Germany, Switzerland and Australia. Despite these encouraging
results, the supervised injection backers worry that the recently
elected Conservative leadership in Canada will terminate the
successful program by year’s end.
While some may hope and pray for a "drug free society," the reality is
that there will always be some who will find their way to drugs. We
need to do everything we can to make treatment available to heroin
users and everyone trying to quit drugs. But we should also study what
Vancouver and other countries are exploring. We need to find ways to
reduce the death, disease, crime and suffering of people who are
unwilling or unable to stop.
New Research Shows Supervised Drug Injection Sites Work
DPA Awards Rapid Response Grants for Work on Civil Liberties and Medical Marijuana Access
California Legislators Show Support for Treatment-vs-Incarceration
New Research Shows Supervised Drug Injection Sites Work
Tony Newman, communications director for the Drug Policy Alliance, offers his thoughts on Vancouver's safe injection site, Insite.
What should be done about the millions of people in the United States and around the world who inject heroin and other drugs? For 30-plus years, the U.S. has pushed a war on drugs that is more accurately a war on drug users. This war on drugs has not delivered on its promise to keep drugs off our streets or prevent people from using, but it has filled our prisons beyond capacity and led to far too many cases of HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their city's problems associated with injection drug use. In 2003, the city established a clean injection site where users can take their drugs in a sterile environment, and under the supervision of clinical staff. The rationale is that as much as we don't want people shooting up drugs, some--often society's most marginalized--inevitably will.
There are three likely settings for injection drug use: 1) public places like parks and street corners; 2) "shooting galleries" that are often dirty, violent, controlled by drug dealers, and conducive to the sharing of dirty needles; and 3) safe, clean facilities under the supervision of nurses and public health officials. Aside from making sure people are using clean needles and are not overdosing, health professionals can use the opportunity to provide treatment options designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver's strategy? A study released on Friday in the esteemed British journal Addiction found that not only is the Vancouver injection site accomplishing the goals of reducing public drug use, cutting down on the spread of HIV/AIDS and overdose deaths, but is also a bridge helping people get into treatment. The study found that the city's supervised injection site increased the rate of addicts entering detox by 30 percent. The study confirmed that all of these concrete benefits are happening without increasing drug use. Similar findings were reported in studies of safer injection rooms in Germany, Switzerland and Australia. Despite these encouraging results, the supervised injection backers worry that the recently elected Conservative leadership in Canada will terminate the successful program by year's end.
While some may hope and pray for a "drug free society," the reality is that there will always be some who will find their way to drugs. We need to do everything we can to make treatment available to heroin users and everyone trying to quit drugs. But we should also study what Vancouver and other countries are exploring. We need to find ways to reduce the death, disease, crime and suffering of people who are unwilling or unable to stop.
New Research Shows Supervised Drug Injection Sites Work
Thursday, May 31, 2007
New research indicates that Vancouver's safe injection site, Insite,
is getting more people into treatment without increasing drug use.
Tony Newman, communications director for the Drug Policy Alliance,
offers his thoughts.
What should be done about the millions of people in the United States
and around the world who inject heroin and other drugs? For 30-plus
years, the U.S. has pushed a war on drugs that is more accurately a
war on drug users. This war on drugs has not delivered on its promise
to keep drugs off our streets or prevent people from using, but it has
filled our prisons beyond capacity and led to far too many cases of
HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their
city’s problems associated with injection drug use. In 2003, the city
established a clean injection site where users can take their drugs in
a sterile environment, and under the supervision of clinical staff.
The rationale is that as much as we don’t want people shooting up
drugs, some—-often society’s most marginalized—-inevitably will.
There are three likely settings for injection drug use: 1) public
places like parks and street corners; 2) "shooting galleries" that are
often dirty, violent, controlled by drug dealers, and conducive to the
sharing of dirty needles; and 3) safe, clean facilities under the
supervision of nurses and public health officials. Aside from making
sure people are using clean needles and are not overdosing, health
professionals can use the opportunity to provide treatment options
designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver’s strategy? A study released on
Friday in the esteemed British journal Addiction found that not only
is the Vancouver injection site accomplishing the goals of reducing
public drug use, cutting down on the spread of HIV/AIDS and overdose
deaths, but is also a bridge helping people get into treatment. The
study found that the city’s supervised injection site increased the
rate of addicts entering detox by 30 percent. The study confirmed that
all of these concrete benefits are happening without increasing drug
use. Similar findings were reported in studies of safer injection
rooms in Germany, Switzerland and Australia. Despite these encouraging
results, the supervised injection backers worry that the recently
elected Conservative leadership in Canada will terminate the
successful program by year’s end.
While some may hope and pray for a "drug free society," the reality is
that there will always be some who will find their way to drugs. We
need to do everything we can to make treatment available to heroin
users and everyone trying to quit drugs. But we should also study what
Vancouver and other countries are exploring. We need to find ways to
reduce the death, disease, crime and suffering of people who are
unwilling or unable to stop.
New Research Shows Supervised Drug Injection Sites Work
DPA Awards Rapid Response Grants for Work on Civil Liberties and Medical Marijuana Access
California Legislators Show Support for Treatment-vs-Incarceration
New Research Shows Supervised Drug Injection Sites Work
Tony Newman, communications director for the Drug Policy Alliance, offers his thoughts on Vancouver's safe injection site, Insite.
What should be done about the millions of people in the United States and around the world who inject heroin and other drugs? For 30-plus years, the U.S. has pushed a war on drugs that is more accurately a war on drug users. This war on drugs has not delivered on its promise to keep drugs off our streets or prevent people from using, but it has filled our prisons beyond capacity and led to far too many cases of HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their city's problems associated with injection drug use. In 2003, the city established a clean injection site where users can take their drugs in a sterile environment, and under the supervision of clinical staff. The rationale is that as much as we don't want people shooting up drugs, some--often society's most marginalized--inevitably will.
There are three likely settings for injection drug use: 1) public places like parks and street corners; 2) "shooting galleries" that are often dirty, violent, controlled by drug dealers, and conducive to the sharing of dirty needles; and 3) safe, clean facilities under the supervision of nurses and public health officials. Aside from making sure people are using clean needles and are not overdosing, health professionals can use the opportunity to provide treatment options designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver's strategy? A study released on Friday in the esteemed British journal Addiction found that not only is the Vancouver injection site accomplishing the goals of reducing public drug use, cutting down on the spread of HIV/AIDS and overdose deaths, but is also a bridge helping people get into treatment. The study found that the city's supervised injection site increased the rate of addicts entering detox by 30 percent. The study confirmed that all of these concrete benefits are happening without increasing drug use. Similar findings were reported in studies of safer injection rooms in Germany, Switzerland and Australia. Despite these encouraging results, the supervised injection backers worry that the recently elected Conservative leadership in Canada will terminate the successful program by year's end.
While some may hope and pray for a "drug free society," the reality is that there will always be some who will find their way to drugs. We need to do everything we can to make treatment available to heroin users and everyone trying to quit drugs. But we should also study what Vancouver and other countries are exploring. We need to find ways to reduce the death, disease, crime and suffering of people who are unwilling or unable to stop.
altruism and the brain
altruism and the brain
Proc Natl Acad Sci U S A. 2006 Oct 17;103(42):15623-8. Epub 2006 Oct 9.
Human fronto-mesolimbic networks guide decisions about charitable
donation.
Moll J, Krueger F, Zahn R, Pardini M, de Oliveira-Souza R, Grafman J.
Cognitive Neuroscience Section, National Institute of Neurological
Disorders and
Stroke, National Institutes of Health, Bethesda, MD 20892-1440, USA.
Humans often sacrifice material benefits to endorse or to oppose
societal
causes based on moral beliefs. Charitable donation behavior, which has
been the target of recent experimental economics studies, is an
outstanding contemporary manifestation of this ability. Yet the neural
bases of this unique aspect of human altruism, which extends beyond
interpersonal interactions, remain obscure. In this article, we use
functional magnetic resonance imaging while participants anonymously
donated to or opposed real charitable organizations related to major
societal causes. We show that the mesolimbic reward system is engaged by
donations in the same way as when monetary rewards are obtained.
Furthermore, medial orbitofrontal-subgenual and lateral orbitofrontal
areas, which also play key roles in more primitive mechanisms of social
attachment and aversion, specifically mediate decisions to donate or to
oppose societal causes. Remarkably, more anterior sectors of the
prefrontal cortex are distinctively recruited when altruistic choices
prevail over selfish material interests.
PMID: 17030808 [PubMed - indexed for MEDLINE]
http://www.washingtonpost.com/wp-dyn/content/article/2007/05/27/AR2007052701056_pf.html
>
> If It Feels Good to Be Good, It Might Be Only Natural
>
> By Shankar Vedantam
> Washington Post Staff Writer
> Monday, May 28, 2007; A01
>
>
> The e-mail came from the next room.
>
> "You gotta see this!" Jorge Moll had written. Moll and Jordan Grafman,
neuroscientists at the National Institutes of Health, had been scanning
the brains of volunteers as they were asked to think about a scenario
involving either donating a sum of money to charity or keeping it for
themselves.
>
> As Grafman read the e-mail, Moll came bursting in. The scientists
stared at each other. Grafman was thinking, "Whoa -- wait a minute!"
>
> The results were showing that when the volunteers placed the interests
of others before their own, the generosity activated a primitive part of
the brain that usually lights up in response to food or sex. Altruism,
the experiment suggested, was not a superior moral faculty that
suppresses basic selfish urges but rather was basic to the brain,
hard-wired and pleasurable.
>
> Their 2006 finding that unselfishness can feel good lends scientific
support to the admonitions of spiritual leaders such as Saint Francis of
Assisi, who said, "For it is in giving that we receive." But it is also
a dramatic example of the way neuroscience has begun to elbow its way
into discussions about morality and has opened up a new window on what
it means to be good.
>
> Grafman and others are using brain imaging and psychological
experiments to study whether the brain has a built-in moral compass. The
results -- many of them published just in recent months -- are showing,
unexpectedly, that many aspects of morality appear to be hard-wired in
the brain, most likely the result of evolutionary processes that began
in other species.
>
> No one can say whether giraffes and lions experience moral qualms in
the same way people do because no one has been inside a giraffe's head,
but it is known that animals can sacrifice their own interests: One
experiment found that if each time a rat is given food, its neighbor
receives an electric shock, the first rat will eventually forgo eating.
>
> What the new research is showing is that morality has biological roots
-- such as the reward center in the brain that lit up in Grafman's
experiment -- that have been around for a very long time.
>
> The more researchers learn, the more it appears that the foundation of
morality is empathy. Being able to recognize -- even experience
vicariously -- what another creature is going through was an important
leap in the evolution of social behavior. And it is only a short step
from this awareness to many human notions of right and wrong, says Jean
Decety, a neuroscientist at the University of Chicago.
>
> The research enterprise has been viewed with interest by philosophers
and theologians, but already some worry that it raises troubling
questions. Reducing morality and immorality to brain chemistry -- rather
than free will -- might diminish the importance of personal
responsibility. Even more important, some wonder whether the very idea
of morality is somehow degraded if it turns out to be just another
evolutionary tool that nature uses to help species survive and
propagate.
>
> Moral decisions can often feel like abstract intellectual challenges,
but a number of experiments such as the one by Grafman have shown that
emotions are central to moral thinking. In another experiment published
in March, University of Southern California neuroscientist Antonio R.
Damasio and his colleagues showed that patients with damage to an area
of the brain known as the ventromedial prefrontal cortex lack the
ability to feel their way to moral answers.
>
> When confronted with moral dilemmas, the brain-damaged patients coldly
came up with "end-justifies-the-means" answers. Damasio said the point
was not that they reached immoral conclusions, but that when confronted
by a difficult issue -- such as whether to shoot down a passenger plane
hijacked by terrorists before it hits a major city -- these patients
appear to reach decisions without the anguish that afflicts those with
normally functioning brains.
>
> Such experiments have two important implications. One is that morality
is not merely about the decisions people reach but also about the
process by which they get there. Another implication, said Adrian Raine,
a clinical neuroscientist at the University of Southern California, is
that society may have to rethink how it judges immoral people.
>
> Psychopaths often feel no empathy or remorse. Without that awareness,
people relying exclusively on reasoning seem to find it harder to sort
their way through moral thickets. Does that mean they should be held to
different standards of accountability?
>
> "Eventually, you are bound to get into areas that for thousands of
years we have preferred to keep mystical," said Grafman, the chief
cognitive neuroscientist at the National Institute of Neurological
Disorders and Stroke. "Some of the questions that are important are not
just of intellectual interest, but challenging and frightening to the
ways we ground our lives. We need to step very carefully."
>
> Joshua D. Greene, a Harvard neuroscientist and philosopher, said
multiple experiments suggest that morality arises from basic brain
activities. Morality, he said, is not a brain function elevated above
our baser impulses. Greene said it is not "handed down" by philosophers
and clergy, but "handed up," an outgrowth of the brain's basic
propensities.
>
> Moral decision-making often involves competing brain networks vying
for supremacy, he said. Simple moral decisions -- is killing a child
right or wrong? -- are simple because they activate a straightforward
brain response. Difficult moral decisions, by contrast, activate
multiple brain regions that conflict with one another, he said.
>
> In one 2004 brain-imaging experiment, Greene asked volunteers to
imagine that they were hiding in a cellar of a village as enemy soldiers
came looking to kill all the inhabitants. If a baby was crying in the
cellar, Greene asked, was it right to smother the child to keep the
soldiers from discovering the cellar and killing everyone?
>
> The reason people are slow to answer such an awful question, the study
indicated, is that emotion-linked circuits automatically signaling that
killing a baby is wrong clash with areas of the brain that involve
cooler aspects of cognition. One brain region activated when people
process such difficult choices is the inferior parietal lobe, which has
been shown to be active in more impersonal decision-making. This part of
the brain, in essence, was "arguing" with brain networks that reacted
with visceral horror.
>
> Such studies point to a pattern, Greene said, showing "competing
forces that may have come online at different points in our evolutionary
history. A basic emotional response is probably much older than the
ability to evaluate costs and benefits."
>
> While one implication of such findings is that people with certain
kinds of brain damage may do bad things they cannot be held responsible
for, the new research could also expand the boundaries of moral
responsibility. Neuroscience research, Greene said, is finally
explaining a problem that has long troubled philosophers and moral
teachers: Why is it that people who are willing to help someone in front
of them will ignore abstract pleas for help from those who are distant,
such as a request for a charitable contribution that could save the life
of a child overseas?
>
> "We evolved in a world where people in trouble right in front of you
existed, so our emotions were tuned to them, whereas we didn't face the
other kind of situation," Greene said. "It is comforting to think your
moral intuitions are reliable and you can trust them. But if my analysis
is right, your intuitions are not trustworthy. Once you realize why you
have the intuitions you have, it puts a burden on you" to think about
morality differently.
>
> Marc Hauser, another Harvard researcher, has used cleverly designed
psychological experiments to study morality. He said his research has
found that people all over the world process moral questions in the same
way, suggesting that moral thinking is intrinsic to the human brain,
rather than a product of culture. It may be useful to think about
morality much like language, in that its basic features are hard-wired,
Hauser said. Different cultures and religions build on that framework in
much the way children in different cultures learn different languages
using the same neural machinery.
>
> Hauser said that if his theory is right, there should be aspects of
morality that are automatic and unconscious -- just like language.
People would reach moral conclusions in the same way they construct a
sentence without having been trained in linguistics. Hauser said the
idea could shed light on contradictions in common moral stances.
