Recreational vs. Therapeutic
The Kansas City Star just published a series on 7-OH, which is a gray market synthetic derivative of the opioid kratom. When I saw the headline about “a growing opioid epidemic,” I didn’t expect much nuance, but was I pleasantly surprised!
If you’re not familiar with kratom, its natural form is a leaf. The FDA has not regulated it thus far, but some states have placed controls or outright bans on it. Maine is not one of them, and I first learned of kratom when my opioid-dependent patients in treatment told me they were using it as a safer alternative to better-known opioids. And this is the argument for companies selling 7-OH—which is much more potent than regular kratom—in smoke shops, gas stations, and “mainstream retail environments:” it’s a therapeutic tool, they say, for people dependent on other opioids.
Guess what? Consumers report becoming dependent on 7-OH, spending hundreds of dollars per day on it and suffering terrible withdrawal when they try to quit. Providers say people are routinely showing up to substance use treatment for help getting and staying off 7-OH. And now 7-OH manufacturers are being sued for the same reason Purdue Pharma et al. were sued: for deliberately developing and marketing an addictive opioid while denying risks of which they were aware. In a prior, smaller opioid lawsuit along the same lines, Reckitt, manufacturer of the prescription opioid Suboxone, was found liable for downplaying Suboxone’s risks. Suboxone is currently considered the “first line” of “evidence-based” treatment for opioid use disorders because it is a safer alternative to street drugs. The pattern goes back even further. You may have seen vintage print advertisements for heroin; it was initially marketed as a safer alternative to morphine.
Some drugs really are safer than others, particularly in terms of overdose risk. Method of use matters too, e.g. smoking compared to injecting, injecting with single-use rather than multiple-use syringes. But we need to be very skeptical when any drug—illicit, prescribed, or over-the-gas station-counter—is pitched as a safer alternative for people already addicted to a different drug. Why? Let’s say the existing drug, whose risks and harms are already well known, is Drug A, and the new “safer alternative” is Drug B.
1. A long track record shows Drug B might not be as safe as purported. (See above.)
2. Drug B will always end up being marketed to new users: people who never used Drug A. Some of these new users will become addicted, for the first time, to Drug B. Providers quoted in the series are seeing it with 7-OH, and I have seen it with Suboxone.
Drug B may also prove harder to quit than Drug A due to worse or longer withdrawal symptoms. I have heard of people on Suboxone (a recent Drug B) "switching back" to morphine (a first-generation Rx Drug A) when they wanted to go drug-free: they found morphine easier to taper off if they weren't going to replace it with another opioid.
3. All entities selling drugs have the same business model—it just plays out differently depending on the legal context of that drug's market. We have prescription drugs, legal recreational drugs (think alcohol, nicotine, caffeine), and illicit or street market drugs. Many drugs come in both prescription and street trade varieties, and legal status changes over time. In every case, for a drug's purveyors, more consumers is better no matter who they are. Dependent or addicted consumers bring the most reliable sales. (Drugging The Poor by Merrill Singer is a great source on this.)
4. Nonetheless, the makers of Drug B will insist they are just providing a safer alternative for people dependent on Drug A, and claim no responsibility when people (including new users) start experiencing harms, including addiction and possibly overdose, from Drug B.
The fake-out, with every Drug B, involves the putative distinction between therapeutic and recreational drugs. That is, Drug A is the dangerous old recreational drug, which people used to get high, while Drug B is the safe new therapeutic that people use to avoid withdrawal (or replace the missing medicinal effect of Drug A).
This distinction has never held up. So much of drug regulation and public opinion on drugs comes down to attempts to categorize drugs that have always been both recreational and therapeutic, depending on who uses them and when. (By "when," I don't mean what year it is, I mean when in this person's career of drug use, and how their life is otherwise going right now.) And this is without even considering “recreational” experiences of pleasure or joy as necessary, equally important as relieving uncomfortable symptoms. The culture of drug control leaves little space for the value of pleasure.
...For some people, at some times, drugs are the only way to access pleasure. This is more a social, political and economic problem than a chemical one.
I'll pick up that idea later!
Next week: Why is addiction treatment always done in groups? Just kidding--you already know why. Here's the problem.
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