CHAPTER REFERENCES – Abstinence Kills – Addiction Treatment Must Change

Chapter 1 - This Ain’t Your Parent’s Heroin Epidemic

Bill Wilson, the co-founder and main architect of Alcoholics Anonymous (AA), would not miss a beat if he were magically transported into a 21st century AA meeting.
… AA’s signature 12-Steps have never changed since he first published them in 1939.
The current opioid epidemic began in the late 1990s with the heavy marketing of the painkiller, OxyContin.
Epidemic of prescription opioid abuse
Heroin had been a problem in the 1960s and 1970s but had largely died down after that.
… by 2010, heroin experienced a resurgence and began to replace prescription opioid abuse.
Barely three years later, in 2013, a new threat had emerged: illegally produced fentanyl.
Fentanyl rapidly dominated the illicit drug market to the point that heroin is now actually hard to find on the streets of America.
Fentanyl now comes in a bewildering number of variants, such as acetyl fentanyl, para-fluorofentanyl, and the ultra-potent carfentanil.
There are now new types of opioids, such as nitazenes and U-compounds, that are as different from fentanyl as fentanyl is different from heroin.
These chemicals include animal tranquilizers, such as xylazine and medetomidine, as well as bromazolam, the designer benzodiazepine sedative.
These new additives make the fentanyl even more potent and also do not respond to naloxone (Narcan), the overdose-reversing drug.
… fentanyl is now available as counterfeit pills.
It is not only fake pain pills that may have fentanyl, but also counterfeit sedatives like alprazolam (Xanax), or counterfeit stimulants like amphetamine (Adderall).
As of 2024, my message that abstinence kills applies mostly to the United States of America and Canada.
Fentanyl is still relatively rare in Australia, New Zealand, and Africa.
Fentanyl has begun to show up in parts of Europe and South America. as well as parts of Asia.
Illegal fentanyl did not show up on the streets of America until 2013.
A recent study from 2024 showed that more than 42% of American adults personally knew at least one person who died of an overdose.
… one in eight American adults reported their lives were disrupted by these deaths.
teenagers have always experimented with easily available drugs …
The Drug Enforcement Administration (DEA) launched a “One Pill Can Kill” campaign in 2021.
Deaths from fentanyl overdoses have surged in teenagers.
Casual drug users, such as people who flirt with drugs occasionally at parties or when attending concerts, are also dying from fentanyl overdoses.
The biggest group I worry about succumbing to fatal overdoses are relapsing opioid addicts.
This group includes addicts released from incarceration, going through drug-free rehab treatment, or discontinuing opioid-based treatments.
… Unfortunately, a high percentage of these addicts will relapse.
Public perceptions of the opioid crisis still often revolve around the role of prescription opioids that started the opioid epidemic in the early years of the 21st century.
According to the Centers for Disease Control and Prevention (CDC) about 178,000 Americans died from excessive alcohol in 2021 compared to about 81,000 deaths that year from opioid overdoses.
The CDC estimates 2,200 people die of alcohol overdose every year.
risking death from the acute alcohol withdrawal syndrome known as delirium tremens or DTs
Opioid overdoses kill by slowing down breathing
The addict’s brain adapts to chronic opioid use by building up tolerance so that opioids are less effective at suppressing breathing to dangerous levels.
These books include Maia Szalavitz's Unbroken Brain, Gabor Maté's In the Realm of Hungry Ghosts, Marc Lewis's The Biology of Desire
Einstein reputedly said of science, “You do not really understand something unless you can explain it to your grandmother.”

Chapter 2 - Hooked!

Chapter 3 - A Matter of Life or Death

… people who live in high mountains, such as the Himalayas or Andes, produce more blood cells to better tolerate the oxygen-poor environment.
Marathon runners develop changes in their hearts and lungs to tolerate extreme levels of exercise.
Bodybuilding puts severe stresses on the body and the body responds by increasing muscle mass to tolerate weights that would crush untrained people.
The Merriam-Webster Medical Dictionary defines the term, mithridatism, as “tolerance to a poison acquired by taking gradually increased doses of it.”
Workers in arsenic mines in 19th century Austria were reputed to have been “arsenic eaters” in order to do the work.
In the 1987 cult classic movie, The Princess Bride, the Dread Pirate Roberts claims to have spent two years deliberately ingesting small amounts of the fictional “iocaine powder” in order to build up tolerance to the deadly poison.
Tolerance develops to two different properties of opioids: analgesia (pain relief) and breathing.
Normally, our breathing reflex is driven by the level of carbon dioxide (CO2) in our blood.
If opioids were suddenly stopped (withdrawn), the unopposed mechanisms of tolerance could produce severe withdrawal symptoms.
Recent years have seen high-potency opioids, such as fentanyl being substituted for heroin, or extremely potent variants like carfentanil being substituted for fentanyl.
Recent years have also seen surges in new, non-opioid drugs finding their way into the drug supply, such as xylazine, medetomidine, or bromazolam.
… teenagers experimenting with drugs and casual users flirting with drugs at parties.
A second group includes opioid addicts who had acquired adequate protective tolerance, but subsequently lost this protection.
This rapid loss of tolerance helps to explain why so many addicts die of fatal overdoses after just a week or two in jail.
There is no doubt that street drugs have been getting more lethal.
Heroin on US streets has largely been replaced by the far more potent fentanyl.
We have seen potent non-opioid drugs like xylazine and bromazolam being mixed into the fentanyl drug supply.
The Drug Enforcement Administration (DEA) reported in December 2021 that four out of ten counterfeit pills they intercepted that year contained a potentially fatal dose of fentanyl.
The proportion of fake pills with potentially lethal fentanyl doses rose to six out of ten in 2022, and then to seven out of ten in 2023.
… moderate drinking is defined as 1 drink a day for females or 2 drinks a day for males.
A fifth of liquor (750 ml.) is roughly equivalent to 17 standard drinks.
Casual drinkers can usually consume two standard drinks and still pass a breathalyzer test.
… we have a standard measure of opioid consumption, known as the morphine milligram equivalent (MME).
Most guidelines for chronic pain management consider doses over 50 to 90 MME per day to be high doses.
Fentanyl is 50 times more potent than heroin (100 times more potent than morphine).
Doses around 200 MME could prove fatal for a healthy person without any tolerance for opioids.