>
> U.S. law, for example, distinguishes between a physician who removes a
feeding tube from a terminally ill patient and a physician who
administers a drug to kill the patient.
>
> Hauser said the only difference is that the second scenario is more
emotionally charged -- and therefore feels like a different moral
problem, when it really is not: "In the end, the doctor's intent is to
reduce suffering, and that is as true in active as in passive
euthanasia, and either way the patient is dead."
Proc Natl Acad Sci U S A. 2006 Oct 17;103(42):15623-8. Epub 2006 Oct 9.
Human fronto-mesolimbic networks guide decisions about charitable
donation.
Moll J, Krueger F, Zahn R, Pardini M, de Oliveira-Souza R, Grafman J.
Cognitive Neuroscience Section, National Institute of Neurological
Disorders and
Stroke, National Institutes of Health, Bethesda, MD 20892-1440, USA.
Humans often sacrifice material benefits to endorse or to oppose
societal
causes based on moral beliefs. Charitable donation behavior, which has
been the target of recent experimental economics studies, is an
outstanding contemporary manifestation of this ability. Yet the neural
bases of this unique aspect of human altruism, which extends beyond
interpersonal interactions, remain obscure. In this article, we use
functional magnetic resonance imaging while participants anonymously
donated to or opposed real charitable organizations related to major
societal causes. We show that the mesolimbic reward system is engaged by
donations in the same way as when monetary rewards are obtained.
Furthermore, medial orbitofrontal-subgenual and lateral orbitofrontal
areas, which also play key roles in more primitive mechanisms of social
attachment and aversion, specifically mediate decisions to donate or to
oppose societal causes. Remarkably, more anterior sectors of the
prefrontal cortex are distinctively recruited when altruistic choices
prevail over selfish material interests.
PMID: 17030808 [PubMed - indexed for MEDLINE]
http://www.washingtonpost.com/wp-dyn/content/article/2007/05/27/AR2007052701056_pf.html
>
> If It Feels Good to Be Good, It Might Be Only Natural
>
> By Shankar Vedantam
> Washington Post Staff Writer
> Monday, May 28, 2007; A01
>
>
> The e-mail came from the next room.
>
> "You gotta see this!" Jorge Moll had written. Moll and Jordan Grafman,
neuroscientists at the National Institutes of Health, had been scanning
the brains of volunteers as they were asked to think about a scenario
involving either donating a sum of money to charity or keeping it for
themselves.
>
> As Grafman read the e-mail, Moll came bursting in. The scientists
stared at each other. Grafman was thinking, "Whoa -- wait a minute!"
>
> The results were showing that when the volunteers placed the interests
of others before their own, the generosity activated a primitive part of
the brain that usually lights up in response to food or sex. Altruism,
the experiment suggested, was not a superior moral faculty that
suppresses basic selfish urges but rather was basic to the brain,
hard-wired and pleasurable.
>
> Their 2006 finding that unselfishness can feel good lends scientific
support to the admonitions of spiritual leaders such as Saint Francis of
Assisi, who said, "For it is in giving that we receive." But it is also
a dramatic example of the way neuroscience has begun to elbow its way
into discussions about morality and has opened up a new window on what
it means to be good.
>
> Grafman and others are using brain imaging and psychological
experiments to study whether the brain has a built-in moral compass. The
results -- many of them published just in recent months -- are showing,
unexpectedly, that many aspects of morality appear to be hard-wired in
the brain, most likely the result of evolutionary processes that began
in other species.
>
> No one can say whether giraffes and lions experience moral qualms in
the same way people do because no one has been inside a giraffe's head,
but it is known that animals can sacrifice their own interests: One
experiment found that if each time a rat is given food, its neighbor
receives an electric shock, the first rat will eventually forgo eating.
>
> What the new research is showing is that morality has biological roots
-- such as the reward center in the brain that lit up in Grafman's
experiment -- that have been around for a very long time.
>
> The more researchers learn, the more it appears that the foundation of
morality is empathy. Being able to recognize -- even experience
vicariously -- what another creature is going through was an important
leap in the evolution of social behavior. And it is only a short step
from this awareness to many human notions of right and wrong, says Jean
Decety, a neuroscientist at the University of Chicago.
>
> The research enterprise has been viewed with interest by philosophers
and theologians, but already some worry that it raises troubling
questions. Reducing morality and immorality to brain chemistry -- rather
than free will -- might diminish the importance of personal
responsibility. Even more important, some wonder whether the very idea
of morality is somehow degraded if it turns out to be just another
evolutionary tool that nature uses to help species survive and
propagate.
>
> Moral decisions can often feel like abstract intellectual challenges,
but a number of experiments such as the one by Grafman have shown that
emotions are central to moral thinking. In another experiment published
in March, University of Southern California neuroscientist Antonio R.
Damasio and his colleagues showed that patients with damage to an area
of the brain known as the ventromedial prefrontal cortex lack the
ability to feel their way to moral answers.
>
> When confronted with moral dilemmas, the brain-damaged patients coldly
came up with "end-justifies-the-means" answers. Damasio said the point
was not that they reached immoral conclusions, but that when confronted
by a difficult issue -- such as whether to shoot down a passenger plane
hijacked by terrorists before it hits a major city -- these patients
appear to reach decisions without the anguish that afflicts those with
normally functioning brains.
>
> Such experiments have two important implications. One is that morality
is not merely about the decisions people reach but also about the
process by which they get there. Another implication, said Adrian Raine,
a clinical neuroscientist at the University of Southern California, is
that society may have to rethink how it judges immoral people.
>
> Psychopaths often feel no empathy or remorse. Without that awareness,
people relying exclusively on reasoning seem to find it harder to sort
their way through moral thickets. Does that mean they should be held to
different standards of accountability?
>
> "Eventually, you are bound to get into areas that for thousands of
years we have preferred to keep mystical," said Grafman, the chief
cognitive neuroscientist at the National Institute of Neurological
Disorders and Stroke. "Some of the questions that are important are not
just of intellectual interest, but challenging and frightening to the
ways we ground our lives. We need to step very carefully."
>
> Joshua D. Greene, a Harvard neuroscientist and philosopher, said
multiple experiments suggest that morality arises from basic brain
activities. Morality, he said, is not a brain function elevated above
our baser impulses. Greene said it is not "handed down" by philosophers
and clergy, but "handed up," an outgrowth of the brain's basic
propensities.
>
> Moral decision-making often involves competing brain networks vying
for supremacy, he said. Simple moral decisions -- is killing a child
right or wrong? -- are simple because they activate a straightforward
brain response. Difficult moral decisions, by contrast, activate
multiple brain regions that conflict with one another, he said.
>
> In one 2004 brain-imaging experiment, Greene asked volunteers to
imagine that they were hiding in a cellar of a village as enemy soldiers
came looking to kill all the inhabitants. If a baby was crying in the
cellar, Greene asked, was it right to smother the child to keep the
soldiers from discovering the cellar and killing everyone?
>
> The reason people are slow to answer such an awful question, the study
indicated, is that emotion-linked circuits automatically signaling that
killing a baby is wrong clash with areas of the brain that involve
cooler aspects of cognition. One brain region activated when people
process such difficult choices is the inferior parietal lobe, which has
been shown to be active in more impersonal decision-making. This part of
the brain, in essence, was "arguing" with brain networks that reacted
with visceral horror.
>
> Such studies point to a pattern, Greene said, showing "competing
forces that may have come online at different points in our evolutionary
history. A basic emotional response is probably much older than the
ability to evaluate costs and benefits."
>
> While one implication of such findings is that people with certain
kinds of brain damage may do bad things they cannot be held responsible
for, the new research could also expand the boundaries of moral
responsibility. Neuroscience research, Greene said, is finally
explaining a problem that has long troubled philosophers and moral
teachers: Why is it that people who are willing to help someone in front
of them will ignore abstract pleas for help from those who are distant,
such as a request for a charitable contribution that could save the life
of a child overseas?
>
> "We evolved in a world where people in trouble right in front of you
existed, so our emotions were tuned to them, whereas we didn't face the
other kind of situation," Greene said. "It is comforting to think your
moral intuitions are reliable and you can trust them. But if my analysis
is right, your intuitions are not trustworthy. Once you realize why you
have the intuitions you have, it puts a burden on you" to think about
morality differently.
>
> Marc Hauser, another Harvard researcher, has used cleverly designed
psychological experiments to study morality. He said his research has
found that people all over the world process moral questions in the same
way, suggesting that moral thinking is intrinsic to the human brain,
rather than a product of culture. It may be useful to think about
morality much like language, in that its basic features are hard-wired,
Hauser said. Different cultures and religions build on that framework in
much the way children in different cultures learn different languages
using the same neural machinery.
>
> Hauser said that if his theory is right, there should be aspects of
morality that are automatic and unconscious -- just like language.
People would reach moral conclusions in the same way they construct a
sentence without having been trained in linguistics. Hauser said the
idea could shed light on contradictions in common moral stances.
>
> U.S. law, for example, distinguishes between a physician who removes a
feeding tube from a terminally ill patient and a physician who
administers a drug to kill the patient.
>
> Hauser said the only difference is that the second scenario is more
emotionally charged -- and therefore feels like a different moral
problem, when it really is not: "In the end, the doctor's intent is to
reduce suffering, and that is as true in active as in passive
euthanasia, and either way the patient is dead."
more on drug testing
more on drug testing
---------
http://news.yahoo.com/s/usatoday/20070508/cm_usatoday/noquickfix
No quick fix
By Marsha Rosenbaum
USA Today
May 8, 2007
Though touted by the Bush administration as the "silver bullet" that
will force teenagers to "just say no," random drug testing is of
questionable effectiveness. It is also costly, counterproductive and
violates basic American values. That's why the million-member California
State PTA, the American Academy of Pediatrics, the National Education
Association, the National Council on Alcoholism and Drug Dependence, and
the majority of the nation's school districts oppose school-based drug
testing.
According to the Academy of Pediatrics, "There is little evidence of the
effectiveness of school-based drug testing in the scientific
literature." In fact, the only federally funded, peer-reviewed study,
which compared 94,000 students in 900 U.S. schools, found no difference
in illegal drug use between schools with and without a testing program.
Before subjecting secondary school students to a policy as invasive as
random drug testing, evidence of its efficacy should be more conclusive
than anecdotes offered by a few enthusiastic proponents and a drug
testing industry that stands to reap billions.
Drug testing is costly. With federal grants, individual schools, many of
them strapped for funds, spend between $10,000 and $40,000 per year for
testing. This money could be used more productively for sports, arts,
drama, music and other extracurricular activities that keep teens
engaged between3 and 6 p.m., when they are bored and unsupervised. The
funds could also be used to hire credentialed counselors who couldfocus
full-time on substance abuse and related mental health issues.
Drug testing, regardless of how it's packaged, is an invasive diagnostic
procedure. Like other health issues, alcohol and other drug use should
first and foremost be the domain of parents and physicians. If parents
want to drug-test their own children, they can easily buy
over-the-counter kits at their local pharmacies or see their family
doctors, leaving schools out of it.
There is no quick fix for the complex issue of substance abuse. Quality
drug education and after-school programs that help students thrive will
best result in the kind of responsible decision-making that endures
beyond the teen years and into adulthood.
Dr. Marsha Rosenbaum, a medical sociologist, directs the San Francisco
office of the Drug Policy Alliance. She is co-author of Making Sense of
Student Drug Testing: Why Educators are Saying No
---------
http://news.yahoo.com/s/usatoday/20070508/cm_usatoday/noquickfix
No quick fix
By Marsha Rosenbaum
USA Today
May 8, 2007
Though touted by the Bush administration as the "silver bullet" that
will force teenagers to "just say no," random drug testing is of
questionable effectiveness. It is also costly, counterproductive and
violates basic American values. That's why the million-member California
State PTA, the American Academy of Pediatrics, the National Education
Association, the National Council on Alcoholism and Drug Dependence, and
the majority of the nation's school districts oppose school-based drug
testing.
According to the Academy of Pediatrics, "There is little evidence of the
effectiveness of school-based drug testing in the scientific
literature." In fact, the only federally funded, peer-reviewed study,
which compared 94,000 students in 900 U.S. schools, found no difference
in illegal drug use between schools with and without a testing program.
Before subjecting secondary school students to a policy as invasive as
random drug testing, evidence of its efficacy should be more conclusive
than anecdotes offered by a few enthusiastic proponents and a drug
testing industry that stands to reap billions.
Drug testing is costly. With federal grants, individual schools, many of
them strapped for funds, spend between $10,000 and $40,000 per year for
testing. This money could be used more productively for sports, arts,
drama, music and other extracurricular activities that keep teens
engaged between3 and 6 p.m., when they are bored and unsupervised. The
funds could also be used to hire credentialed counselors who couldfocus
full-time on substance abuse and related mental health issues.
Drug testing, regardless of how it's packaged, is an invasive diagnostic
procedure. Like other health issues, alcohol and other drug use should
first and foremost be the domain of parents and physicians. If parents
want to drug-test their own children, they can easily buy
over-the-counter kits at their local pharmacies or see their family
doctors, leaving schools out of it.
There is no quick fix for the complex issue of substance abuse. Quality
drug education and after-school programs that help students thrive will
best result in the kind of responsible decision-making that endures
beyond the teen years and into adulthood.
Dr. Marsha Rosenbaum, a medical sociologist, directs the San Francisco
office of the Drug Policy Alliance. She is co-author of Making Sense of
Student Drug Testing: Why Educators are Saying No
New report to Congress from the US Sentencing Commission on cocaine.
Cocaine sentencing report
http://www.ussc.gov/r_congress/cocaine2007.pdf
New report to Congress from the US Sentencing Commission on cocaine.
http://www.ussc.gov/r_congress/cocaine2007.pdf
New report to Congress from the US Sentencing Commission on cocaine.
Opioid Antagonism of Cannabinoid Effects: Differences between Marijuana Smokers and Nonmarijuana Smokers
opioid-cannabinoid system interaction
http://www.nature.com/npp/journal/v32/n6/full/1301243a.html
Neuropsychopharmacology (2007) 32, 1391-1403
Opioid Antagonism of Cannabinoid Effects: Differences between Marijuana Smokers and Nonmarijuana Smokers
Margaret Haney
ABSTRACT
In non-human animals, opioid antagonists block the reinforcing and
discriminative-stimulus effects of 9-tetrahydrocannabinol (THC), while
in human marijuana smokers, naltrexone (50 mg) enhances the reinforcing
and subjective effects of THC.
The objective of this study was to test a lower, more opioid-selective
dose of naltrexone (12 mg) in combination with THC. The influence of
marijuana-use history and sex was also investigated.
Naltrexone (0, 12 mg) was administered 30 min before oral THC (0-40 mg)
or methadone (0-10 mg) capsules, and subjective effects, task
performance, pupillary diameter, and cardiovascular parameters were
assessed in marijuana smoking (Study 1; n=22) and in nonmarijuana
smoking (Study 2; n=21) men and women.
The results show that in marijuana smokers, low-dose naltrexone blunted
the intoxicating effects of a low THC dose (20 mg), while increasing
ratings of anxiety at a higher THC dose (40 mg).
In nonmarijuana smokers, low-dose naltrexone shifted THC's effects in
the opposite direction, enhancing the intoxicating effects of a low THC
dose (2.5 mg) and decreasing anxiety ratings following a high dose of
THC (10 mg).
There were no sex differences in these interactions, although among
nonmarijuana smokers, men were more sensitive to the effects of THC
alone than women.
To conclude, a low, opioid-selective dose of naltrexone blunted THC
intoxication in marijuana smokers, while in nonmarijuana smokers,
naltrexone enhanced THC intoxication.
These data demonstrate that the interaction between opioid antagonists
and cannabinoid agonists varies as a function of marijuana use history.
http://www.nature.com/npp/journal/v32/n6/full/1301243a.html
Neuropsychopharmacology (2007) 32, 1391-1403
Opioid Antagonism of Cannabinoid Effects: Differences between Marijuana Smokers and Nonmarijuana Smokers
Margaret Haney
ABSTRACT
In non-human animals, opioid antagonists block the reinforcing and
discriminative-stimulus effects of 9-tetrahydrocannabinol (THC), while
in human marijuana smokers, naltrexone (50 mg) enhances the reinforcing
and subjective effects of THC.
The objective of this study was to test a lower, more opioid-selective
dose of naltrexone (12 mg) in combination with THC. The influence of
marijuana-use history and sex was also investigated.
Naltrexone (0, 12 mg) was administered 30 min before oral THC (0-40 mg)
or methadone (0-10 mg) capsules, and subjective effects, task
performance, pupillary diameter, and cardiovascular parameters were
assessed in marijuana smoking (Study 1; n=22) and in nonmarijuana
smoking (Study 2; n=21) men and women.
The results show that in marijuana smokers, low-dose naltrexone blunted
the intoxicating effects of a low THC dose (20 mg), while increasing
ratings of anxiety at a higher THC dose (40 mg).
In nonmarijuana smokers, low-dose naltrexone shifted THC's effects in
the opposite direction, enhancing the intoxicating effects of a low THC
dose (2.5 mg) and decreasing anxiety ratings following a high dose of
THC (10 mg).
There were no sex differences in these interactions, although among
nonmarijuana smokers, men were more sensitive to the effects of THC
alone than women.
To conclude, a low, opioid-selective dose of naltrexone blunted THC
intoxication in marijuana smokers, while in nonmarijuana smokers,
naltrexone enhanced THC intoxication.
These data demonstrate that the interaction between opioid antagonists
and cannabinoid agonists varies as a function of marijuana use history.
LA Times on student drug testing
LA Times on student drug testing
http://www.latimes.com/la-he-drugtesting21may21,0,7094993.story?coll=la-home-middleright
Put to the test
More schools are asking students to take drug tests, saying it gives
them a reason to 'say no.' Addiction experts contend results are
unreliable.
By Shari Roan
LA Times Staff Writer
May 21, 2007
ONCE a year or so, Roy Tialavea is summoned from his classes at
Oceanside High School to report to the athletic director's office
bathroom. He receives a urine specimen cup and heads for a stall.
The 17-year-old is unruffled. Random drug testing has been going on for
two years at the school. He's used to it. "I don't use drugs so I don't
have to worry about getting caught," he says.
His mother, Robyn, thinks her son steers clear of drugs and alcohol.
But, she says, no parent can know for sure what a teenager is up to.
"If he doesn't like testing, I really don't care," she says. "I think
it's a wonderful tool. It creates the fear that they could be tested."
Call it the 2007 version of "just say no."
Concerned with high rates of adolescent substance abuse, hundreds of
middle schools and high schools nationwide have quietly begun testing
some or all students for drugs - to the dismay of some health and
addiction experts.
Although less than 5% of all high schools have such programs, testing is
now common in schools throughout Texas, Florida, Kentucky and parts of
California. In Southern California, many private high schools have
implemented drug testing, as have several public school districts in
Orange County and San Diego. Nationwide, as many as 1,000 schools have
established programs, according to the White House Office of National
Drug Control Policy.
The number of schools administering drug tests is expected to grow.
Federal funding for school drug testing increased 400% between 2003 and
2006. The Bush administration spent $8.6 million on such programs last
year and has requested $17.9 million for fiscal year 2008.
"This is the best new idea to reduce the onset of drug use," says Dr.
Robert L. DuPont, president of the Institute for Behavior and Health, a
nonprofit drug policy organization that has studied school testing.
"About half of high school seniors have used an illicit drug by the time
they graduate and about one-quarter are regular users by the time they
graduate. Those figures are worrisome."
School-based drug testing gives kids a reason to say no, say DuPont and
other proponents. The tests are meant to identify students who are using
and guide them into counseling or treatment programs before they develop
addictions.
But health officials, by and large, oppose school-based drug testing.
NAADAC, the Assn. for Addiction Professionals, has released a statement
critical of such programs. And in March, the American Academy of
Pediatrics cautioned against random school-based drug testing until more
research is completed. The two groups are among those who say testing is
not reliable enough, violates trust between adults and teens and is not
set up to deal effectively with students who have positive results.
Though adults debate testing's merits, students at some high schools
hand over urine specimen cups as comfortably as they turn in late
library books.
"Kids pretty much know who does drugs and who doesn't," says Alex
Podobas, a senior at San Clemente High School, which has had voluntary
testing for several years. "But no one says, 'Oh, you're a pothead' when
you get called out for testing."
Screening kids for marijuana, cocaine, amphetamines and other illegal
drugs at school is an offshoot of two decades of experience with
workplace and military drug testing, experts say. Testing methods have
improved during that time to reduce the number of false test results
while providing greater privacy and confidentiality, says DuPont.
And though substance abuse among teens has dropped in the last decade,
parents and school administrators still consider the rates unacceptably
high. Just over 20% of eighth-graders and about half of all high school
seniors say they have taken an illicit drug, according to 2006 data from
Monitoring the Future, the University of Michigan's nationwide annual
survey. About 30% of high school seniors say they have been drunk in the
last month.
Little faith is put in traditional classroom drug education programs to
further drive down substance abuse rates, says Jennifer Kern of the Drug
Policy Alliance, a New York City-based organization that focuses on a
harm-reduction approach to drug education.
"People are overwhelmed and are looking for new approaches," she says.
"A lot of the concern comes from a good place. We haven't done a good
job preventing substance abuse."
School drug testing got its biggest boost in 2002 when the Supreme Court
ruled that schools may conduct random drug tests among students who wish
to participate in school-sponsored extracurricular activities, such as
sports, marching band or debate team.
"Fifteen years ago, school drug testing was too controversial," says
John P. Walters, director of the White House Office of National Drug
Control Policy. "People thought the test was going to throw kids out of
school or give them a criminal record. The Supreme Court decision was an
enormously positive step."
But critics say the court's decision opened the floodgates for programs
that have not been studiously researched or properly evaluated.
"If you look on the surface, drug testing seems like a good idea; a
simple thing to do," says Dr. Sharon Levy, director of the Adolescent
Substance Abuse Program at Children's Hospital Boston. "It's only when
you sit down and look at it closely that it really starts to unravel a
bit."
Chief among the pediatricians' complaints is the reliability of testing.
A study published in April in the journal Pediatrics found a substantial
risk of error even when drug testing was performed as part of an
established adolescent substance abuse program. In the study, Levy and
her colleagues reviewed 710 random urine tests from 110 teens and
compared the results with confirmatory lab tests. (Initial screening
samples should be confirmed with a second, more rigorous, analysis -
something most school programs say they do.) They found 12% of the tests
were subject to misinterpretation. For example, some of the urine
samples were diluted (despite rigorous collection procedures designed to
prevent kids from cheating) and could not be interpreted properly.
Further, of the samples, 21% were positive due to legitimate
prescription drug use, Levy says. And several samples that were found in
confirmatory testing to be positive for the painkiller OxyContin - a
popular drug of abuse among teens - were identified as negative in the
initial screen.
"Drug testing is premature policy," says Levy. "We need to understand
the combination of risks and costs compared to the benefits. That hasn't
been done at all."
Further, critics say, the drug testing panels used by schools are
typically those used in the workplace - screens for marijuana,
amphetamines, cocaine, opiates and PCP. The panels usually do not assess
alcohol or other drugs kids may be likely to use, such as inhalants,
OxyContin and Ecstasy. Standard urine tests only detect use that has
occurred in the last 48 to 72 hours.
Negative screens may mislead parents, school personnel and the community
from searching for a truer picture of adolescent drug and alcohol use,
Kern says.
"Parents can say 'OK, the schools are doing testing, we'll know what is
going on,' " she says. "But drug testing gives you very little
information. It can give parents a false sense of security."
Even the belief that testing deters kids from using drugs or gives them
a peer-worthy reason to say no has not been proven, Kern says. A 2003
study by the University of Michigan surveying 76,000 students found no
difference in marijuana or other illicit drug use in schools with
testing compared with those without programs.
Podobas, the San Clemente senior, says few students fear being caught.
The tests don't pick up all drugs and are administered too infrequently
to worry teens, he says. Others have learned to beat the system by
sharing a clean urine sample when called to the bathrooms in groups. "I
don't think it has lessened the number of kids using drugs," says
Podobas, although he thinks some kids use less frequently than they
otherwise would.
Others critics of the program say school drug testing can make teens
feel guilty before being proven innocent. While many programs - such as
several in Orange County - only test students if they and their parents
consent, kids may feel that adults distrust them, Kern says.
"There may be unintended consequences to drug testing," says Dr. Howard
Taras, a pediatrics professor at UC San Diego, who studies school health
issues. "Kids may be deterred from joining a sport or extracurricular
activity because they will be tested. Those are the kids that most need
extracurricular activities. They may not get engaged in math or science
but they may get engaged by a sport or dance class."
Proponents of drug testing say such shortcomings simply don't exist in
most schools. The programs, they say, are diligent about collection
procedures and lab analysis, privacy issues and follow-up for kids found
to have used drugs.
"Where are they finding these programs doing the bad things?" says
DuPont of the critics. A study by his office of nine programs found all
were following testing protocols and handling kids with positive tests
nonpunitively.
Even if testing programs aren't perfect, recent research on the effect
of drug use on adolescent brains warrants an aggressive approach to the
problem, Walters says. Studies show that heavy drug use during
adolescence may permanently damage parts of the brain related to
learning and memory. People who avoid drinking and using drugs before
age 21 are far less likely to abuse drugs or develop an addiction later.
"This is an area where doing the right thing for our kids is durable,"
Walters says. "We can change the face of substance abuse for
generations."
Students feel secure knowing that adults are savvy about drug use in
their schools, proponents add. "Middle and high school kids are aware of
their peers who are involved in drinking and drugging," says Walters.
"They will frequently ask 'Why do we look the other way? Why do we allow
this to happen?' In schools with random drug testing, they feel safe."
Local school administrators say programs have drawn little protest from
parents and students.
In Oceanside Unified School District, which is in its second year of
testing all high school students who wish to participate in sports,
community focus groups are held on a regular basis to gauge reaction.
The program is funded through the Office of National Drug Control
Policy.
"Our community has always been cooperative, and I think it's because we
included them in the process when we were developing the program," says
Tim Ware, the district's school intervention manager. "I think our kids
have reacted better than anyone. It's part of what we do."
One of the few complaints, he says, is that athletes feel they are being
singled out and that all students should be randomly tested.
A more common approach to testing, at least in California, are voluntary
programs in which both the students agree to enroll in random testing
with parental consent. Jon Hamro, athletic director and secondary
teaching assistant principal of San Clemente High School, launched one
of the state's first school-based testing programs in 2001. The program
has expanded to each high school in the Capistrano Unified School
District, which encompasses much of south Orange County. Recently three
district middle schools began offering testing.
The voluntary nature of the program has taken the steam out of would-be
objectors, Hamro says. Samples are collected by an outside lab and the
results shared with the student's parents - not school officials.
Students with positive results are not punished.
"We took a tack of how can we do this where there are no privacy issues
and yet it's a powerful tool to dissuade kids from using," he says.
"It's invisible to the administration, but it's very visible to the
kids."
At San Clemente High School, just over half of the school's 3,100
students are enrolled. Students testing positive are referred to either
fee-for-service or free counseling, including confidential counseling on
campus.
A survey conducted of 2,500 students at the high school last year showed
the program is having an effect, Hamro says. Almost 60% of the students
said the decision on whether or not to enroll in the program prompted a
discussion at home about substance abuse. Almost 60% of the students
said that the program should continue and 48% said it made it easier for
them to avoid using drugs. Just over one-quarter said testing had
reduced their frequency of drug use.
The study will be published in June in the American School Board
Journal.
Even those who disagree about the merits of school-based drug testing
agree that more research should be done to evaluate whether the programs
reduce drug use and help students who are caught using.
"There are these two sides and they can argue until they are blue in the
face," says Taras. "But until you study it, you can't really say
anything about it."
Schools, however, may not wait for academia to weigh in, especially if
the federal government extends money for testing programs.
"I actually believe that what you'll see is a rapid adoption of this,"
says Walters. "In a relatively short period of time we're going to look
back and say 'Why did it take us so long to do this?' This is safe and
it's enormously powerful."
*
------------------------------------------------------------------------
--------
shari.roan@latimes.com
*
(INFOBOX BELOW)
Screening varies from school to school
Schools vary widely in how they conduct drug testing.
* Deciding when and whom to test: Some schools only test students when
there is a suspicion of drug use. A growing number, however, utilize
random, "suspicionless" testing of a large group of students. In some
schools, only students who volunteer for the program and whose parents
consent are tested. Other schools screen all students who wish to
participate in extracurricular activities, such as sports and clubs.
* How testing is conducted: Some schools purchase tests kits and make
them available to parents. Other schools use outside testing labs to
randomly select students, conduct the tests and report back only to
parents - barring school personnel from learning the results. In still
other places, school personnel gather samples, send the results to labs
for assessment and receive the results back at school. School officials
then contact parents.
* Handling positive results: In some cases, the results are made
available to parents only, and it is their choice on how - or whether -
to act. Some labs are under contract to give parents a list of
drug-treatment and counseling resources in the community. Some schools
choose to provide the student's family with references. Many programs
with random, voluntary testing stress that students with positive tests
should be treated nonpunitively. Little is known about the outcome of
students who test positive in terms of whether follow-up counseling is
obtained and is successful.
* Technology and costs: Initial screenings are often done using urine
samples. Saliva, hair, sweat and blood tests can also be used but vary
in cost and reliability. Screening tests for a five-drug urine panel
typically cost $15 to $30 per student, according to the White House
Office of National Drug Control Policy. Many schools finance drug
testing on their own or through fundraisers or community donations.
Others apply for federal grants.
**
Testing resources
For more information on school-based drug testing, as well as arguments
for and against testing, go to:
* White House Office of National Drug Control Policy - the Bush
administration's case for testing, how it works and how to get
information on federal grants. http://www.randomstudentdrugtesting.org
* Monitoring the Future survey - the most recent statistical analysis
of adolescent drug use in the United States, from the University of
Michigan's annual survey. http://www.monitoringthefuture.org
* NAADAC (Assn. for Addiction Professionals) - this nonprofit
organization's policy statement on school-based drug testing.
naadac.org/documents/display.phpDocumentID102
* Institute for Behavior and Health - information for communities,
educators, parents and students on adolescent drug use and testing,
including how to implement testing programs, from an organization that
studies drug prevention and treatment strategies and advocates school
drug testing. http://www.PreventionNotPunishment.org
* Drug Policy Alliance - research on drug testing policies from a
nonprofit group that opposes school-based testing.
http://www.drugpolicy.org
* American Academy of Pediatrics - the most recent policy statement
from the AAP on student drug testing:
aappolicy.aappublications.org/cgi/content/full/pediatrics119/3/627<252>
http://www.latimes.com/la-he-drugtesting21may21,0,7094993.story?coll=la-home-middleright
Put to the test
More schools are asking students to take drug tests, saying it gives
them a reason to 'say no.' Addiction experts contend results are
unreliable.