Chapter 4 - Myth: It’s About Getting High

… one of the oldest, most powerful misconceptions, that addiction is driven by the selfish pursuit of pleasure
Addiction is blamed, not on chasing the normal everyday desire for pleasure, but on the pursuit of euphoria, the intense, crazed pleasure available only through drugs or other unnatural activities.
Today, the psychological explanation based on euphoria has been replaced by its scientific, neurobiological equivalent: dopamine, the brain chemical believed to trigger pleasure.
Dopamine is involved with pleasure, but it is also involved with lots of brain functions, including memory, concentration, thought, learning, sleep, attention, judgment, etc.
The standard explanation for addiction comes from our experiences with alcohol addiction.
"correlation is not causation"
Naltrexone blocks the euphoria from opioids and it has been used to treat not only opioid addiction but also alcohol addiction.
Tobacco kills roughly 480,000 Americans every year, compared to 178,000 deaths annually from alcohol and 81,000 from opioids.
The percentage of US adults who use tobacco has steadily declined from 40% in the 1960s to about 12% in 2021.
As of 2020, tobacco was used daily by over one billion people worldwide.
Galileo’s discovery of Jupiter’s moons broke the rule that every heavenly body had to revolve around the Earth
The psychedelic (hallucinogenic) drug LSD (lysergic acid diethylamide) is classified as non-addictive.
Other recreational drugs of abuse, such as the hallucinogen psilocybin (found in magic mushrooms), ketamine, and MDMA (3,4-Methylenedioxymethamphetamine) are well known “party drugs” despite their potent mind-altering properties, do not seem to be highly addictive.
there has recently been great interest and promising research into the use of hallucinogenic drugs like psilocybin for the treatment of addiction.
the “party drug” MDMA is commonly known as Molly or Ecstasy, attesting to its capacity to induce intense euphoria
Yet Ecstasy is considered non-addictive or only mildly addictive.
Other drugs of abuse, such as huffing glue, paint, gasoline, and other volatile petrochemicals, clearly get users very high.
However, these agents are used primarily by adolescents who tend to stop using these cheap and legal products by early adulthood
many of my patients tell me that they seldom, if ever, experience euphoria anymore
Dopamine has been called the “feel good” or “pleasure chemical.”
Both euphoria and the “dopamine rush” are variants of what might be called the Reward Theory of Addiction.
The National Institute of Drug Abusee (NIDA), addiction specialists, and medical journals are just some of the numerous institutions proclaiming the role of dopamine and pleasure in causing addiction.
Dopamine’s role in the brain’s reward circuits is portrayed as the “final common pathway” for the development of addictions
… the idea that dopamine induces feelings of pleasure has been called into question
… Dopamine surges in the brain with both pleasurable and non-pleasurable experiences, such as with traumatic experiences like PTSD. Animal studies show that dopamine also surges when an animal loses a fight.
Dopamine is increasingly thought of not as a pleasure-inducing brain signal but as a mediator of motivation.
Perhaps it is pleasure that triggers the release of dopamine rather than dopamine that causes feelings of pleasure
The current hypothesis is that pleasurable experiences trigger dopamine release, activating the brain’s reward pathway and motivating individuals to repeat that experience.
Neuroscientists believe addictive drugs trigger massive releases of dopamine, flooding the reward pathway with roughly 10 times the amount of dopamine compared to natural rewards.
Serotonin, endorphins, and oxytocin are more closely associated with feelings of pleasure, happiness, and wellbeing
… the neurobiology and neuroanatomy of addiction has been intensely investigated using various methodologies and sophisticated neuroimaging studies like PET scans and fMRI scans.
Addiction appears to involve many areas of the brain such as the Ventral Tegmental Area, Nucleus Accumbens, Prefrontal Cortex, etc. as well as the limbic system (known as our “lizard brain”) and the basal ganglia.
Other neurotransmitters affected by addictions include serotonin, glutamate, acetylcholine, gamma-aminobutyric acid, endorphins, etc.
Dopamine is also involved in functions such as movement, cognition, memory, sleep/arousal, mood, learning, and even breast milk production.
Every scientist is taught that “correlation does not indicate causation,” meaning that two things occurring together do not mean that one caused the other.
Tobacco also causes the release of dopamine but without euphoria, as we usually understand the word.
Further complicating the picture, chronic cocaine addiction has actually been shown to lead to lower levels of dopamine, or dopamine depletion.
There are many medications that boost dopamine, especially medications used to treat Parkinson’s disease, such as pramipexole (Mirapex) or ropinirole (Requip).
Some antidepressants, such as bupropion (Wellbutrin) and mirtazapine (Remeron) also boost dopamine, but these medications are also not addictive.
Interestingly, some Parkinsonian medications can sometimes produce bizarre side effects of compulsive behaviors, such as compulsive gambling or greatly increased sex drive.
People who suffer with Obsessive-Compulsive Disorder (OCD) are very much distressed by their unwanted intrusive thoughts.
Conversely, we also have medications that block the effect of dopamine in the brain.
… medications used in the treatment of schizophrenia, such as haloperidol (Haldol), olanzapine (Zyprexa), aripiprazole (Abilify), and many others.
Finally, mind-altering and hallucinogenic drugs including LSD, ketamine, MDMA, and psilocybin all exert potent effects on dopamine levels but have little if any addictive potential.