By Shari Roan
LA Times Staff Writer
May 21, 2007
ONCE a year or so, Roy Tialavea is summoned from his classes at
Oceanside High School to report to the athletic director's office
bathroom. He receives a urine specimen cup and heads for a stall.
The 17-year-old is unruffled. Random drug testing has been going on for
two years at the school. He's used to it. "I don't use drugs so I don't
have to worry about getting caught," he says.
His mother, Robyn, thinks her son steers clear of drugs and alcohol.
But, she says, no parent can know for sure what a teenager is up to.
"If he doesn't like testing, I really don't care," she says. "I think
it's a wonderful tool. It creates the fear that they could be tested."
Call it the 2007 version of "just say no."
Concerned with high rates of adolescent substance abuse, hundreds of
middle schools and high schools nationwide have quietly begun testing
some or all students for drugs - to the dismay of some health and
addiction experts.
Although less than 5% of all high schools have such programs, testing is
now common in schools throughout Texas, Florida, Kentucky and parts of
California. In Southern California, many private high schools have
implemented drug testing, as have several public school districts in
Orange County and San Diego. Nationwide, as many as 1,000 schools have
established programs, according to the White House Office of National
Drug Control Policy.
The number of schools administering drug tests is expected to grow.
Federal funding for school drug testing increased 400% between 2003 and
2006. The Bush administration spent $8.6 million on such programs last
year and has requested $17.9 million for fiscal year 2008.
"This is the best new idea to reduce the onset of drug use," says Dr.
Robert L. DuPont, president of the Institute for Behavior and Health, a
nonprofit drug policy organization that has studied school testing.
"About half of high school seniors have used an illicit drug by the time
they graduate and about one-quarter are regular users by the time they
graduate. Those figures are worrisome."
School-based drug testing gives kids a reason to say no, say DuPont and
other proponents. The tests are meant to identify students who are using
and guide them into counseling or treatment programs before they develop
addictions.
But health officials, by and large, oppose school-based drug testing.
NAADAC, the Assn. for Addiction Professionals, has released a statement
critical of such programs. And in March, the American Academy of
Pediatrics cautioned against random school-based drug testing until more
research is completed. The two groups are among those who say testing is
not reliable enough, violates trust between adults and teens and is not
set up to deal effectively with students who have positive results.
Though adults debate testing's merits, students at some high schools
hand over urine specimen cups as comfortably as they turn in late
library books.
"Kids pretty much know who does drugs and who doesn't," says Alex
Podobas, a senior at San Clemente High School, which has had voluntary
testing for several years. "But no one says, 'Oh, you're a pothead' when
you get called out for testing."
Screening kids for marijuana, cocaine, amphetamines and other illegal
drugs at school is an offshoot of two decades of experience with
workplace and military drug testing, experts say. Testing methods have
improved during that time to reduce the number of false test results
while providing greater privacy and confidentiality, says DuPont.
And though substance abuse among teens has dropped in the last decade,
parents and school administrators still consider the rates unacceptably
high. Just over 20% of eighth-graders and about half of all high school
seniors say they have taken an illicit drug, according to 2006 data from
Monitoring the Future, the University of Michigan's nationwide annual
survey. About 30% of high school seniors say they have been drunk in the
last month.
Little faith is put in traditional classroom drug education programs to
further drive down substance abuse rates, says Jennifer Kern of the Drug
Policy Alliance, a New York City-based organization that focuses on a
harm-reduction approach to drug education.
"People are overwhelmed and are looking for new approaches," she says.
"A lot of the concern comes from a good place. We haven't done a good
job preventing substance abuse."
School drug testing got its biggest boost in 2002 when the Supreme Court
ruled that schools may conduct random drug tests among students who wish
to participate in school-sponsored extracurricular activities, such as
sports, marching band or debate team.
"Fifteen years ago, school drug testing was too controversial," says
John P. Walters, director of the White House Office of National Drug
Control Policy. "People thought the test was going to throw kids out of
school or give them a criminal record. The Supreme Court decision was an
enormously positive step."
But critics say the court's decision opened the floodgates for programs
that have not been studiously researched or properly evaluated.
"If you look on the surface, drug testing seems like a good idea; a
simple thing to do," says Dr. Sharon Levy, director of the Adolescent
Substance Abuse Program at Children's Hospital Boston. "It's only when
you sit down and look at it closely that it really starts to unravel a
bit."
Chief among the pediatricians' complaints is the reliability of testing.
A study published in April in the journal Pediatrics found a substantial
risk of error even when drug testing was performed as part of an
established adolescent substance abuse program. In the study, Levy and
her colleagues reviewed 710 random urine tests from 110 teens and
compared the results with confirmatory lab tests. (Initial screening
samples should be confirmed with a second, more rigorous, analysis -
something most school programs say they do.) They found 12% of the tests
were subject to misinterpretation. For example, some of the urine
samples were diluted (despite rigorous collection procedures designed to
prevent kids from cheating) and could not be interpreted properly.
Further, of the samples, 21% were positive due to legitimate
prescription drug use, Levy says. And several samples that were found in
confirmatory testing to be positive for the painkiller OxyContin - a
popular drug of abuse among teens - were identified as negative in the
initial screen.
"Drug testing is premature policy," says Levy. "We need to understand
the combination of risks and costs compared to the benefits. That hasn't
been done at all."
Further, critics say, the drug testing panels used by schools are
typically those used in the workplace - screens for marijuana,
amphetamines, cocaine, opiates and PCP. The panels usually do not assess
alcohol or other drugs kids may be likely to use, such as inhalants,
OxyContin and Ecstasy. Standard urine tests only detect use that has
occurred in the last 48 to 72 hours.
Negative screens may mislead parents, school personnel and the community
from searching for a truer picture of adolescent drug and alcohol use,
Kern says.
"Parents can say 'OK, the schools are doing testing, we'll know what is
going on,' " she says. "But drug testing gives you very little
information. It can give parents a false sense of security."
Even the belief that testing deters kids from using drugs or gives them
a peer-worthy reason to say no has not been proven, Kern says. A 2003
study by the University of Michigan surveying 76,000 students found no
difference in marijuana or other illicit drug use in schools with
testing compared with those without programs.
Podobas, the San Clemente senior, says few students fear being caught.
The tests don't pick up all drugs and are administered too infrequently
to worry teens, he says. Others have learned to beat the system by
sharing a clean urine sample when called to the bathrooms in groups. "I
don't think it has lessened the number of kids using drugs," says
Podobas, although he thinks some kids use less frequently than they
otherwise would.
Others critics of the program say school drug testing can make teens
feel guilty before being proven innocent. While many programs - such as
several in Orange County - only test students if they and their parents
consent, kids may feel that adults distrust them, Kern says.
"There may be unintended consequences to drug testing," says Dr. Howard
Taras, a pediatrics professor at UC San Diego, who studies school health
issues. "Kids may be deterred from joining a sport or extracurricular
activity because they will be tested. Those are the kids that most need
extracurricular activities. They may not get engaged in math or science
but they may get engaged by a sport or dance class."
Proponents of drug testing say such shortcomings simply don't exist in
most schools. The programs, they say, are diligent about collection
procedures and lab analysis, privacy issues and follow-up for kids found
to have used drugs.
"Where are they finding these programs doing the bad things?" says
DuPont of the critics. A study by his office of nine programs found all
were following testing protocols and handling kids with positive tests
nonpunitively.
Even if testing programs aren't perfect, recent research on the effect
of drug use on adolescent brains warrants an aggressive approach to the
problem, Walters says. Studies show that heavy drug use during
adolescence may permanently damage parts of the brain related to
learning and memory. People who avoid drinking and using drugs before
age 21 are far less likely to abuse drugs or develop an addiction later.
"This is an area where doing the right thing for our kids is durable,"
Walters says. "We can change the face of substance abuse for
generations."
Students feel secure knowing that adults are savvy about drug use in
their schools, proponents add. "Middle and high school kids are aware of
their peers who are involved in drinking and drugging," says Walters.
"They will frequently ask 'Why do we look the other way? Why do we allow
this to happen?' In schools with random drug testing, they feel safe."
Local school administrators say programs have drawn little protest from
parents and students.
In Oceanside Unified School District, which is in its second year of
testing all high school students who wish to participate in sports,
community focus groups are held on a regular basis to gauge reaction.
The program is funded through the Office of National Drug Control
Policy.
"Our community has always been cooperative, and I think it's because we
included them in the process when we were developing the program," says
Tim Ware, the district's school intervention manager. "I think our kids
have reacted better than anyone. It's part of what we do."
One of the few complaints, he says, is that athletes feel they are being
singled out and that all students should be randomly tested.
A more common approach to testing, at least in California, are voluntary
programs in which both the students agree to enroll in random testing
with parental consent. Jon Hamro, athletic director and secondary
teaching assistant principal of San Clemente High School, launched one
of the state's first school-based testing programs in 2001. The program
has expanded to each high school in the Capistrano Unified School
District, which encompasses much of south Orange County. Recently three
district middle schools began offering testing.
The voluntary nature of the program has taken the steam out of would-be
objectors, Hamro says. Samples are collected by an outside lab and the
results shared with the student's parents - not school officials.
Students with positive results are not punished.
"We took a tack of how can we do this where there are no privacy issues
and yet it's a powerful tool to dissuade kids from using," he says.
"It's invisible to the administration, but it's very visible to the
kids."
At San Clemente High School, just over half of the school's 3,100
students are enrolled. Students testing positive are referred to either
fee-for-service or free counseling, including confidential counseling on
campus.
A survey conducted of 2,500 students at the high school last year showed
the program is having an effect, Hamro says. Almost 60% of the students
said the decision on whether or not to enroll in the program prompted a
discussion at home about substance abuse. Almost 60% of the students
said that the program should continue and 48% said it made it easier for
them to avoid using drugs. Just over one-quarter said testing had
reduced their frequency of drug use.
The study will be published in June in the American School Board
Journal.
Even those who disagree about the merits of school-based drug testing
agree that more research should be done to evaluate whether the programs
reduce drug use and help students who are caught using.
"There are these two sides and they can argue until they are blue in the
face," says Taras. "But until you study it, you can't really say
anything about it."
Schools, however, may not wait for academia to weigh in, especially if
the federal government extends money for testing programs.
"I actually believe that what you'll see is a rapid adoption of this,"
says Walters. "In a relatively short period of time we're going to look
back and say 'Why did it take us so long to do this?' This is safe and
it's enormously powerful."
*
------------------------------------------------------------------------
--------
shari.roan@latimes.com
*
(INFOBOX BELOW)
Screening varies from school to school
Schools vary widely in how they conduct drug testing.
* Deciding when and whom to test: Some schools only test students when
there is a suspicion of drug use. A growing number, however, utilize
random, "suspicionless" testing of a large group of students. In some
schools, only students who volunteer for the program and whose parents
consent are tested. Other schools screen all students who wish to
participate in extracurricular activities, such as sports and clubs.
* How testing is conducted: Some schools purchase tests kits and make
them available to parents. Other schools use outside testing labs to
randomly select students, conduct the tests and report back only to
parents - barring school personnel from learning the results. In still
other places, school personnel gather samples, send the results to labs
for assessment and receive the results back at school. School officials
then contact parents.
* Handling positive results: In some cases, the results are made
available to parents only, and it is their choice on how - or whether -
to act. Some labs are under contract to give parents a list of
drug-treatment and counseling resources in the community. Some schools
choose to provide the student's family with references. Many programs
with random, voluntary testing stress that students with positive tests
should be treated nonpunitively. Little is known about the outcome of
students who test positive in terms of whether follow-up counseling is
obtained and is successful.
* Technology and costs: Initial screenings are often done using urine
samples. Saliva, hair, sweat and blood tests can also be used but vary
in cost and reliability. Screening tests for a five-drug urine panel
typically cost $15 to $30 per student, according to the White House
Office of National Drug Control Policy. Many schools finance drug
testing on their own or through fundraisers or community donations.
Others apply for federal grants.
**
Testing resources
For more information on school-based drug testing, as well as arguments
for and against testing, go to:
* White House Office of National Drug Control Policy - the Bush
administration's case for testing, how it works and how to get
information on federal grants. http://www.randomstudentdrugtesting.org
* Monitoring the Future survey - the most recent statistical analysis
of adolescent drug use in the United States, from the University of
Michigan's annual survey. http://www.monitoringthefuture.org
* NAADAC (Assn. for Addiction Professionals) - this nonprofit
organization's policy statement on school-based drug testing.
naadac.org/documents/display.phpDocumentID102
* Institute for Behavior and Health - information for communities,
educators, parents and students on adolescent drug use and testing,
including how to implement testing programs, from an organization that
studies drug prevention and treatment strategies and advocates school
drug testing. http://www.PreventionNotPunishment.org
* Drug Policy Alliance - research on drug testing policies from a
nonprofit group that opposes school-based testing.
http://www.drugpolicy.org
* American Academy of Pediatrics - the most recent policy statement
from the AAP on student drug testing:
aappolicy.aappublications.org/cgi/content/full/pediatrics119/3/627<252>
Lower syringe sharing and re-use after syringe legalization in Rhode Island
needle exchange in RI vs. MA
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T63-4NBRYFX-1&_user=861681&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=8782a5059338af9c4f043db077c
b4221
Drug and Alcohol Dependence
Volume 89, Issues 2-3, 10 July 2007, Pages 292-297
Lower syringe sharing and re-use after syringe legalization in Rhode
Island
Josiah D. Richa et al.
ABSTRACT
Increased access to sterile syringes reduces the transmission of HIV,
viral hepatitis and other infectious diseases, without increasing
injection drug use.
In Rhode Island, in 2000, syringes were legalized to reduce spread of
disease but remained outlawed in Massachusetts until 2006.
Drug users undergoing inpatient detoxification in Rhode Island and
Massachusetts were surveyed about their syringe usage between October
2001 and August 2003. Two hundred forty-seven Rhode Island, and 226
Massachusetts inpatients completed surveys.
Of these, 61% (n = 151) from Rhode Island and 46% (n = 105) from
Massachusetts reported injecting within 6 months.
Respondents from Rhode Island reported reusing a syringe in the last 30
days less often than Massachusetts respondents (0.35 versus 0.50; 95% CI
on difference 0.01-0.29).
Syringe re-use and sharing among drug injectors in Rhode Island was
markedly lower than in Massachusetts.
This difference is attributed at least in part to the legalization of
non-prescription sterile syringes in Rhode Island in 2000.
Laws and policies that increase legal syringe availability can decrease
injection related transmission of HIV and other infectious diseases.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T63-4NBRYFX-1&_user=861681&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=8782a5059338af9c4f043db077c
b4221
Drug and Alcohol Dependence
Volume 89, Issues 2-3, 10 July 2007, Pages 292-297
Lower syringe sharing and re-use after syringe legalization in Rhode
Island
Josiah D. Richa et al.
ABSTRACT
Increased access to sterile syringes reduces the transmission of HIV,
viral hepatitis and other infectious diseases, without increasing
injection drug use.
In Rhode Island, in 2000, syringes were legalized to reduce spread of
disease but remained outlawed in Massachusetts until 2006.
Drug users undergoing inpatient detoxification in Rhode Island and
Massachusetts were surveyed about their syringe usage between October
2001 and August 2003. Two hundred forty-seven Rhode Island, and 226
Massachusetts inpatients completed surveys.