Chapter 5 - Truth: It’s About Feeling Better

Chapter 6 - Body & Soul

There is a growing emphasis on practicing “culturally competent medicine” to deliver the best care for our patients.
Increasingly, medical schools recognize that healthcare must respect differences in our patients’ culture, customs, values, beliefs, gender, sexual identity, etc.
… the bio-psycho-social model of addiction
Perhaps addiction treatments should address all four domains of this holistic bio-psycho-socio-spiritual approach for best results.
There is a long tradition of spirituality in addiction treatments that should be respected.
… the Pope of the Roman Catholic Church consults his personal physician for medical care.
Similarly, the supreme spiritual leader of Iran, Ayatollah Khamenei was served by his personal physician.
Newton’s laws showed that heavenly bodies moved without continuous divine control; yet Newton’s laws did not disprove the existence of God.
Galileo’s observations proved that not all heavenly bodies revolve around the Earth, but this scientific conclusion should not have needed the church’s endorsement
AA denies being a religious or moral organization but describes its orientation as spiritual.
Some people describe spirituality as the recognition that we are not alone in the world, that there is some entity bigger than the individual.
This “beehive explanation” of spirituality does not necessarily entail anything “otherworldly” but does involve what AA might acknowledge to be a “higher power”
In this sense, spirituality may be seen as the foundation of moral authority, a power governing the common good.
For many people, spirituality is an awareness of a higher plane of existence…
Attempts to access this otherworldly dimension include deliberately inducing altered states of consciousness.
Shamans may induce trance states through meditation or ascetic practices, or use psychoactive herbs such as peyote.
Beyond personally experiencing this higher plane, many believers consult people they believe have special spiritual powers to predict the future, tell fortunes, or communicate with the dead through seances.
This understanding of spirituality goes toward magical thinking and the occult.
The most mainstream otherworldly understanding of spirituality is one of “God-consciousness” which takes spirituality in the direction of religion, possibly even mysticism.
A person’s spirit is generally defined as the nonphysical part of that person, the seat of their consciousness, the “soul.”
The spirit world is similarly the nonmaterial part of the universe.
… the laws of science do not apply to the spiritual realm.
Separating medicine from spirituality shouldn’t be controversial – we have always talked about “body and soul.”
“What about medical miracles?
What about the healing power of prayer?”
… gluttony (overeating) was included as one of the Seven Deadly Sins during the Middle Ages.
… forcing blood transfusions upon patients whose religion forbid such procedures.
When the HIV/AIDS epidemic first appeared in the 1980s When the HIV/AIDS epidemic first appeared in the 1980s, it predominantly affected homosexuals and intravenous drug users.
… about 43% of people surveyed believed that AIDS was God’s punishment for immoral behavior
Of course, HIV/AIDS also affected innocent children who received blood transfusions.
… gout was known as the “rich man’s disease”
Church teaching at the time recognized Seven Deadly Sins, one of which was gluttony.
Lepers in Jesus’ day were … considered unclean and rabbis were forbidden to touch them
Yet Jesus touched lepers and healed them.

Chapter 7 - It Looks, Swims, and Quacks Like a Duck

Dr. Benjamin Rush, one of the signers of America’s Declaration of Independence, is credited with being one of the earliest physicians to call alcoholism a disease.
More recently in the 20th century, Alcoholics Anonymous (AA) also declared alcoholism to be an illness. However, these opinions were offered without proof that alcoholism (and other addictions by extension) truly are diseases.
As proof that addiction is a disease, doctors and scientists often show brain images from specialized sca, …
Neurobiologists might point to an area of the brain that lights up differently in addicts… (or) point to another area of the brain involved in “reward pathways”…
An alcoholic who has been sober for years would likely have a normal brain scan, but AA would tell us (correctly) that the sober alcoholic is still an alcoholic.
Proving that addiction is a disease is technically impossible because there are no rules that govern whether a condition should be considered a disease or not.
... is myopia (shortsightedness) a disease?
What about male-pattern baldness, mental retardation, social anxiety, etc.?
How about obesity?
“If it looks like a duck, swims like a duck, and quacks like a duck, it’s probably a duck.”…
Addiction responds well to medical treatment.
Both diabetes and alcoholism run in families.
Traits like alcoholism or diabetes might run in families for two reasons, nature or nurture.
Some genetic diseases such as sickle cell disease, cystic fibrosis, or hemophilia, are determined by a single inherited gene (nature only).
… most genetic conditions involve both nature and nurture.
Many medical conditions (including diabetes and alcoholism, but also heart disease, many cancers, arthritis, etc.) are determined by both nature and nurture.
Someone growing up among Mormon communities in Utah is unlikely to become alcoholic because Mormons do not consume alcohol.
However, all bets are off if this person were to move one state over to live in “Sin City” Las Vegas.
Similarly, alcoholism is extremely rare in Saudi Arabia, where alcohol is illegal and largely unavailable.
Someone growing up poor in southern states like Alabama or Mississippi may be four times more likely to become diabetic than someone who grows up middle-class in Colorado.
Lifestyle factors play outsized roles in both alcoholism and diabetes.
Lifestyles play such large roles in our health that the concept of “lifestyle diseases” has emerged, including heart disease, diabetes, strokes, chronic obstructive pulmonary disease, and certain cancers.
The Centers for Disease Control and Prevention (CDC) tracks five lifestyle factors, which are alcohol consumption, weight gain, physical activity, sleep, and smoking.
Diabetes affects many different organ systems because it damages blood vessels.
Similarly, alcohol affects multiple organs, involving cirrhosis of the liver, chronic pancreatitis, alcoholic cardiomyopathy (heart muscle dysfunction), neuropathies, etc.
In fact, many diabetics develop a condition known as non-alcoholic fatty liver disease (NAFLD) that is almost indistinguishable under the microscope from alcoholic liver disease.
Type 2 diabetes usually arises from the inability to control the consumption of sugar and calories
For example, tobacco addiction also runs in families….
Smoking rates are roughly 3 times higher in West Virginia than in Utah.
Rates of smoking are clearly related to lifestyle choices.
Tobacco is a terrible toxin that probably affects even more organs than alcohol or diabetes.
There are several genetic makeups that are associated with RA, especially the HLA-DR4 genotype.
Just like diabetes and alcoholism, rates of RA vary by geographic location, with some rural areas having roughly 6 times the rate of RA compared to cities.
... studies show that smoking increases the risks of developing RA by 400%.
RA can also affect the lung, heart, and nervous tissues.
Lifestyle choices contribute heavily to “non-communicable disease,” a category of disease that accounts for 70% of all deaths worldwide.
Step One of 12-Step programs is for the participant to acknowledge that they are powerless over their addiction.
Compulsion, one of the 4 C’s of addiction outlined in Chapter 2, is precisely about this lack of choice
many of my patients have had to “choose” to forego buying certain medicines, or “choose” not to buy health insurance because they could not afford it.
The persistent idea of addiction as a “spiritual illness” is inherited from AA.
The majority of addiction treatment programs offered in the US were abstinence-based in 2021, with only 20% of addicts getting medication treatments.

Chapter 8 - Medical Treatment Works!

There are three medications currently approved by the Food and Drug Administration (FDA) for the treatment of opioid addiction
Some readers may be familiar with the term, Medication-Assisted Treatment (MAT), which includes all three agents.
Naltrexone is a full opioid blocker that completely prevents opioids from acting on the opioid receptor.
Naltrexone is related to naloxone (Narcan) and nalmefene (Opvee), which are medications used to treat opioid overdoses.
Since naltrexone totally blocks opioids, it can put addicts on opioids into a sudden and very severe form of withdrawal known as “precipitated withdrawal”
Patients must be totally abstinent from all opioids for at least 7 days before they can start on naltrexone.
… patients will lose all the tolerance they have built up when they discontinue naltrexone
… drug courts and the criminal justice system as well as those ideologically opposed to the use of medical opioids that we discuss below.
The FDA has also approved naltrexone for the treatment of alcohol addiction, both in pill form and in a once-monthly injectable form.
Both buprenorphine and methadone stimulate the opioid receptor and the official term for such molecules is “opioid agonist.”
Methadone is known as a full agonist, which means that it fully activates (stimulates) the same receptors as heroin or fentanyl.
… methadone is absorbed slowly and builds up gradually over 3 or 4 hours.
Oral methadone does not trigger any “drug rush” or sensation of being “high.”
Methadone is also very long-acting so once the dose stabilizes, methadone lasts longer than 24 hours.
Buprenorphine works differently from methadone.
Buprenorphine is a partial agonist …
Addicts prescribed buprenorphine or methadone do not get “high.”
Nobody gets upset over using nicotine replacement treatments to treat nicotine addiction.
Fighting “like with like” is also the premise behind immunizations.
...chemotherapeutic drugs can also cause cancer, as can radiation therapy.
the use of stimulants such as methylphenidate (like Ritalin or Concerta) or amphetamines (such as Adderall) to treat hyperactive kids
… firefighters “fight fire with fire” by using a controlled “prescribed burn” to rob forest fires of fuel to spread.
The goal of treatment for most chronic diseases is not cure but control; to minimize the harms from the disease …
… the goal of diabetes treatment is not to cure the disease but to control blood sugars to prevent organ damage from the disease.
The better we control diabetes, the lower the risks will be of complications such as heart attacks and strokes, kidney damage, retinal damage, nerve damage, loss of circulation to the lower limbs, or death.
We can divide benefits of medical treatment of opioid addiction into four categories: Mortality (death rates), morbidity (health and suffering), social/societal benefits, and improved functioning.
Clinical studies on the use of buprenorphine or methadone for opioid addiction consistently show that both these medications reduce “all-cause mortality” by roughly 50%.
… medications commonly used to lower mortality from cardiovascular diseases: statins, blood pressure-lowering drugs, and low-dose aspirin.
Statins reduce all-cause mortality … by about 28%.
Blood pressure medications lower mortality by less than one-quarter.
The benefits of low-dose aspirin are questionable, especially for people over the age of 60.
… also reduce cases of non-fatal overdoses.
… reduce complications of drug use, such as Hepatitis C, HIV, heart valve infections, sepsis, infections, etc.
Incarcerations can cost taxpayers more than $40,000 per inmate per year.
However, studies find crime rates actually drop in the neighborhood of methadone clinics after the clinic opens.
Other societal benefits include reducing the public burdens of healthcare costs,
the costs of law enforcement and the criminal justice system, and other expenses paid by taxpayers.
Medical opioid treatments result in significant healthcare savings
Fewer arrests and incarcerations reduce burdens on the criminal justice system (incarcerations cost taxpayers over $30,000 per inmate per year).
Lastly, opioid addicts treated with buprenorphine or methadone show improvements in their social functioning and well-being.
Methadone acts slowly and has a very long duration of action.
It is true methadone withdrawal lasts longer than heroin withdrawal…
I can only think of two medications that have been studied for over eight decades: one is aspirin; the other is methadone.
Methadone clinics have been in existence for more than fifty years.
Methadone clinics even exist in unexpected countries of the world such as China and Iran, which are not countries “soft” on drugs.
Methadone clinics … are endorsed by the World Health Organization.

Chapter 9 - Beware of “Success”

...similar statements about successful surgeries and dead patients have been said many times throughout history.
My story ... points out the difference between declaring a treatment “successful” and actually getting the results we want.
We should ask how success is defined.
Is it a success if the injured worker with back pain still cannot return to work after surgery?
Should it be up to the surgeon alone to decide whether or not the surgery was successful, or does the patient have to agree?
Is the surgery a success if the pain is better 3 months after surgery but is even worse than before surgery 12 months later?
These questions about how success is determined point to what the patient is really interested in knowing – not success rates but treatment outcomes.
… cured means that the disease is totally vanquished and can never come back.
Unfortunately, most chronic diseases are not curable.
Most of the time with chronic diseases, we can only seek to control the disease…
The medical term for complete control is “remission.”
For example, the official medical term for a sober alcoholic is “alcohol use disorder, in remission.”
… abstinence is a term that comes from Alcoholics Anonymous (AA).
Abstinence means that the person has abstained from alcohol (or drugs).
… “abstinence” indicates the absence of “bad” behavior.
(According to AA’s Big Book) “The only relief we have to suggest is entire abstinence.”
Relapse rates for alcoholism have been estimated to be as high as 85%.
Even among alcoholics in “stable abstinence” of 18 months or longer, roughly 30% relapse over the next decade.
Anyone who has ever tried to lose weight will tell you that the problem isn’t losing weight but keeping it off.
… organizations such as AA do not keep records of their attendees (because they are anonymous organizations) so there is no easy way to conduct studies on relapse rates.
The field of addiction treatments falls into two main camps: harm reduction programs that approach addiction as a disease, and abstinence-based programs.
There are also non-12-Step abstinence-based programs, but these have not been systematically studied.
The best evidence of the effectiveness of 12-Step programs come from two large systematic reviews published by an organization known as the Cochrane Library.
Systematic reviews extract and crunch data from previous studies to summarize the state of medical knowledge on a specific question.
Cochrane Reviews are widely acclaimed as the gold standard for systematic reviews in medicine.
The first of two Cochrane Reviews on 12-Step programs, published in 2006, failed to show any benefit.
The second review published in 2020 showed 12-Step programs to be better at promoting continuous abstinence from alcohol than other therapy modalities, such as cognitive-behavioral therapy.
Based on these results, AA now claims to be evidence-based.
Stanford University’s website proclaimed that this Cochrane Review validated AA, and that, “It (AA) absolutely does work.”
Similarly, Cornell University’s website states that “Alcoholics Anonymous is an effective treatment for alcohol addiction.”
… the 2020 Cochrane Review has been held up as validating 12-Step programs in general, even for addictions other than alcohol.
I am not the first to critique either AA or the 2020 Cochrane Reviews. See also Dodes. L. and Z: The sober truth. Debunking the Bad Science behind 12-Step Programs and the Rehab Industry.
... benefits of medical treatment of opioid addiction: Mortality (death rates), morbidity (health and suffering), social/societal benefits, and improved functioning.
A recent study has suggested that... abstinence-based treatments actually increase the risks of fatal overdoses compared to no treatment by 77%
Abstinence is what researchers call a surrogate endpoint with abstinent rates functioning as proxy markers of the surrogate endpoint.
For years, doctors used a blood pressure-lowering medication, nifedipine (Adalat), because it was highly effective at cutting blood pressure.
However, we later found out that, even though nifedipine dropped blood pressure well, it actually increased rates of heart attacks and sudden cardiac death, especially at higher doses.
Nifedipine may also make heart failure worse.
There are urine drug tests available for alcohol metabolites, such as ethyl sulfate or ethyl glucuronide, that can pick up alcohol intake 3 or 4 days after ingestion.
Many of the studies included in the 2020 Cochrane review had participants complete a Drinker Inventory of Consequences (DrInC) questionnaire.
If you’ve read AA’s Big Book, you will know that it is full of personal stories of struggles, failures, and final redemption through AA.
I have no doubt that these stories are true, but in research, such stories are known as anecdotal evidence.
Anecdotal evidence is recognized as the weakest type of evidence.
… taking daily aspirin is known to help prevent heart attacks and strokes.
However, aspirin can also cause stomach ulcers and bleeding.
The current recommendation for daily aspirin is only for those at high risk of heart disease.
... the Food and Drug Administration (FDA) has a mandate to ensure that drugs are both safe and effective.
Many block-buster drugs that were very effective were withdrawn from the market due to due to safety concerns.
Reporting the harms of treatment along with the benefits is a principle known in medical research as “fair balance.”
… Step Four of the 12-Steps requires participants to conduct a “fearless” moral inventory.
the study already alluded to several times by Dr. Heimer of Yale suggesting that the risks of fatal overdoses are higher for people in abstinence treatments than for untreated addicts
The AA Member-Medications & Other Drugs.
The entire enterprise of science is constructed upon empirical knowledge.