Of these, 61% (n = 151) from Rhode Island and 46% (n = 105) from
Massachusetts reported injecting within 6 months.
Respondents from Rhode Island reported reusing a syringe in the last 30
days less often than Massachusetts respondents (0.35 versus 0.50; 95% CI
on difference 0.01-0.29).
Syringe re-use and sharing among drug injectors in Rhode Island was
markedly lower than in Massachusetts.
This difference is attributed at least in part to the legalization of
non-prescription sterile syringes in Rhode Island in 2000.
Laws and policies that increase legal syringe availability can decrease
injection related transmission of HIV and other infectious diseases.
Giant to limit access to DXM Grocer joins effort to prevent abuse of cough medication
http://www.baltimoresun.com/business/bal-bz.cough16may16,0,6393827.story?coll=bal-home-headlines
Giant to limit access to DXM Grocer joins effort to prevent abuse of cough medication
By M. William Salganik
Baltimore Sun reporter
May 16, 2007
Joining other retailers and chain pharmacies, Giant Food announced
yesterday that it won't sell certain types of cough medicine to
customers under 18 because the products have been abused by teenagers.
Beginning Sunday, Giant and other grocery chains owned by Royal Ahold NV
will limit sales of products containing dextromethorphan (DXM), a common
ingredient in cough and cold syrups, lozenges and pills.
"It's similar to buying cigarettes - if the cashier has a question, we
will ask for verification," said Jamie Miller, manager of public affairs
for Landover-based Giant Food Inc., which has 186 supermarkets in
Maryland and nearby states.
Among more than 100 products containing DXM are Robitussin Maximum
Strength Cough Suppressant, Sucrets 8 Hour Cough Suppressant and Vicks
44 Cough Relief, according to the National Institutes of Health. Those
brands also have products that do not contain DXM.
The Food and Drug Administration issued a warning in 2005 that five
teenagers died in cases "that may be associated with the consumption of
powered DXM," although it said the ingredient, when used as directed, is
"generally safe and effective."
Concerns over DXM heated up this spring when drug counselors on Long
Island reported nine teenagers hospitalized in one month after abusing
over-the-counter cough medicines, according to Newsday.
The importance of the action against DXM is a reminder that legal drugs,
even over-the-counter drugs, aren't safe if they're misused, said
Michael M. Gimbel, director of substance abuse education for the
Sheppard Pratt Health System. "When I go out to talk to parents, I have
my bottle of cough medicine," he said. Pharmacies have also restricted
sales of products containing pseudoephedrine, an over-the-counter
decongestant that can be used in the manufacture of methamphetamines.
"It's a sad state of affairs," Gimbel said. "We're slowly but surely
emptying the shelves of our pharmacies of over-the-counter medicines."
"As soon as we find out what the kids are up to and do something about
it, three days later, they're onto something else," he said.
Gimbel, and state and Baltimore health officials, said there is no
indication that DXM use is a particular problem in this area.
Dr. Peter Cohen, medical director of the state health department's
alcohol and drug abuse administration, said the state did not have any
figures tracking DXM abuse in Maryland and that it was "not high
prevalence compared to other substances."
Dr. Joshua Sharfstein, Baltimore health commissioner, said he had talked
to police, school health staff and drug abuse treatment providers, and
"so far, in Baltimore, it's not hitting our radar screens."
Sharfstein added that the city health department, after consulting with
pediatricians, doesn't recommend cough medicines containing DXM for
children under age 6, even when used as directed, because "there is not
an adequate margin of safety and they are not effective."
Nationally, a survey released in December by the University of Michigan
reported that 4 percent of 8th-graders, 5 percent of 10th- graders and 7
percent of high school seniors said they had used cough or cold
medicines to get high.
Abuse can occur either by concentrating DXM into powdered form or by
taking large amounts of the cough syrups.
"It isn't someone taking a few more tablespoons or a couple more pills -
it's 25 to 50 times the recommended dose," said Elizabeth Funderburk,
communications director for the Consumer Healthcare Products
Association, the trade association for manufacturers of over-the-counter
medications.
Gimbel and Cohen said that in large doses, DXM can produce feelings of
euphoria, but also disorientation and hallucinations. They said DXM can
be particularly dangerous when combined with other drugs or alcohol or
if used while driving.
Several states - including Maryland - have considered legislation this
year limiting sales of DXM to adults, but none has yet done so,
according to Kevin Nicholson, vice president for pharmacy regulatory
affairs for the National Association of Chain Drug Stores. His trade
association is also supporting similar federal legislation.
While DXM sales are not restricted by law, most large chain stores have
imposed voluntary restrictions, Nicholson said.
Among the stores that restrict the sale of products containing DXM are
Rite Aid, Wal-Mart, CVS, Target, Walgreens, Brooks, Eckerd and Costco,
according to Nicholson, with most adopting the policies since the FDA
warning two years ago. Safeway put DXM age restrictions in place in
March, said spokesman Greg TenEyck.
Although there haven't been widespread reports of abuse in this area,
"We were kind of taking the lead from the Food and Drug Administration,"
said Miller, the Giant spokesman.
Giant to limit access to DXM Grocer joins effort to prevent abuse of cough medication
By M. William Salganik
Baltimore Sun reporter
May 16, 2007
Joining other retailers and chain pharmacies, Giant Food announced
yesterday that it won't sell certain types of cough medicine to
customers under 18 because the products have been abused by teenagers.
Beginning Sunday, Giant and other grocery chains owned by Royal Ahold NV
will limit sales of products containing dextromethorphan (DXM), a common
ingredient in cough and cold syrups, lozenges and pills.
"It's similar to buying cigarettes - if the cashier has a question, we
will ask for verification," said Jamie Miller, manager of public affairs
for Landover-based Giant Food Inc., which has 186 supermarkets in
Maryland and nearby states.
Among more than 100 products containing DXM are Robitussin Maximum
Strength Cough Suppressant, Sucrets 8 Hour Cough Suppressant and Vicks
44 Cough Relief, according to the National Institutes of Health. Those
brands also have products that do not contain DXM.
The Food and Drug Administration issued a warning in 2005 that five
teenagers died in cases "that may be associated with the consumption of
powered DXM," although it said the ingredient, when used as directed, is
"generally safe and effective."
Concerns over DXM heated up this spring when drug counselors on Long
Island reported nine teenagers hospitalized in one month after abusing
over-the-counter cough medicines, according to Newsday.
The importance of the action against DXM is a reminder that legal drugs,
even over-the-counter drugs, aren't safe if they're misused, said
Michael M. Gimbel, director of substance abuse education for the
Sheppard Pratt Health System. "When I go out to talk to parents, I have
my bottle of cough medicine," he said. Pharmacies have also restricted
sales of products containing pseudoephedrine, an over-the-counter
decongestant that can be used in the manufacture of methamphetamines.
"It's a sad state of affairs," Gimbel said. "We're slowly but surely
emptying the shelves of our pharmacies of over-the-counter medicines."
"As soon as we find out what the kids are up to and do something about
it, three days later, they're onto something else," he said.
Gimbel, and state and Baltimore health officials, said there is no
indication that DXM use is a particular problem in this area.
Dr. Peter Cohen, medical director of the state health department's
alcohol and drug abuse administration, said the state did not have any
figures tracking DXM abuse in Maryland and that it was "not high
prevalence compared to other substances."
Dr. Joshua Sharfstein, Baltimore health commissioner, said he had talked
to police, school health staff and drug abuse treatment providers, and
"so far, in Baltimore, it's not hitting our radar screens."
Sharfstein added that the city health department, after consulting with
pediatricians, doesn't recommend cough medicines containing DXM for
children under age 6, even when used as directed, because "there is not
an adequate margin of safety and they are not effective."
Nationally, a survey released in December by the University of Michigan
reported that 4 percent of 8th-graders, 5 percent of 10th- graders and 7
percent of high school seniors said they had used cough or cold
medicines to get high.
Abuse can occur either by concentrating DXM into powdered form or by
taking large amounts of the cough syrups.
"It isn't someone taking a few more tablespoons or a couple more pills -
it's 25 to 50 times the recommended dose," said Elizabeth Funderburk,
communications director for the Consumer Healthcare Products
Association, the trade association for manufacturers of over-the-counter
medications.
Gimbel and Cohen said that in large doses, DXM can produce feelings of
euphoria, but also disorientation and hallucinations. They said DXM can
be particularly dangerous when combined with other drugs or alcohol or
if used while driving.
Several states - including Maryland - have considered legislation this
year limiting sales of DXM to adults, but none has yet done so,
according to Kevin Nicholson, vice president for pharmacy regulatory
affairs for the National Association of Chain Drug Stores. His trade
association is also supporting similar federal legislation.
While DXM sales are not restricted by law, most large chain stores have
imposed voluntary restrictions, Nicholson said.
Among the stores that restrict the sale of products containing DXM are
Rite Aid, Wal-Mart, CVS, Target, Walgreens, Brooks, Eckerd and Costco,
according to Nicholson, with most adopting the policies since the FDA
warning two years ago. Safeway put DXM age restrictions in place in
March, said spokesman Greg TenEyck.
Although there haven't been widespread reports of abuse in this area,
"We were kind of taking the lead from the Food and Drug Administration,"
said Miller, the Giant spokesman.
Inhaling cannabis without the smoke Study shows vaporizer delivers marijuana 'safely and effectively'
http://www.nature.com/news/2007/070508/full/070508-11.html
Nature
11 May 2007
Inhaling cannabis without the smoke Study shows vaporizer delivers marijuana 'safely and effectively'
Arran Frood
Vaporizing cannabis leaves instead of burning them can release the drug's active ingredient just as effectively - while avoiding the harmful toxins inhaled through smoking the drug, according to a pilot study.
The result could be good news for those who choose to use marijuana medicinally.
The potential benefits of marijuana include pain relief for multiple-sclerosis sufferers, a treatment for glaucoma, as an appetite stimulant for AIDS patients and an anti-nausea agent for people on chemotherapy. But smoking isn't a good method of drug delivery because the harmful effects - such as lung cancer and heart disease - outweigh the likely merits of marijuana for all but terminal cases.
Rather than smoking, some use the leaves to make tea or cakes for consumption. But this means that the active agents are metabolized by the liver rather than entering the bloodstream unaltered. Others have focused on extracting active ingredients such as tetrahydrocannabinol (THC) and delivering them alone in a pill or oral spray. However, many think that the isolated ingredients are not as effective as the whole plant, and it is more difficult to customize the dose for each individual with a pill.
Hot stuff
Donald Abrams of the University of California, San Francisco, and his team decided to investigate the benefits of the 'Volcano', a commercially available vaporizer. The device heats marijuana leaves to a temperature between 180 and 200 °C so that THC is released from oils on the surface of the leaf but no actual combustion takes place.
Previous studies have shown that harmful toxins released through smoking cannabis such as carbon monoxide, benzene and a host of compounds known as polycyclic aromatic hydrocarbons (many of which are known carcinogens) are not produced by such devices.
Abrams' study is the first to compare the effects of smoking and vaporizing cannabis on human subjects. "We were able to deliver more-or-less equivalent amounts of THC into the bloodstream," he says. The main difference between the two delivery methods was that THC seemed to be absorbed into the bloodstream faster when using the vaporizer1. "The pharmacological and physiological effects were comparable," he says, although a larger study would be needed to prove that they are biologically equivalent.
Slow burn
The first studies to highlight the advantages of using vaporizers for cannabis were published more than five years ago, but the pace of research has been slow, partly because there is only one source of research-approved marijuana in the United States - the National Institute on Drug Abuse (NIDA) - which critics accuse of dictating research along a political agenda. A legal ruling this February recommended that the US Drug Enforcement Administration (DEA) end NIDA's monopoly on the production of marijuana for research approved by the US Food and Drug Administration and by the DEA.
Laura Bell of the Multiple Sclerosis Society in the UK says that her society supports cannabinoid research for people with multiple sclerosis. "Smoking cannabis results in exposure to many toxic chemicals," she says. "We welcome research into better and safer delivery methods."
Cannabis leaf is not the only substrate suited to a vaporizer. Other herbal preparations, such as eucalyptus and chamomile can also be used, or any plant with medicinal properties in the volatile compounds of its leaves.
Nature
11 May 2007
Inhaling cannabis without the smoke Study shows vaporizer delivers marijuana 'safely and effectively'
Arran Frood
Vaporizing cannabis leaves instead of burning them can release the drug's active ingredient just as effectively - while avoiding the harmful toxins inhaled through smoking the drug, according to a pilot study.
The result could be good news for those who choose to use marijuana medicinally.
The potential benefits of marijuana include pain relief for multiple-sclerosis sufferers, a treatment for glaucoma, as an appetite stimulant for AIDS patients and an anti-nausea agent for people on chemotherapy. But smoking isn't a good method of drug delivery because the harmful effects - such as lung cancer and heart disease - outweigh the likely merits of marijuana for all but terminal cases.
Rather than smoking, some use the leaves to make tea or cakes for consumption. But this means that the active agents are metabolized by the liver rather than entering the bloodstream unaltered. Others have focused on extracting active ingredients such as tetrahydrocannabinol (THC) and delivering them alone in a pill or oral spray. However, many think that the isolated ingredients are not as effective as the whole plant, and it is more difficult to customize the dose for each individual with a pill.
Hot stuff
Donald Abrams of the University of California, San Francisco, and his team decided to investigate the benefits of the 'Volcano', a commercially available vaporizer. The device heats marijuana leaves to a temperature between 180 and 200 °C so that THC is released from oils on the surface of the leaf but no actual combustion takes place.
Previous studies have shown that harmful toxins released through smoking cannabis such as carbon monoxide, benzene and a host of compounds known as polycyclic aromatic hydrocarbons (many of which are known carcinogens) are not produced by such devices.
Abrams' study is the first to compare the effects of smoking and vaporizing cannabis on human subjects. "We were able to deliver more-or-less equivalent amounts of THC into the bloodstream," he says. The main difference between the two delivery methods was that THC seemed to be absorbed into the bloodstream faster when using the vaporizer1. "The pharmacological and physiological effects were comparable," he says, although a larger study would be needed to prove that they are biologically equivalent.
Slow burn
The first studies to highlight the advantages of using vaporizers for cannabis were published more than five years ago, but the pace of research has been slow, partly because there is only one source of research-approved marijuana in the United States - the National Institute on Drug Abuse (NIDA) - which critics accuse of dictating research along a political agenda. A legal ruling this February recommended that the US Drug Enforcement Administration (DEA) end NIDA's monopoly on the production of marijuana for research approved by the US Food and Drug Administration and by the DEA.
Laura Bell of the Multiple Sclerosis Society in the UK says that her society supports cannabinoid research for people with multiple sclerosis. "Smoking cannabis results in exposure to many toxic chemicals," she says. "We welcome research into better and safer delivery methods."
Cannabis leaf is not the only substrate suited to a vaporizer. Other herbal preparations, such as eucalyptus and chamomile can also be used, or any plant with medicinal properties in the volatile compounds of its leaves.
BOOK REVIEW: 'Pharmako Gnosis'
-----------
http://www.latimes.com/features/books/la-bk-green13may13,1,3334407.story
?coll=la-books-headlines&ctrack=1&cset=true
BOOK REVIEW
'Pharmako Gnosis' by Dale Pendell
If Homer had been a drug connoisseur, his epic poems would have sounded
like this.
By Emily Green
Emily Green is a Los Angeles-based freelance writer.