Chapter 10 - The Gamble of Abstinence

... codeine was considered the "gold standard" cough suppressant.
... morphine was used for decades to improve blood supply to the heart during a heart attack
For AA, success is measured in terms of abstinence.
“It has never been, by any treatment with which we are familiar, permanently eradicated. The only relief we have to suggest is entire abstinence.”
Once an alcoholic, always an alcoholic
... some people disagree that addiction is irreversible.
It is exceedingly common for patients who find sobriety through buprenorphine or methadone to be told …”They are just a crutch.”
… relapses are a normal part of the disease of addiction.
The neural circuits of addiction probably never fade completely.
… opioid addicts have lost their tolerance to opioids and are highly vulnerable to fatal overdoses.
Most people think the problem is losing weight, but the bigger problem is actually keeping weight off.
… fatal overdose rates skyrocket by up to 1,200% after release (from incarceration).
Opioid overdose is the leading cause of death among people recently released from prison.
… legal argument known as the “but-for” test to determine the cause of an undesired outcome, to determine liability.”
In this case, the fatal overdoses would not have happened but for the fact that the addict was forced into a state of abstinence.
Every opioid addict should be given a supply of narcan prior to release from jails and prisons.
Unfortunately, relapses are a natural part of the disease of addiction.
Studies of fatal overdoses after inpatient medication-free rehab or detox programs show higher death rates after loss of tolerance.
Risks of fatal overdoses after abstinence can be expected to be much higher today in the era of high-potency fentanyl compared to even a decade ago.
that the risk of fatal overdoses were higher for those who went to abstinence-based programs than even untreated opioid addicts
Fatal opioid overdoses spike 600% after patients go off methadone or buprenorphine
Naltrexone, a longer-acting medication, is approved by the Food and Drug Administration (FDA) for the treatment of both alcohol and opioid addictions.
Naltrexone is available as a once-monthly injectable form (Vivitrol).
Vivitrol is also often favored by judges in drug courts who can coerce addicts into accepting Vivitrol
Naltrexone can … cause a very severe reaction known as precipitated withdrawal.
Side effects can include abdominal pain/cramps, diarrhea, headaches, depression, and even suicide.
...opioid pain medications will not work if addicts on naltrexone ever experience severe pain, such as passing a kidney stone or injuries from a motor vehicular accident.
… once naltrexone is stopped, the risk of fatal overdoses begins to climb …
Since Vivitrol is a once-monthly injection, the risk of fatal overdoses does not begin to climb until the second month, after the final Vivitrol shot begins wearing off.
Fatal overdoses involving both fentanyl and a stimulant has been called the “Fourth Wave of the Opioid Epidemic.”
That’s why the CDC, Surgeon General of the United States, the American Psychiatric Association, etc. all recognize medical opioids as the “Gold Standard” for opioid addiction treatment.
There is a wide array of different programs that promote but do not always insist on immediate and total abstinence, at least initially. These include SMART Recovery, LifeRing Secular Recovery, Secular Organizations for Sobriety (S.O.S), etc.
Many abstinence programs utilize evidence-based practices, such as cognitive-behavioral therapy, or clinically-proven methods like motivational interviewing.