May 13, 2007
Los Angelese Times
DALE PENDELL has the kind of counterculture bona fides that either kill
you or make you eccentric. He was in the Bay Area leading up to the
Summer of Love. In 14 years living in and out of the Sierra, he
botanized with old miners, hooked up with Gary Snyder, started a poetry
journal and published Allen Ginsberg. He did just about every drug with
a street value until 1989, when he curbed taking them, the better to be
able to write about them. "Pharmako Poeia," the first of a trilogy,
appeared in 1995; the second, "Pharmako Dynamis" in 2002; and the third,
"Pharmako Gnosis," last year. If there has ever been a more sustained
but unremarked effort to shock, it would be hard to find. All three
books have gone largely unnoticed.
It's a shame. They could not be more collectible, particularly volumes
one and two. It might have been the style. They were conceived as epic
poems, shifting freely between poetry, chemistry, taxonomy and bouts of
backchat. It might have been censorship. Perhaps the book-reviewing
world Just Said No. More likely, Pendell has bet his career on a subject
that exists in a twilight beyond polite conversation. He writes in a
country where doing drugs is so basic to youth that it might as well be
curricular, and denying having done them is just as basic a rite of
passage into adulthood.
For those interested in some recidivism, the books are helpfully
arranged by high. Volume one is devoted to dreamy stuff: alcohol,
absinthe, heroin and pot. Volume two's about speed: caffeine,
amphetamines, cocaine, Ecstasy and more. Volume three, it's a trip. It's
about psilocybin, mescal, peyote and LSD.
Every subject has its perils. Compared with the first two books, the
third is blurry and grandiose. One wonders whether the wine taster
forgot to spit. The best line about acid is a closing fillip in which he
remarks on "a certain sparkle." There are even baseball stories -
including the legendary one about Pirates pitcher Dock Ellis throwing a
1970 no-hitter against the San Diego Padres after taking a tab of acid.
Every so often you think Pendell's in earnest sociological mode, as when
he delivers a list of uses of peyote, until you arrive at the entry "a
good reason to get people together and enjoy each other." Dangling acid
before the inexperienced, he taunts, "Pop a ten strip!" (That's enough
to have a football team dancing to "Swan Lake.") "You deserve such joy!"
he baits. "You deserve release from so many years of encrusted cynicism.
You have worn your pain as a hair shirt, a burden-basket trumped and
creased on your forehead. Lay it down. Give it to Jesus. Give it to
Buddha. Give it to the great psychedelic Earth, and let the Earth
respond and accept you just as you are. You deserve it." Then his alter
egos, protestants all, appear:
And now, O Arbiters of Responsibility, what do I deserve?
A flogging, I'd say.
He wishes. What he got instead was stony silence from the daylight world
of modern America.
http://www.latimes.com/features/books/la-bk-green13may13,1,3334407.story
?coll=la-books-headlines&ctrack=1&cset=true
BOOK REVIEW
'Pharmako Gnosis' by Dale Pendell
If Homer had been a drug connoisseur, his epic poems would have sounded
like this.
By Emily Green
Emily Green is a Los Angeles-based freelance writer.
May 13, 2007
Los Angelese Times
DALE PENDELL has the kind of counterculture bona fides that either kill
you or make you eccentric. He was in the Bay Area leading up to the
Summer of Love. In 14 years living in and out of the Sierra, he
botanized with old miners, hooked up with Gary Snyder, started a poetry
journal and published Allen Ginsberg. He did just about every drug with
a street value until 1989, when he curbed taking them, the better to be
able to write about them. "Pharmako Poeia," the first of a trilogy,
appeared in 1995; the second, "Pharmako Dynamis" in 2002; and the third,
"Pharmako Gnosis," last year. If there has ever been a more sustained
but unremarked effort to shock, it would be hard to find. All three
books have gone largely unnoticed.
It's a shame. They could not be more collectible, particularly volumes
one and two. It might have been the style. They were conceived as epic
poems, shifting freely between poetry, chemistry, taxonomy and bouts of
backchat. It might have been censorship. Perhaps the book-reviewing
world Just Said No. More likely, Pendell has bet his career on a subject
that exists in a twilight beyond polite conversation. He writes in a
country where doing drugs is so basic to youth that it might as well be
curricular, and denying having done them is just as basic a rite of
passage into adulthood.
For those interested in some recidivism, the books are helpfully
arranged by high. Volume one is devoted to dreamy stuff: alcohol,
absinthe, heroin and pot. Volume two's about speed: caffeine,
amphetamines, cocaine, Ecstasy and more. Volume three, it's a trip. It's
about psilocybin, mescal, peyote and LSD.
Every subject has its perils. Compared with the first two books, the
third is blurry and grandiose. One wonders whether the wine taster
forgot to spit. The best line about acid is a closing fillip in which he
remarks on "a certain sparkle." There are even baseball stories -
including the legendary one about Pirates pitcher Dock Ellis throwing a
1970 no-hitter against the San Diego Padres after taking a tab of acid.
Every so often you think Pendell's in earnest sociological mode, as when
he delivers a list of uses of peyote, until you arrive at the entry "a
good reason to get people together and enjoy each other." Dangling acid
before the inexperienced, he taunts, "Pop a ten strip!" (That's enough
to have a football team dancing to "Swan Lake.") "You deserve such joy!"
he baits. "You deserve release from so many years of encrusted cynicism.
You have worn your pain as a hair shirt, a burden-basket trumped and
creased on your forehead. Lay it down. Give it to Jesus. Give it to
Buddha. Give it to the great psychedelic Earth, and let the Earth
respond and accept you just as you are. You deserve it." Then his alter
egos, protestants all, appear:
And now, O Arbiters of Responsibility, what do I deserve?
A flogging, I'd say.
He wishes. What he got instead was stony silence from the daylight world
of modern America.
FDA - MedWatch - OxyContin - Illegal Promotion By Manufacturer
Date: Thu, 10 May 2007 15:54:56 -0400
From: CDER MEDWATCH LISTSERV
Subject: FDA - MedWatch - OxyContin - Illegal Promotion By Manufacturer
May Cause Health Risks For Consumers
MedWatch - The FDA Safety Information and Adverse Event Reporting
Program
FDA informed healthcare professionals of criminal charges and civil
liabilities brought against Purdue Frederick in connection with several
illegal schemes to promote, market and sell OxyContin, a powerful
prescription pain reliever that the company produces. The manufacturer's
sales force was trained to make false claims about the product to
healthcare professionals, thereby, misbranding OxyContin by illegally
promoting the drug as being less addictive, less subject to abuse, and
less likely to cause tolerance and withdrawal than other pain
medications. These practices falsely promote the product and may cause
health risks for consumers.
Read the complete 2007 Safety summary, including a link to the FDA Press
Release regarding this issue at:
http://www.fda.gov/medwatch/safety/2007/safety07.htm#OxyContin
From: CDER MEDWATCH LISTSERV
Subject: FDA - MedWatch - OxyContin - Illegal Promotion By Manufacturer
May Cause Health Risks For Consumers
MedWatch - The FDA Safety Information and Adverse Event Reporting
Program
FDA informed healthcare professionals of criminal charges and civil
liabilities brought against Purdue Frederick in connection with several
illegal schemes to promote, market and sell OxyContin, a powerful
prescription pain reliever that the company produces. The manufacturer's
sales force was trained to make false claims about the product to
healthcare professionals, thereby, misbranding OxyContin by illegally
promoting the drug as being less addictive, less subject to abuse, and
less likely to cause tolerance and withdrawal than other pain
medications. These practices falsely promote the product and may cause
health risks for consumers.
Read the complete 2007 Safety summary, including a link to the FDA Press
Release regarding this issue at:
http://www.fda.gov/medwatch/safety/2007/safety07.htm#OxyContin
Alcohol's Effects Tough on Brain
http://www.medpagetoday.com/MeetingCoverage/AANMeeting/tb2/5559?pfc=101&spc=222
Alcohol's Effects Tough on Brain
By Neil Osterweil, Senior Associate Editor, MedPage Today
Reviewed by Rubeen K. Israni, M.D., Fellow, Renal-Electrolyte and Hypertension Division, University of Pennsylvania School of Medicine
May 03, 2007
BOSTON, May 3 -- Heavy drinking takes a toll on brain size, with a shrinking effect equivalent to about one to two years of brain aging for every higher level of alcohol consumption, investigators reported here.
Action Points
§ Explain to patients who ask that alcohol in moderation is thought to be protective against heart disease and stroke, but this study suggests that heavy drinking may accelerate the decline in brain volume normally seen with aging. The clinical significance of this finding is uncertain, but may suggest greater risk for cognitive decline in heavy imbibers.
§ Explain that this cross-sectional study found no benefit to the brain from even light drinking.
§ This study was published as an abstract and presented as a poster and orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.
Even light drinking had no beneficial effect on brain aging, unlike an often-reported cardiovascular benefit found from mild levels of alcohol, reported Carol Ann Paul, M.S., a senior instructor at Wellesley College in Wellesley, Mass.
The cross-sectional study of more than 1,800 patients was designed to determine whether the cardiovascular benefits associated with light-to-moderate alcohol consumption could also be seen in the brain, said Paul at the American Academy of Neurology meeting here.
Those who reported more than 14 alcoholic drinks per week had a significantly smaller brain volume compared with non-drinkers.
"Brain volume normally declines with age and that's often accompanied by cognitive impairment in the later stages," she said. "So brain volume is some sort of indicator of brain capacity."
She and her colleagues took advantage of MRI scans acquired from 1999 to 2002 from 1,839 non-demented participants in the Framingham Offspring Study, which itself is an offspring of the Framingham Heart Study.
They divided the participants into five categories on the basis of self-reported alcohol consumption frequency: abstainers, former drinkers, low drinkers (one to seven drinks per week), moderate drinkers (eight to 14 drinks per week), and heavy drinkers (more than 14 drinks per week).
The authors made pair-wise comparisons of mean total cranial volumes across the various groups, and created multivariate linear regression models to see whether there was an association between brain size and alcohol consumption. They controlled their analyses for age, gender, body mass index, height, educational level attained, and Framingham Stroke Risk Profile. They also looked at the longitudinal history of alcohol consumption from 1987 to 2001 to see whether there were associations with total cranial volume.
"I found that unlike what I had hypothesized, there was no beneficial effect of alcohol on brain volume," Paul said. "In addition, I found that there was a slightly more strong effect in women than in men, and on the preliminary longitudinal studies, it seemed that people who had been heavy drinkers throughout the 12-year period we looked at, had significantly decreased brain volume in comparison to the others."
Specifically, the authors found a reduction in brain volume of 0.25% for every additional category of alcohol consumption. In contrast, the average age-related decline in brain volume is 0.19% per year, she noted.
Gender modified the alcohol-brain volume relationship significantly (P=0.0029), with men having a slightly lower downward slope than women, meaning that brain volume decreased more in women than men across categories of alcohol consumption.
The authors also detected a significant negative correlation between alcohol consumption and brain volume among women in their 70's (P= 0.013), and in the longitudinal analysis, they found that heavy drinking was negatively associated with brain volume (P=0.005, -0.026).
"Each drink category is approximately equivalent to one-to-two years of aging," Paul said, adding that the effect was linear across the categories from low to high.
She suggested that although alcohol consumption in moderation has beneficial effects on the cardiovascular system, it may be found to be associated with deleterious effects on neurons and neural circuitry.
Neither funding sources nor author conflicts of interest were reported.
Complete AAN Coverage
Primary source: American Academy of Neurology 2007 Annual Meeting
Source reference:
Paul CA et al. "The Effect of Alcohol Consumption on Total Brain Volume: The Framingham Heart Study." Abstract P05.030, presented May 2.
Alcohol's Effects Tough on Brain
By Neil Osterweil, Senior Associate Editor, MedPage Today
Reviewed by Rubeen K. Israni, M.D., Fellow, Renal-Electrolyte and Hypertension Division, University of Pennsylvania School of Medicine
May 03, 2007
BOSTON, May 3 -- Heavy drinking takes a toll on brain size, with a shrinking effect equivalent to about one to two years of brain aging for every higher level of alcohol consumption, investigators reported here.
Action Points
§ Explain to patients who ask that alcohol in moderation is thought to be protective against heart disease and stroke, but this study suggests that heavy drinking may accelerate the decline in brain volume normally seen with aging. The clinical significance of this finding is uncertain, but may suggest greater risk for cognitive decline in heavy imbibers.
§ Explain that this cross-sectional study found no benefit to the brain from even light drinking.
§ This study was published as an abstract and presented as a poster and orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.
Even light drinking had no beneficial effect on brain aging, unlike an often-reported cardiovascular benefit found from mild levels of alcohol, reported Carol Ann Paul, M.S., a senior instructor at Wellesley College in Wellesley, Mass.
The cross-sectional study of more than 1,800 patients was designed to determine whether the cardiovascular benefits associated with light-to-moderate alcohol consumption could also be seen in the brain, said Paul at the American Academy of Neurology meeting here.
Those who reported more than 14 alcoholic drinks per week had a significantly smaller brain volume compared with non-drinkers.
"Brain volume normally declines with age and that's often accompanied by cognitive impairment in the later stages," she said. "So brain volume is some sort of indicator of brain capacity."
She and her colleagues took advantage of MRI scans acquired from 1999 to 2002 from 1,839 non-demented participants in the Framingham Offspring Study, which itself is an offspring of the Framingham Heart Study.
They divided the participants into five categories on the basis of self-reported alcohol consumption frequency: abstainers, former drinkers, low drinkers (one to seven drinks per week), moderate drinkers (eight to 14 drinks per week), and heavy drinkers (more than 14 drinks per week).
The authors made pair-wise comparisons of mean total cranial volumes across the various groups, and created multivariate linear regression models to see whether there was an association between brain size and alcohol consumption. They controlled their analyses for age, gender, body mass index, height, educational level attained, and Framingham Stroke Risk Profile. They also looked at the longitudinal history of alcohol consumption from 1987 to 2001 to see whether there were associations with total cranial volume.
"I found that unlike what I had hypothesized, there was no beneficial effect of alcohol on brain volume," Paul said. "In addition, I found that there was a slightly more strong effect in women than in men, and on the preliminary longitudinal studies, it seemed that people who had been heavy drinkers throughout the 12-year period we looked at, had significantly decreased brain volume in comparison to the others."
Specifically, the authors found a reduction in brain volume of 0.25% for every additional category of alcohol consumption. In contrast, the average age-related decline in brain volume is 0.19% per year, she noted.
Gender modified the alcohol-brain volume relationship significantly (P=0.0029), with men having a slightly lower downward slope than women, meaning that brain volume decreased more in women than men across categories of alcohol consumption.
The authors also detected a significant negative correlation between alcohol consumption and brain volume among women in their 70's (P= 0.013), and in the longitudinal analysis, they found that heavy drinking was negatively associated with brain volume (P=0.005, -0.026).
"Each drink category is approximately equivalent to one-to-two years of aging," Paul said, adding that the effect was linear across the categories from low to high.
She suggested that although alcohol consumption in moderation has beneficial effects on the cardiovascular system, it may be found to be associated with deleterious effects on neurons and neural circuitry.
Neither funding sources nor author conflicts of interest were reported.
Complete AAN Coverage
Primary source: American Academy of Neurology 2007 Annual Meeting
Source reference:
Paul CA et al. "The Effect of Alcohol Consumption on Total Brain Volume: The Framingham Heart Study." Abstract P05.030, presented May 2.