Chapter 11 - A Deep Dive into Harm Reduction

… such as handing out clean needles to drug addicts, or having safe injection sites.
…such practices give drug addicts “permission” to keep using drugs.
people who use needle exchange programs are more than five times more likely to enter treatment for their addiction and three times more likely to report cutting down or stopping intravenous drug use.
…the Goals of Medicine embraced by the American Medical Association
The original goal of clean needle exchanges was not to help the individual addict, but to reduce the spread of HIV transmitted through sharing contaminated needles
Harm reduction is practical and accepts the notion of partial success.
. …the risks of heart attacks, strokes, blindness, and kidney failure are much lower for partially controlled diabetics than for uncontrolled diabetics…
Harm reduction first appeared in the field of addiction during the 1980s in the community of Merseyside, outside of Liverpool, England.
Those were the early years of the Acquired Immunodeficiency Syndrome (AIDS) epidemic, spread by the Human Immunodeficiency Virus (HIV).
Merseyside escaped an AIDS epidemic among IV drug users because of this program.
Harm reduction dealt not only with medical issues around addiction but also social issues, such as stigma.
Harm reduction emphasizes positive change rather than negative condemnation.
Addicts’ rights are respected as human rights.
Treatment is offered without coercion, or discrimination, just as treatment for any other medical condition.
Addicts are supported unconditionally, regardless of their current level of drug use.
…the four fundamental Principles of Medical Ethics: autonomy, beneficence, nonmaleficence, and justice.
The goal of treating diabetes is NOT to have diabetics totally abstain from sugar, but to reduce the health problems that come with diabetes…
… better outcomes, such as lowering rates of deaths, heart attacks, and eye/kidney disease (were) proven with a landmark diabetic study known as the UKPDS study published in 1998.
Abstinence-based programs have dominated addiction treatments for most of the 20th century, into the 21st century.
… one of AA’s co-founders was a physician, Dr. Bob Smith.
AA also enjoyed the support of highly influential people (such as) John D. Rockefeller Jr…
AA’s Big Book may never have been published without Rockfeller’s financial support.
AA was first incorporated into medical practices in the early 1950s in what came to be called the Minnesota Model through the Hazelden Foundation.
The Minnesota model is also known as the abstinence model.
Hazelden became active in training medical students and addiction counselors and was also accredited by the Joint Commission on the Accreditation of Hospitals.
In 1951, the American Public Health Association awarded AA the prestigious Lasker Prize, an award often compared to the Nobel Prize in medicine.
The development of addiction medicine as a specialty was also heavily influenced by alcoholic physicians who found sobriety through AA.
…annual conferences of (ASAM) include twice-daily mutual-help meetings bookending each day of the conference.
By definition, spirituality is independent of physiology, anatomy, or any other scientific understanding of medicine.
…abstinence is the proverbial “800-pound gorilla in the room.”
…comes from an old joke, “Q: Where does a 800-pound gorilla sit? A: Anywhere it wants!”
Spirituality then fits another idiom, the “elephant in the room,” referring to an obvious and enormous topic that nobody wants to talk about.
... in any other area of medicine, you would want a second opinion if you were told your treatment involved surrendering to a “higher power,” praying to have your defects of character lifted, and accepting your “powerlessness.”
According to (NIDA), only one in five opioid addicts received methadone or buprenorphine to treat their addiction in 2021!
…medications to treat opioid addiction are considered to be the gold standard in the treatment of opioid addiction.

Chapter 12 - Abstinence Kills: Death by Stigma

… the term cure in medicine signifies the absence of disease while control or remission means absence of signs or symptoms of the disease.
In contrast, abstinence actually indicates the absence of “bad” behaviors.
… abstinence rates actually measure compliance to treatment rather than effectiveness or efficacy of treatment.
The addict being abstinent suggests that drug dependence is under control but does NOT indicate that the addiction has resolved.
The abstinent alcoholic is still an alcoholic.
… abstinence is often used as a measure of treatment effectiveness
If you look up abstinence online, you will likely land on pages dealing with topics of sexual abstinence or drug use.
…abstain is also applied to avoiding foods forbidden for religious reasons, such as non-Kosher for Jews or non-Halal foods for Muslims, beef for Hindus, or eating during daylight hours during the month of Ramadan for Muslims.
… vices are generally thought of as negative or harmful habits or behaviors considered morally wrong or unacceptable by society.
Abstinence has to do with moral purity …
One important exception is to abstain from voting, but even in this case, the abstention is often motivated by a perceived moral objection to voting one way or another.
If we do not intend to attach moral values, we should use the term “refrain” instead
. … not adhering to religious dietary prohibitions also paints the offender as an ungodly person.
… difference between abstinence and prohibition is that abstinence is voluntary while prohibition is externally enforced.
AA may insist that addiction is not a moral failing,
… recent years have seen the distinctions between abstinence-based and harm reduction strategies become blurry.
Medications like buprenorphine have made initial treatment of addicted individuals much easier and more comfortable.
… many abstinence-based programs will now initially use buprenorphine as well as other medications to detox the addict and to control withdrawal symptoms.
… abstinence and harm reduction both end up on a continuous spectrum, seen as equally valid.
… most addicts, and frankly most addiction physicians as well, end up with a hybrid belief system.
Abstinence-based practitioners may claim that addiction is not a moral failing but the entire premise of abstinence is based on moral self-control.
Harm reduction and abstinence approaches are no longer recognized as opposing philosophies but appear to coexist in harmony.
The message of abstinence has potential to be harmful, which goes against the Hippocratic oath to “do no harm.” We must also not forget that 12-Step programs have never been shown to be safe or effective for non-alcohol addictions, specifically for opioid addictions, which is where they are being applied.
… addicts in abstinence-based programs actually do much worse than addicts who receive no treatment at all!
Fatal overdoses were 77% higher for those who received abstinence-based compared to untreated addicts.
One result of this hybrid belief system of simultaneously accepting both abstinence and harm reduction is a messy mixed up idea that addiction is somehow a shameful disease.
To me, this “clean” versus “dirty” view of addiction betrays how we understand addiction.
The Trojan Horse Parable
… a well controlled asthmatic might experience a flare up from time to time, such as during allergy season.
Similarly, well controlled diabetics periodically have episodes where their sugar reading spikes, due to weight gain, infections, or certain medications that cause sugars to rise.
…flare ups or sudden return of symptoms are part of almost every chronic disease.
Addiction is no different
… asthmatics who experience a sudden return of disease may need more medications…
Diabetics who lose control of their sugar may also need more medications …
… abstinence pins the blame on the behavior, making the addict ashamed and guilty for letting his treatment team down.
There is an old saying that, “Sticks and stones may break my bones, but words can never hurt me.”
... cyberbullying can push teenagers to suicide ...

Chapter 13 - Recovery is ... Complicated!

The first use of the term “recovery” in the context of alcoholism appears to have been in AA’s Big Book.
… recovery is widely used to mean a variety of different things.
I am a big admirer of Bill Wilson, the main architect of AA.
Confidentiality in healthcare was enshrined into law by passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
AA made him famous but not rich; he did not become wealthy from his work.
He was the main architect of AA and could likely have taken full credit, but he only ever claimed to be a co-founder of the organization …
His humility also shows in how he referred to himself in AA circles simply as Bill W.
The iconic circle of chairs at AA meetings was designed so that everyone in the circle was equal …
By comparison, the US Constitution has been amended six times over the same time period.
Bill W.’s revolutionary idea behind AA was that alcoholics could help other alcoholics stay sober.
Once an alcoholic, always an alcoholic.
The metaphor of a journey is often used to describe the process of recovery
In medical usage, a synonym for recovery is recuperation.

Chapter 14 - Three Types of Overdoses

Alcohol addiction kills almost twice as many people as opioid addiction, but rarely through fatal overdoses.
... alcohol addiction mainly kills through chronic diseases, such as heart disease, cirrhosis, pancreatitis, and cancers.
… suicide rates have risen by 35% over the past two decades and that people using opioids are 14 times more likely to die of suicide.
Over the course of their lives, it is estimated that between 17% and 48% of opioid addicts may attempt suicide.
Suicides are closely related to mental illness.
Opioid addiction and mental health problems tend together, with each causing the other
… survivors of trauma are highly vulnerable to falling victim to drug addiction. The trauma history could be physical trauma, emotional trauma, or sexual trauma, or any combination.
… opioids are potent painkillers, not only of physical pain but also of emotional pain.
Some drugs can directly cause users to develop psychosis.
Psychosis is a severe mental state where an individual loses contact with reality...
Drugs that cause psychosis include methamphetamine, cathinones (“bath salts”), synthetic cannabinoids (e.g. “spice”), or inhalants (e,g, aerosols, glue, gasoline, etc.).
Young addicts may fall victim to sex trafficking.
We need to improve access to mental health care.
… we need to reduce stigma.
The word “patient” derives from the Latin root word pati or patiens, which means to suffer.
Fentanyl changed that fgorever.
Fentanyl was much cheaper for the drug dealer and also about 50 times more potent than heroin.
As I write this in 2024, fentanyl has largely replaced the heroin supply in the United States with actual heroin becoming difficult to find.
The next wrinkle came when fentanyl began to come in a bewildering number of varieties with minor changes in the chemical structure.
For example, carfentanil is 100X more potent than regular fentanyl, or 100,000X more potent than morphine.
...enough fentanyl to balance on the tip of a pencil could be a fatal dose.
Addicts and their dealers have no clue what they are buying/selling but are also in the dark about how much drug they are dealing with.
Recent years have seen new opioids coming into the mix that do not belong to the fentanyl class of opioids.
One example is a class of opioids known as nitazenes… not detectable on the average drug test.
…deadly chemicals that aren’t even opioids … like xylazine (a non-opioid horse tranquilizer) and bromazolam (a benzodiazepine never approved for use in humans) …
… fentanyl being pressed into counterfeit pills …
These fake pills might be made to mimic painkillers like oxycodone or sedatives such as Xanax (alprazolam).
...seven out of ten fake pills contain a potentially lethal dose of fentanyl...
There has been a sharp rise in fatal opioid overdoses among teenagers.
This helps explain why cocaine or methamphetamine are also found in about half the people dying of fentanyl overdoses
Many researchers describe the rising involvement of stimulants like cocaine and methamphetamine with fentanyl as the ”Fourth Wave” of the opioid epidemic
In the past, stimulant addicts did not die from overdoses like opioid addicts whose breathing slowed down and stopped.
Roughly 12-15% of samples of cocaine or methamphetamine on the street may contain fentanyl.
Stimulants also make people impulsive and more prone to risky behaviors, so stimulant users can also die from accidents and criminal activities.
...stimulants like cocaine and methamphetamine speed up the heart, which increases the heart’s requirements for oxygen
...speed up the heart chemically with medications like dobutamine
One avenue is to make the overdose-reversing drug Narcan more available
There are also resources on websites such as Neverusealone.com that provide backup plans for people who do use alone.
Another highly controversial harm reduction policy aimed at the problem of drugs getting more dangerous has been tried in some locations, such as Vancouver, Canada. This strategy is to provide addicts with a safe supply of pharmaceutical-grade fentanyl.
Crystalized versions of cocaine and methamphetamine are less likely to contain fentanyl because it is harder to mix fentanyl powder into crystals.

Chapter 15 - A Closer Look at Relapses

Step One of Alcoholics Anonymous (AA) iconic twelve-step program is for the alcoholic to admit they are powerless over their alcohol intake.
Being powerless also reflects “compulsion,” one of the Four C’s that define addiction…
I used this analogy (weight loss) earlier, but I think it is worth repeating because it is so relatable.
People tend to think that losing weight is the hard part, but research has shown that keeping the weight off is actually the bigger challenge.
To borrow a disclaimer found on many investments, “Past performance is no guarantee of future results.”
… diabetics may lose control of their sugar if they gain weight, are fighting an infection, or get prescribed steroids for any reason.
People with arthritis in remission might experience periodic flare ups in cold weather.
An asthmatic who managed to get the asthma under control might experience an exacerbation during allergy season.
We have all heard how terrible heroin withdrawal is.
…studies show that the majority of people released from prisons for drug offenses are rearrested within 3 years.
The difficulty of this quest is reflected in the wit of Mark Twain who said, “Giving up smoking is the easiest thing in the world. I know because I have done it thousands of times.”
Similarly, Bill W., co-founder of Alcoholics Anonymous (AA), had quit drinking numerous times, including 4 admissions to Towns Hospital before finding long term sobriety.
Detox is only the first step of a lifelong journey.
… being “hooked” on drugs actually involves two different types of “hooks” – dependence hooks the body while addiction hooks the mind.
… someone standing up at an AA meeting to announce, “Hi! My name is ____. I am an alcoholic. My last drink was ten years ago.”
This type of craving is described by AA’s phrase of “people, places, and things.”
AA lumps these triggers under the acronym, H.A.L.T. which stands for Hungry, Angry, Lonely, Tired.
Can a diabetic ever get off insulin or other diabetic medications? The answer is, “Yes!
… a patient with appendicitis needs to understand the risks before consenting to surgery:
A patient with appendicitis wishing to leave the hospital without surgery must sign an “AMA” (against medical advice) form…
Studies show that the risk of fatal overdoses spikes 6-fold after discontinuing buprenorphine or methadone treatment.
Histories of severe depression, anxiety, bipolar disorder, PTSD, schizophrenia, or high impulsivity are concerning.
About one-third of sober alcoholics relapse within the first year and it takes about five years for the risk of relapse for alcohol to drop below 15%.