Saturday
Lancet on piperazine Adverse Events
Lancet on piperazine AEs
Two papers: one on a piperazine ED visit and the other a commentary
-------------
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4NKCD9Y-18&_user=861681&_coverDate=05%2F04%2F2007&_rdoc=1&_fmt=full&_orig=browse&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=ce218b61dfc43491ead6fb867504e5cb
The Lancet Volume 369, Issue 9571,
28 April 2007-4 May 2007, Page 1490
Case Report
Collapse, reported seizure—and an unexpected pill
David M Wood, Paul I Dargan, Jennifer Button, David W Holt, Hanna Ovaska, John Ramsey and Alison L Jones
In May, 2006, on a Bank Holiday weekend, an 18-year-old woman presented to an inner-city London emergency department. She had been at a nightclub with friends and purchased tablets, which she understood to be Ecstasy or amphetamines, from a dealer. After ingesting five tablets, she collapsed in the nightclub and appeared to have a seizure lasting 10 min. On arrival in the emergency department, she was agitated and had dilated pupils (8 mm), sinus tachycardia (156 bpm), and a blood pressure of 150/51 mm Hg. Her score on the Glasgow coma scale was 15 and she was apyrexial (35·9°C). She had no significant past medical history and was on no regular medication.
She was one of seven patients to attend the department that night with a similar presentation. We therefore considered it possible that she had taken a contaminated drug, or a substance not previously sold in the area; and we took a serum sample for analysis, in addition to treating the patient symptomatically with intravenous benzodiazepines (4 mg lorazepam followed by 15 mg diazepam). After 12 h, she was asymptomatic and discharged with advice to avoid recreational drugs. The serum sample was analysed by gas chromatography with mass-spectrometric detection (GCMS); 1-benzylpiperazine was detected at a concentration of 2·5 mg/L. Toxicological screening of the same serum sample did not detect the presence of other piperazines, other drugs, or ethanol. A tablet purchased by the patient (figure) was also analysed, and found to contain 1-benzylpiperazine.
1-benzylpiperazine is one of the piperazine family of drugs, initially developed as veterinary anthelmintic agents in the 1950s. Its chemical structure is similar to that of amphetamine.1 Piperazines are marketed in the UK, where they are legally available in shops and over the internet, as having similar effects to controlled recreational drugs; pills containing piperazines are known as “pep pills”.2 No reliable data are available on the consumption of piperazines in the UK, although one manufacturer claims that “over 20 million pills have been consumed in New Zealand with no deaths, or significant lasting injuries”.2 However, in initial clinical trials of 1-benzylpiperazine, adverse effects similar to those of amphetamines were noted.3 A prospective study in New Zealand identified adverse effects including nausea, vomiting, tachycardia, hypertension, anxiety, and agitation among 80 patients presenting to emergency departments after 1-benzylpiperazine ingestion.4 Seizures were reported in 15 (19%), at up to 8 h after ingestion. Three patients had potentially life-threatening recurrent seizures; ingestion of 1-benzylpiperazine by these patients was confirmed by toxicological screening of their urine. Other potentially serious adverse effects included QTc prolongation (QTc duration 430–490 ms in 32 patients) and hyponatraemia (serum sodium concentration 118 mmol/L and serum osmolality 242 mmol/kg) in one patient. Clinicians should be aware of the potential presenting features of piperazine toxicity, particularly because commercially available urine toxicological screening kits for drugs of abuse may not detect piperazines. All patients with strongly suspected or reported ingestion of 1-benzylpiperazine should have an initial baseline ECG, to seek features of cardiotoxicity. They should be observed for up to 8 h after ingestion, because the onset of seizures can be delayed. Initial treatment should be based on the clinical presentation. Further management can require the advice of a clinical toxicologist.
References
1 M Wikstrom, P Holmgren and J Ahlner, A2 (N-benzylpiperazine) a new drug of abuse in Sweden, J Anal Toxicol 28 (2004), pp. 67–70. View Record in Scopus Cited By in Scopus
2 Spiritualhigh.co.uk – Staying Safe on PEP Pillshttp://www.spiritualhigh.co.uk/information/drug-harm-minimisation-and-legal-highs/staying-safe-on-pep-pills/3-7-7-19 (accessed April 2, 2007)..
3 C Bye, AD Munro-Faure, AW Peck and PA Young, A comparison of the effects of 1-benzylpiperazine and dexamphetamine on human performance tests, Eur J Clin Pharmacol 6 (1973), pp. 163–169. Full Text via CrossRef View Record in Scopus Cited By in Scopus
4 P Gee, S Richardson, W Woltersdorf and G Moore, Toxic effects of BZP-based herbal party pills in humans: a prospective study in Christchurch, New Zealand, N Z Med J 118 (2005), p. U1784.
---------------
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4NKCD9Y-8&_user=861681&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=052f888a3af245e97f046b0a6e64f7db
Comment
Piperazine designer drugs of abuse
Roland F Staack
In today's Lancet, David Wood and colleagues report on the first case of poisoning with 1-benzylpiperazine (BZP) in the UK.1 This case report is a valuable contribution to the development of a better understanding of the toxicity of this new drug of abuse. To date, only a few cases of poisonings and deaths with BZP have been reported.2, 3 and 4 However, in these reports, no detailed clinical data were given, the cases were polydrug intoxications, or only limited analytical toxicological analysis was available. The case reported by Wood and colleagues describes for the first time the clinical symptoms of an acute mono-intoxication with BZP, which was confirmed by toxicological analysis.
BZP is the most prevalent compound of a new class of designer drugs of abuse called piperazines (figure). Besides BZP and 1-(3,4-methylenedioxybenzyl)piperazine (MDBP), there are the phenylpiperazine derivatives: 1-(3-trifluoromethylphenyl)piperazine (TFMPP), 1-(3-chlorophenyl)piperazine (mCPP), and 1-(4-methoxyphenyl)piperazine (MeOPP).5
The amfetaminergic effects of BZP have been known since the 1970s. A mixture of BZP and TFMPP mimics the molecular mechanism of 3,4-methylenedioxymethamfetamine (MDMA, ecstasy).3, 5, 6, 7 and 8 The phenylpiperazines are well-characterised serotonergic compounds, which is also the reason for the use of 1-(3-chlorophenyl)piperazine (mCPP) as a probe drug in psychiatric research.5, 6 and 7 Commonly, piperazines are sold as party pills in the form of tablets, capsules, or powders on the black drug-market and in so-called headshops or over the internet. They are also found in tablets sold as ecstasy or amfetamine. Generally, piperazine blends are consumed. Besides the most prevalent mixture of BZP with TFMPP, there are also blends of up to four different piperazines (named X4). Furthermore, mixtures of piperazines with other drugs of abuse, such as ecstasy or cocaine, have been reported.6 and 7 Since the end of the 1990s, piperazines are often proffered as a legal and safe alternative to amfetamine-derived drugs. The discussion on their legal status is ongoing in many countries. However, some countries (eg, the USA, Australia, Japan, and some European countries) already control BZP under drug control or equivalent legislation.6, 7 and 9 Thus the claimed advantage of legality is not given anymore in these countries. In March, 2007, in the UK, the Medicines and Healthcare products Regulatory Agency declared the selling of BZP products illegal.10 Predictably, the legal measures started a kind of cat-and-mouse play. Instead of BZP, other, not yet scheduled, piperazines, mainly mCPP, increasingly appeared on the market.
The widespread use of piperazines with only a low record of attributable toxicity is stated by activists as proof of safety for legalisation of these drugs. However, from a toxicological point of view, such a stance cannot be affirmed. In view of the similar pharmacological modes of action of piperazines and amfetamines, similar toxicity has to be assumed. This assumption is supported by the reported cases of piperazine poisonings1, 2, 3 and 4 and by the occurrence of serotonin syndromes in a clinical study.11
Special attention should be paid here to polydrug use. Synergistic effects of piperazine blends have been described.8 Furthermore, particularly the phenylpiperazines are extensively metabolised, mainly by the polymorphically expressed cytochrome P450 2D6 (CYP2D6) which might result in an increased risk of toxic side-effects for CYP2D6 poor-metabolisers.5 In addition, these compounds are liable for drug–drug interactions with inhibitors or other substrates of this enzyme (eg, MDMA, cocaine), which might similarly increase the risk of toxicity, especially because piperazines seem to have a narrow safety margin.6, 8 and 11
The low record of reported poisonings with piperazines has also to be put into perspective. Many clinicians are not aware of newer classes of drugs of abuse. Piperazines and amfetamines are similarly marketed, consumed by the same population, and show similar pharmacological symptoms. Therefore a piperazine poisoning can easily be wrongly diagnosed as an amfetamine poisoning. Furthermore, piperazines are not detected by routinely used immunochemical screening procedures for drugs of abuse, but require an appropriate toxicological analysis (eg, by gas-chromatography mass-spectrometry).12 and 13
Hence Wood and colleagues' case report is an excellent example to raise clinicians' awareness of newer drugs of abuse and substantiates the importance of a sound toxicological analysis for a correct clinical diagnosis. As a result, more cases of abuse of new designer drugs will be detected, which in turn will yield data essential for a toxicological risk assessment. Besides piperazines, there are also further new classes of designer drugs of abuse, such as phenethylamines (2C-series), α-pyrrolidinophenones, and new phencyclidine derivatives.5 and 9
References
1 DM Wood, PI Dargan and J Button et al., Pills, collapse, and a negative drug screen, Lancet 369 (2007), p. 1490. SummaryPlus Full Text + Links PDF (73 K)
2 C Balmelli, H Kupferschmidt, K Rentsch and M Schneemann, Fatal brain edema after ingestion of ecstasy and benzylpiperazine, Dtsch Med Wochenschr 126 (2001), pp. 809–811. Full Text via CrossRef View Record in Scopus Cited By in Scopus
3 P Gee, S Richardson, W Woltersdorf and G Moore, Toxic effects of BZP-based herbal party pills in humans: a prospective study in Christchurch, New Zealand, N Z Med J 118 (2005), p. U1784.
4 M Wikström, P Holmgren and J Ahlner, A2 (N-benzylpiperazine) a new drug of abuse in Sweden, J Anal Toxicol 28 (2004), pp. 67–70. View Record in Scopus Cited By in Scopus
5 RF Staack and HH Maurer, Metabolism of designer drugs of abuse, Curr Drug Metab 6 (2005), pp. 259–274. Full Text via CrossRef View Record in Scopus Cited By in Scopus
6 European Monitroing Centre for Drugs and Drug Addiction, Europol-EMCDDA Joint Report on a new psychoactive substance: 1-benzylpiperazine (BZP)http://www.emcdda.europa.eu/?nnodeID=1346 (March 23, 2007) (accessed April 17, 2007)..
7 European Monitroing Centre for Drugs and Drug Addiction, Europol-EMCDDA Joint Report on a new psychoactive substance: 1-(3-chlorophenyl)piperazine (mCPP)http://www.emcdda.europa.eu/?nnodeID=1346 (March 23, 2007) (accessed April 17, 2007)..
8 MH Baumann, RD Clark, AG Budzynski, JS Partilla, BE Blough and RB Rothman, N-substituted piperazines abused by humans mimic the molecular mechanism of 3,4-methylenedioxymethamphetamine (MDMA, or ‘Ecstasy’), Neuropsychopharmacology 30 (2005), pp. 550–560. Full Text via CrossRef View Record in Scopus Cited By in Scopus
9 Anonymous, Schedules of controlled substances; placement of 2,5-dimethoxy-4-(n)-propylthiophenethylamine and N-benzylpiperazine into Schedule I of the Controlled Substances Act. Final rule, Fed Regist 69 (2004), pp. 12794–12797.
10 MHRA, Press release: benzylpiperazine (PEP) pills are dangerous and illegalhttp://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CON2030603&ssTargetNodeId=389 (March 20, 2007) (accessed April 17, 2007)..
11 T Klaassen, KL Ho Pian, HG Westenberg, JA den Boer and HM van Praag, Serotonin syndrome after challenge with the 5-HT agonist meta-chlorophenylpiperazine, Psychiatry Res 79 (1998), pp. 207–212. Abstract Full Text + Links PDF (73 K) View Record in Scopus Cited By in Scopus
12 HH Maurer, Position of chromatographic techniques in screening for detection of drugs or poisons in clinical and forensic toxicology and/or doping control, Clin Chem Lab Med 42 (2004), pp. 1310–1324. Full Text via CrossRef View Record in Scopus Cited By in Scopus
13 FT Peters, S Schaefer, RF Staack, T Kraemer and HH Maurer, Screening for and validated quantification of amphetamines and of amphetamine- and piperazine-derived designer drugs in human blood plasma by gas chromatography/mass spectrometry, J Mass Spectrom 38 (2003), pp. 659–676. Full Text via CrossRef View Record in Scopus Cited By in Scopus
Two papers: one on a piperazine ED visit and the other a commentary
-------------
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4NKCD9Y-18&_user=861681&_coverDate=05%2F04%2F2007&_rdoc=1&_fmt=full&_orig=browse&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=ce218b61dfc43491ead6fb867504e5cb
The Lancet Volume 369, Issue 9571,
28 April 2007-4 May 2007, Page 1490
Case Report
Collapse, reported seizure—and an unexpected pill
David M Wood, Paul I Dargan, Jennifer Button, David W Holt, Hanna Ovaska, John Ramsey and Alison L Jones
In May, 2006, on a Bank Holiday weekend, an 18-year-old woman presented to an inner-city London emergency department. She had been at a nightclub with friends and purchased tablets, which she understood to be Ecstasy or amphetamines, from a dealer. After ingesting five tablets, she collapsed in the nightclub and appeared to have a seizure lasting 10 min. On arrival in the emergency department, she was agitated and had dilated pupils (8 mm), sinus tachycardia (156 bpm), and a blood pressure of 150/51 mm Hg. Her score on the Glasgow coma scale was 15 and she was apyrexial (35·9°C). She had no significant past medical history and was on no regular medication.
She was one of seven patients to attend the department that night with a similar presentation. We therefore considered it possible that she had taken a contaminated drug, or a substance not previously sold in the area; and we took a serum sample for analysis, in addition to treating the patient symptomatically with intravenous benzodiazepines (4 mg lorazepam followed by 15 mg diazepam). After 12 h, she was asymptomatic and discharged with advice to avoid recreational drugs. The serum sample was analysed by gas chromatography with mass-spectrometric detection (GCMS); 1-benzylpiperazine was detected at a concentration of 2·5 mg/L. Toxicological screening of the same serum sample did not detect the presence of other piperazines, other drugs, or ethanol. A tablet purchased by the patient (figure) was also analysed, and found to contain 1-benzylpiperazine.
1-benzylpiperazine is one of the piperazine family of drugs, initially developed as veterinary anthelmintic agents in the 1950s. Its chemical structure is similar to that of amphetamine.1 Piperazines are marketed in the UK, where they are legally available in shops and over the internet, as having similar effects to controlled recreational drugs; pills containing piperazines are known as “pep pills”.2 No reliable data are available on the consumption of piperazines in the UK, although one manufacturer claims that “over 20 million pills have been consumed in New Zealand with no deaths, or significant lasting injuries”.2 However, in initial clinical trials of 1-benzylpiperazine, adverse effects similar to those of amphetamines were noted.3 A prospective study in New Zealand identified adverse effects including nausea, vomiting, tachycardia, hypertension, anxiety, and agitation among 80 patients presenting to emergency departments after 1-benzylpiperazine ingestion.4 Seizures were reported in 15 (19%), at up to 8 h after ingestion. Three patients had potentially life-threatening recurrent seizures; ingestion of 1-benzylpiperazine by these patients was confirmed by toxicological screening of their urine. Other potentially serious adverse effects included QTc prolongation (QTc duration 430–490 ms in 32 patients) and hyponatraemia (serum sodium concentration 118 mmol/L and serum osmolality 242 mmol/kg) in one patient. Clinicians should be aware of the potential presenting features of piperazine toxicity, particularly because commercially available urine toxicological screening kits for drugs of abuse may not detect piperazines. All patients with strongly suspected or reported ingestion of 1-benzylpiperazine should have an initial baseline ECG, to seek features of cardiotoxicity. They should be observed for up to 8 h after ingestion, because the onset of seizures can be delayed. Initial treatment should be based on the clinical presentation. Further management can require the advice of a clinical toxicologist.