Chapter 16 - Addiction Runs on Emotions

Abstinence-based programs originated with alcohol addiction but continue to dominate the treatment of opioid addiction.
The difference between rational logic and emotional logic isn’t “weird” or hard to understand. We can think of these two types of logic as “head” versus “heart”
Drugs and alcohol are often used to cope with unwanted emotions.
Needing a stiff drink” or “unwinding with a glass of wine” are familiar tropes in popular culture
Perhaps that is why people with mental health problems, such as schizophrenia or post-traumatic stress disorder (PTSD), are more prone to developing addictions.
I eat because I am unhappy. I am unhappy because I eat. (Line from Austin Power’s “The Spy Who Shagged Me.”
…nasal decongestants sprays should not be used for longer than 5 days.
Nasal decongestants … can all trigger a phenomenon known as rebound vasocongestion…
Another more common example of a substance being both the problem and the solution is caffeine causing caffeine-withdrawal headaches.
Addicts going through opioid withdrawal suffer not just physical symptoms such as nausea, vomiting, diarrhea, jitteriness, etc...
Opioid addicts sometimes report feeling suicidal during withdrawal.
This kind of brain rewiring might be comparable to the way certain experiences can change the brain/mind, for example with Post-Traumatic Stress Disorder (PTSD)
...people are initially drawn to alcohol, addictive drugs, and activities such as gambling because they like how the drug or activity makes them feel.
Neuroplasticity descries the brain's ability to change its structure and function in response to life experiences.
Adult brains can still grow new brain cells.
Neuroplasticity is also involved in learning a language, how to play a new musical instrument, or developing a new skill.
Neuroplasticity helps us to recover from strokes and other brain injuries as well as allowing us to heal from PTSD and other traumas.
... it is also possible for neuroplasticity to cause negative or destructive brain adaptations
The most important features are probably repetition and practice.
...people are initially drawn to alcohol, addictive drugs, and activities such as gambling because they like how the drug or activity makes them feel
Adolescents experiment with drugs and alcohol because they are curious about how these agents will make them feel.
... emotional need to be accepted into a circle of friends
... there are people who are apparently able to drink socially after a history of alcoholism
For centuries, we have blamed addiction on the substance. “Alcohol is from the devil!”
“Heroin is pure evil!”
“Cocaine is so addictive that to dabble in it is to get addicted.”
Yet although 85% of US adults consume alcohol, “only” 10% meet criteria for alcohol use disorder
Similarly, it has been estimated that 3% to 19% of chronic pain patients on long term opioid medications might develop an opioid addiction.
The idea that any substance including cocaine, is unavoidably addictive is simply not true.

Chapter 17 - Emotional Keys to Sobriety

… anti-drug campaigns like the “Just say no” or the Drug Abuse Resistance Education (D.A.R.E.) programs of the 1980s did not work.
The common image of rock stars’ Bohemian lifestyles of “sex, drugs, and rock & roll” is a myth.
diabetics cannot be brought under control with insulin alone; the diabetic must change how they live.
…sobriety is not a goalpost or final target. It is not an event but a process.
Bill Wilson, co-founder of Alcoholics Anonymous (AA), famously had an intense spiritual experience during his fourth admission into the Charles B. Towns Hospital in New York in 1934.
Sobriety takes time, until it happens suddenly.
… Steve Jobs once said, “If you really look closely, most overnight successes took a long time.”
… consider that a caterpillar turns into a chrysalis, then stays in that stage for several weeks before a butterfly suddenly emerges from the chrysalis.
… Bill Wilson’s report of “suddenly” finding sobriety … happened during Wilson’s fourth admission into Towns Hospital for treatment of his alcoholism.
In fact, both founders of AA, Wilson and Smith, had struggled for years with alcohol.
Investment brokers are fond of warning that “past performance is no guarantee of future results” meaning that past successes do not predict future successes.
… it is important to practice what we call “patient-centered care” where care is individualized to the patient.
…addicts need to be adequately equipped with what might be called their “sobriety toolkit.”
The emotional dimension of treatment is why therapists and drug and alcohol counselors are important components of addiction treatment programs.

Chapter 18 - The Growth Model

… Stages of Grief, a concept coined by psychiatrist Elisabeth Kübler-Ross.
… the Stages of Change, developed in the 1970s by two psychologists, Prochaska and DiClemente.
The metaphor of a journey is often used to describe the process of Recovery or achieving sobriety.
…numerous studies have shown that programs like the Drug Abuse Resistance Education (D.A.R.E.) with its “Just Say No” message were largely ineffective.
... clinical experience is also accepted as a form of evidence in healthcare.
…Jack Mezirow’s Transformative Learning Theory.
Mezirow described transformation mostly in terms of cognitive and rational processes
Whereas Mezirow model uses ten phases, my framework only has five.
Mezirow described his first phase as a “Disorienting Dilemma.”
Rock bottom is a myth.
Psychologists do not consider hope to be a “primary emotion” but a secondary emotion.
There is a line from the 2012 movie, The Hunger Games, where President Snow states, “Hope. It is the only thing stronger than fear.”
Courage is necessary to embark on the next stage of Method.
The poet Maya Angelou famously said, “Hope and Fear cannot occupy the same place at the same time.” Courage is the opposite of fear.
Courage is how we drive out fear.
A five-day treatment (at Town’s Hospital in Manhattan) cost $350 in the 1930s, roughly equivalent to $6,800 in 2024.
They are often disheartened because they have heard a quote often (mis)attributed to Einstein, “Insanity is doing the same thing over and over and expecting different results.”
… the ever-wise Yoda stated, “The greatest teacher, Failure is.”
Step One of AA’s 12-Step program begins with the statement of a Dilemma: “We admitted we were powerless over alcohol — that our lives had become unmanageable.”
Step Two offers a statement of Hope: “Came to believe that a Power greater than ourselves could restore us to sanity.”
Step Three introduces a Method: “Made a decision to turn our will and our lives over to the care of God as we understood Him.”

Parting Thoughts

Some of the increases in fatal overdoses were likely related to the COVID-19 pandemic shutdown.
Fatal overdoses dropped in 2023 for the first time since 2018.
… a recent 2024 study reported that Narcan administration by non-medical persons prior to ambulances arriving at overdose locations increased 43.5% from 2020 to 2023.
A very interesting development is that the nation’s fentanyl supply appears to be drying up.
Many parts of the US have noticed an unprecedented drop in the purity of fentanyl.
The latest figure released in December 2024 shows that now “only” five out of 10 fake pills seized by the DEA in 2024 have a potentially lethal dose of fentanyl.
The US has been trying to get China to cooperate in controlling the export of these chemicals and perhaps this effort is finally bearing fruit.
If China is finally cooperating, will that cooperation disappear with another trade war between the US and China?
The cartels could find a different supplier of precursor chemicals, such as India.
Nitazenes can be forty or fifty times stronger than even fentanyl and have been spiking in many parts of the world.
… very concerning graph released by the World Health Organization.