References
1 M Wikstrom, P Holmgren and J Ahlner, A2 (N-benzylpiperazine) a new drug of abuse in Sweden, J Anal Toxicol 28 (2004), pp. 67–70. View Record in Scopus Cited By in Scopus
2 Spiritualhigh.co.uk – Staying Safe on PEP Pillshttp://www.spiritualhigh.co.uk/information/drug-harm-minimisation-and-legal-highs/staying-safe-on-pep-pills/3-7-7-19 (accessed April 2, 2007)..
3 C Bye, AD Munro-Faure, AW Peck and PA Young, A comparison of the effects of 1-benzylpiperazine and dexamphetamine on human performance tests, Eur J Clin Pharmacol 6 (1973), pp. 163–169. Full Text via CrossRef View Record in Scopus Cited By in Scopus
4 P Gee, S Richardson, W Woltersdorf and G Moore, Toxic effects of BZP-based herbal party pills in humans: a prospective study in Christchurch, New Zealand, N Z Med J 118 (2005), p. U1784.
---------------
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4NKCD9Y-8&_user=861681&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=052f888a3af245e97f046b0a6e64f7db
Comment
Piperazine designer drugs of abuse
Roland F Staack
In today's Lancet, David Wood and colleagues report on the first case of poisoning with 1-benzylpiperazine (BZP) in the UK.1 This case report is a valuable contribution to the development of a better understanding of the toxicity of this new drug of abuse. To date, only a few cases of poisonings and deaths with BZP have been reported.2, 3 and 4 However, in these reports, no detailed clinical data were given, the cases were polydrug intoxications, or only limited analytical toxicological analysis was available. The case reported by Wood and colleagues describes for the first time the clinical symptoms of an acute mono-intoxication with BZP, which was confirmed by toxicological analysis.
BZP is the most prevalent compound of a new class of designer drugs of abuse called piperazines (figure). Besides BZP and 1-(3,4-methylenedioxybenzyl)piperazine (MDBP), there are the phenylpiperazine derivatives: 1-(3-trifluoromethylphenyl)piperazine (TFMPP), 1-(3-chlorophenyl)piperazine (mCPP), and 1-(4-methoxyphenyl)piperazine (MeOPP).5
The amfetaminergic effects of BZP have been known since the 1970s. A mixture of BZP and TFMPP mimics the molecular mechanism of 3,4-methylenedioxymethamfetamine (MDMA, ecstasy).3, 5, 6, 7 and 8 The phenylpiperazines are well-characterised serotonergic compounds, which is also the reason for the use of 1-(3-chlorophenyl)piperazine (mCPP) as a probe drug in psychiatric research.5, 6 and 7 Commonly, piperazines are sold as party pills in the form of tablets, capsules, or powders on the black drug-market and in so-called headshops or over the internet. They are also found in tablets sold as ecstasy or amfetamine. Generally, piperazine blends are consumed. Besides the most prevalent mixture of BZP with TFMPP, there are also blends of up to four different piperazines (named X4). Furthermore, mixtures of piperazines with other drugs of abuse, such as ecstasy or cocaine, have been reported.6 and 7 Since the end of the 1990s, piperazines are often proffered as a legal and safe alternative to amfetamine-derived drugs. The discussion on their legal status is ongoing in many countries. However, some countries (eg, the USA, Australia, Japan, and some European countries) already control BZP under drug control or equivalent legislation.6, 7 and 9 Thus the claimed advantage of legality is not given anymore in these countries. In March, 2007, in the UK, the Medicines and Healthcare products Regulatory Agency declared the selling of BZP products illegal.10 Predictably, the legal measures started a kind of cat-and-mouse play. Instead of BZP, other, not yet scheduled, piperazines, mainly mCPP, increasingly appeared on the market.
The widespread use of piperazines with only a low record of attributable toxicity is stated by activists as proof of safety for legalisation of these drugs. However, from a toxicological point of view, such a stance cannot be affirmed. In view of the similar pharmacological modes of action of piperazines and amfetamines, similar toxicity has to be assumed. This assumption is supported by the reported cases of piperazine poisonings1, 2, 3 and 4 and by the occurrence of serotonin syndromes in a clinical study.11
Special attention should be paid here to polydrug use. Synergistic effects of piperazine blends have been described.8 Furthermore, particularly the phenylpiperazines are extensively metabolised, mainly by the polymorphically expressed cytochrome P450 2D6 (CYP2D6) which might result in an increased risk of toxic side-effects for CYP2D6 poor-metabolisers.5 In addition, these compounds are liable for drug–drug interactions with inhibitors or other substrates of this enzyme (eg, MDMA, cocaine), which might similarly increase the risk of toxicity, especially because piperazines seem to have a narrow safety margin.6, 8 and 11
The low record of reported poisonings with piperazines has also to be put into perspective. Many clinicians are not aware of newer classes of drugs of abuse. Piperazines and amfetamines are similarly marketed, consumed by the same population, and show similar pharmacological symptoms. Therefore a piperazine poisoning can easily be wrongly diagnosed as an amfetamine poisoning. Furthermore, piperazines are not detected by routinely used immunochemical screening procedures for drugs of abuse, but require an appropriate toxicological analysis (eg, by gas-chromatography mass-spectrometry).12 and 13
Hence Wood and colleagues' case report is an excellent example to raise clinicians' awareness of newer drugs of abuse and substantiates the importance of a sound toxicological analysis for a correct clinical diagnosis. As a result, more cases of abuse of new designer drugs will be detected, which in turn will yield data essential for a toxicological risk assessment. Besides piperazines, there are also further new classes of designer drugs of abuse, such as phenethylamines (2C-series), α-pyrrolidinophenones, and new phencyclidine derivatives.5 and 9
References
1 DM Wood, PI Dargan and J Button et al., Pills, collapse, and a negative drug screen, Lancet 369 (2007), p. 1490. SummaryPlus Full Text + Links PDF (73 K)
2 C Balmelli, H Kupferschmidt, K Rentsch and M Schneemann, Fatal brain edema after ingestion of ecstasy and benzylpiperazine, Dtsch Med Wochenschr 126 (2001), pp. 809–811. Full Text via CrossRef View Record in Scopus Cited By in Scopus
3 P Gee, S Richardson, W Woltersdorf and G Moore, Toxic effects of BZP-based herbal party pills in humans: a prospective study in Christchurch, New Zealand, N Z Med J 118 (2005), p. U1784.
4 M Wikström, P Holmgren and J Ahlner, A2 (N-benzylpiperazine) a new drug of abuse in Sweden, J Anal Toxicol 28 (2004), pp. 67–70. View Record in Scopus Cited By in Scopus
5 RF Staack and HH Maurer, Metabolism of designer drugs of abuse, Curr Drug Metab 6 (2005), pp. 259–274. Full Text via CrossRef View Record in Scopus Cited By in Scopus
6 European Monitroing Centre for Drugs and Drug Addiction, Europol-EMCDDA Joint Report on a new psychoactive substance: 1-benzylpiperazine (BZP)http://www.emcdda.europa.eu/?nnodeID=1346 (March 23, 2007) (accessed April 17, 2007)..
7 European Monitroing Centre for Drugs and Drug Addiction, Europol-EMCDDA Joint Report on a new psychoactive substance: 1-(3-chlorophenyl)piperazine (mCPP)http://www.emcdda.europa.eu/?nnodeID=1346 (March 23, 2007) (accessed April 17, 2007)..
8 MH Baumann, RD Clark, AG Budzynski, JS Partilla, BE Blough and RB Rothman, N-substituted piperazines abused by humans mimic the molecular mechanism of 3,4-methylenedioxymethamphetamine (MDMA, or ‘Ecstasy’), Neuropsychopharmacology 30 (2005), pp. 550–560. Full Text via CrossRef View Record in Scopus Cited By in Scopus
9 Anonymous, Schedules of controlled substances; placement of 2,5-dimethoxy-4-(n)-propylthiophenethylamine and N-benzylpiperazine into Schedule I of the Controlled Substances Act. Final rule, Fed Regist 69 (2004), pp. 12794–12797.
10 MHRA, Press release: benzylpiperazine (PEP) pills are dangerous and illegalhttp://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CON2030603&ssTargetNodeId=389 (March 20, 2007) (accessed April 17, 2007)..
11 T Klaassen, KL Ho Pian, HG Westenberg, JA den Boer and HM van Praag, Serotonin syndrome after challenge with the 5-HT agonist meta-chlorophenylpiperazine, Psychiatry Res 79 (1998), pp. 207–212. Abstract Full Text + Links PDF (73 K) View Record in Scopus Cited By in Scopus
12 HH Maurer, Position of chromatographic techniques in screening for detection of drugs or poisons in clinical and forensic toxicology and/or doping control, Clin Chem Lab Med 42 (2004), pp. 1310–1324. Full Text via CrossRef View Record in Scopus Cited By in Scopus
13 FT Peters, S Schaefer, RF Staack, T Kraemer and HH Maurer, Screening for and validated quantification of amphetamines and of amphetamine- and piperazine-derived designer drugs in human blood plasma by gas chromatography/mass spectrometry, J Mass Spectrom 38 (2003), pp. 659–676. Full Text via CrossRef View Record in Scopus Cited By in Scopus
Sentencing Commission on cocaine/crack
Sentencing Commish on cocaine/crack
http://www.ussc.gov/PRESS/rel0407.htm
In addition to those earlier actions, the Commission unanimously
announced today that it will submit to Congress on or before May 15,
2007, a report on federal cocaine sentencing policy. The report will set
forth current data and information that continue to support the
Commission's consistently held position that the 100-to-1 crack-powder
drug quantity ratio significantly undermines various congressional
objectives set forth in the Sentencing Reform Act and elsewhere. The
Commission also will make recommendations to Congress in the report for
modifications to the statutory penalties for crack cocaine offenses. At
today's meeting, the Commission expressed its firm desire that this
report will facilitate prompt congressional action addressing the
100-to-1 crack-powder drug quantity ratio.
The Commission also voted today to promulgate an amendment that modifies
the penalties for crack cocaine offenses. The Commission described the
problems associated with the 100-to-1 drug quantity ratio as so urgent
and compelling that it promulgated the guideline amendment as a measure
to alleviate some of those problems.
The statutory penalties for crack cocaine offenses require a five-year
mandatory minimum sentence for a first-time trafficking offense
involving 5 grams or more of crack cocaine, and a ten-year mandatory
minimum penalty for a first-time trafficking offense involving 50 grams
or more of crack cocaine. When Congress established these penalties in
1986, the Commission responded by incorporating the statutory mandatory
minimum sentences into the guidelines to provide guideline sentencing
ranges that are above the statutory mandatory minimum penalties.
First-time offenses involving 5 grams or more of crack cocaine receive a
sentencing guideline range of 63 to 78 months, and first-time offenses
involving 50 grams or more of crack cocaine receive a sentencing
guideline range of 121 to 151 months, before accounting for other
relevant factors under the guidelines.
The Commission's amendment modifies the guideline drug quantity
thresholds to provide guideline sentencing ranges that include the
statutory mandatory minimum penalties for crack cocaine offenses.
Accordingly, under the amendment, a first-time trafficking offense
involving 5 grams of crack cocaine will receive a guideline sentencing
range of 51 to 63 months, and a first-time trafficking offense involving
50 grams or more of crack cocaine will receive a guideline sentencing
range of 97 to 121 months, before accounting for other relevant factors
under the guidelines. Under the statutory mandatory minimum penalties,
however, a five- and ten-year sentence will still be required,
respectively. As a result, the Commission's amendment provides some
relief to crack cocaine offenders impacted by the disparity created by
federal cocaine sentencing policy.
The Commission emphasized and expressed its strong view that the
amendment is only a partial solution to some of the problems associated
with the 100-to-1 drug quantity ratio. Any comprehensive solution to the
100-to-1 drug quantity ratio would require appropriate legislative
action by Congress.
The text of the Commission's amendments and its accompanying 2007 report
to Congress, Cocaine and Federal Sentencing Policy, will be available in
the coming weeks on the Commission's website, www.ussc.gov.
http://www.ussc.gov/PRESS/rel0407.htm
In addition to those earlier actions, the Commission unanimously
announced today that it will submit to Congress on or before May 15,
2007, a report on federal cocaine sentencing policy. The report will set
forth current data and information that continue to support the
Commission's consistently held position that the 100-to-1 crack-powder
drug quantity ratio significantly undermines various congressional
objectives set forth in the Sentencing Reform Act and elsewhere. The
Commission also will make recommendations to Congress in the report for
modifications to the statutory penalties for crack cocaine offenses. At
today's meeting, the Commission expressed its firm desire that this
report will facilitate prompt congressional action addressing the
100-to-1 crack-powder drug quantity ratio.
The Commission also voted today to promulgate an amendment that modifies
the penalties for crack cocaine offenses. The Commission described the
problems associated with the 100-to-1 drug quantity ratio as so urgent
and compelling that it promulgated the guideline amendment as a measure
to alleviate some of those problems.
The statutory penalties for crack cocaine offenses require a five-year
mandatory minimum sentence for a first-time trafficking offense
involving 5 grams or more of crack cocaine, and a ten-year mandatory
minimum penalty for a first-time trafficking offense involving 50 grams
or more of crack cocaine. When Congress established these penalties in
1986, the Commission responded by incorporating the statutory mandatory
minimum sentences into the guidelines to provide guideline sentencing
ranges that are above the statutory mandatory minimum penalties.
First-time offenses involving 5 grams or more of crack cocaine receive a
sentencing guideline range of 63 to 78 months, and first-time offenses
involving 50 grams or more of crack cocaine receive a sentencing
guideline range of 121 to 151 months, before accounting for other
relevant factors under the guidelines.
The Commission's amendment modifies the guideline drug quantity
thresholds to provide guideline sentencing ranges that include the
statutory mandatory minimum penalties for crack cocaine offenses.
Accordingly, under the amendment, a first-time trafficking offense
involving 5 grams of crack cocaine will receive a guideline sentencing
range of 51 to 63 months, and a first-time trafficking offense involving
50 grams or more of crack cocaine will receive a guideline sentencing
range of 97 to 121 months, before accounting for other relevant factors
under the guidelines. Under the statutory mandatory minimum penalties,
however, a five- and ten-year sentence will still be required,
respectively. As a result, the Commission's amendment provides some
relief to crack cocaine offenders impacted by the disparity created by
federal cocaine sentencing policy.
The Commission emphasized and expressed its strong view that the
amendment is only a partial solution to some of the problems associated
with the 100-to-1 drug quantity ratio. Any comprehensive solution to the
100-to-1 drug quantity ratio would require appropriate legislative
action by Congress.
The text of the Commission's amendments and its accompanying 2007 report
to Congress, Cocaine and Federal Sentencing Policy, will be available in
the coming weeks on the Commission's website, www.ussc.gov.
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