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Jeffrey A. Singer

Jeffrey A. Singer

Articles by Jeffrey A. Singer

Looming Doctor Shortage Demands Innovative Solutions

10 days ago

The Association of American Medical Colleges projects a severe physician shortage by the year 2032, particularly in the primary care fields, as the population of patients as well as doctors continues to age, according to a report today by AAMC projects the national primary care shortage will range from roughly 47,000 to 122,000.
The news report focused on Arizona, one of the fastest growing states in the union, which has a shortage of primary caregivers in every county. Arizona ranks 44thout of the 50 states in total active primary care providers (PCPs), at 77.9 per 100,000 population (the national average is 91.7 per 100,000) according to a recent report from the University of Arizona.
To deal with the problem efforts are underway in the state to expand residency training

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Shaking Down Drug Makers Won’t Stop IV Drug Users

21 days ago

On August 26 Oklahoma State Judge Thad Balkman ruled that Johnson & Johnson must pay $572 million to the state of Oklahoma for contributing to the local opioid addiction crisis. Johnson & Johnson sold two opioids: a fentanyl skin patch with the brand name Duragesic, and Nucynta,a synthetic opioid similar to tramadol but stronger.
Nucynta is not as addictive as most other synthetic and semi-synthetic opioids and has been shown to have low levels of abuse in post-marketing studies. Fentanyl skin patches are very difficult and inconvenient to convert for non-medical use. The Drug Enforcement Administration claims that nearly all the fentanyl seized is so-called “illicit fentanyl,” manufactured mostly in powdered form in clandestine labs in Asia and Mexico, and then smuggled in to the

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It’s Not The Number of Pills–It’s The Number of Deaths That Matter

August 16, 2019

A letter to the editor in the August 14 New England Journal of Medicine by researchers at the University of Michigan proudly reported on the results of their effort, called the Michigan Surgical Quality Collaborative (MSQC), to reduce the volume of opioids prescribed for postoperative pain. The Collaborative developed a set of guidelines for its participating prescribers.
As a result, they found that from January 2017 through May 2018, the mean number of pills prescribed for postoperative pain decreased from 26 (+/-2) pills pre-guideline to 18 (+/– 3) pills post-guideline. Patient pill consumption also decreased from an average of 12 pills (+/-1) pre-guideline to 9 pills (+/-2) post-guideline. During that period there was no discernible difference in the pain scores reported by these

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The March Toward a Pre-Modern Approach to the Treatment of Pain Continues, Undeterred by Science

August 12, 2019

It seems that no amount of data-driven information can get policymakers to reconsider the hysteria-driven pain prescription policies they continue to put in place.
I can understand lay politicians and members of the press misconstruing addiction and dependency, but there is no excuse when doctors make that error. Yet National Public Radio reports that surgeons in 18 Upstate New York hospitals have agreed on an initiative to limit the amount of pain medicine they will prescribe to postoperative patients discharged from the hospital. The reporter says that researchers “now know” that patients prescribed opioids for postoperative pain “can become addicted” and that “the new prescription guidelines can prevent this particular gateway to abuse.” 
But what does the research show? One recent

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CDC Extols the Benefits of Naloxone⁠—Time to Make it OTC

August 7, 2019

Yesterday the Centers for Disease Control and Prevention reported that while naloxone prescriptions have increase 106 percent in the last year, the increase has been spotty, and largely confined to urban areas. Columbia University epidemiologist Katherine Keyes told the Los Angeles Times that she suspects the increase in naloxone distribution is contributing to what appears to be a stabilization of the opioid-related overdose rate in 2018. I agree, as I have written here. 
Distributing the opioid overdose antidote naloxone is one harm reduction measure that has gained widespread acceptance among policy makers, despite a few naysayers who believe making naloxone available presents a moral hazard and may encourage non-medical drug use.
Dr. Anne Schuchat, the CDC Principal Deputy

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New NBER Working Paper Confirms Needle Exchange Programs Reduce HIV—Does It Also Make The Case For Safe Injection Facilities?

August 2, 2019

A recently released working paper from the National Bureau of Economic Research by Analisa Packham of Vanderbilt University examined the impact of needle exchange programs (referred to as Syringe Exchange Programs or SEPs) on the incidence of HIV as well as overdose hospitalizations or deaths. The author concluded that the openings of SEPs decrease the rate of new HIV diagnoses by 18.2 percent. But she also pointed to evidence suggesting that they may be associated with an increase in visits to hospital emergency rooms for overdose, and an increase in overdose deaths. The author concluded, “needle exchanges alone may be less effective than other interventions at stimulating recovery.”
This paper was recently cited in National Review as an argument against needle exchange programs.

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Data From Germany Provide More Reasons For Policy to Shift From Prescription Pills to Harm Reduction

August 1, 2019

In February of this year, I co-authored a paper in the Journal of Pain Research explaining why there is no correlation between the amount of opioids prescribed and the incidence of non-medical use or prescription pain-reliever use disorder. That same month my colleague Jeffrey Miron and co-authors revealed similar findings in this Cato Institute Policy Analysis.
Now researchers in Germany have provided more evidence to pour cold water on the idea of any relationship between the volume of opioid prescribing and the incidence of opioid use disorder. Publishing in the German Medical Association’s international science journal, they found that “the number of persons addicted to opioids in Germany has hardly changes over the past 20 years,” with an average of 3.1 persons per 1000

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Trump Plan For Pharmaceutical Importation A Small Step In The Right Direction

August 1, 2019

On July 31 Secretary of Health and Humans Services Alex Azar announced a proposal that would allow US pharmacies, distributors, and states to import drugs from Canada that are sold there by US drug makers at prices well below the prices for which they are sold in the U.S. US pharmaceutical companies sell many of their products at much lower prices demanded by Canada’s central health ministry called Health Canada. The Secretary was authorized to implement this proposed policy by the Medicare Modernization Act of 2003.
This idea has been long opposed by US pharmaceutical companies. They argue that the Food and Drug Administration’s onerous regulatory requirements cause them to spend an average of 10 years and an estimated $2.6 billion in research and development costs to bring a new

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Senator Portman Presumes To Know How Many Days Of Pain Relief All 328 Million Americans Need

July 26, 2019

With clear evidence that restricting the number of prescriptions increased the death rate by driving non-medical users to heroin and fentanyl, the last thing one wants to hear about is a politician planning to double down on this deadly policy by calling for further prescription limits for patients in pain.
Yet Senator Robert Portman (R-OH) is proposing legislation that would impose a national 3-day limit on opioid prescriptions following surgeries. He will be kind enough to allow exceptions for people dealing with cancer, chronic pain, and “other serious matters”—whatever that means.
Government data show there is no correlation between the number of opioids prescribed and their non-medical use or the development of opioid use disorder. Overdose rates skyrocketed during the last 10

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Is an End in Sight to the Longest Running World War?

July 22, 2019

The War on Drugs is not only fought on the home front. In fact, it is the longest running world war. While Portugal has decriminalized all drugs, Uruguay never criminalized personal drug use and possession, the Czech Republic has decriminalized possession of small amounts of illicit drugs, and Norway and Mexico contemplate decriminalizing all drugs, the world-wide war on drugs continues apace. And drug prohibition’s futility and destruction are on world-wide display.
I have written about the resurgence of methamphetamine use and methamphetamine related overdose deaths in the US, despite state and federal efforts to solve the “meth crisis” earlier in this century. Now comes a report from the United Nations Office on Drugs and Crime that Southeast Asian gangs are making $60billion (US)

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When Addiction is Stigmatized and Criminalized We All Lose

July 21, 2019

In a recent Wall Street Journal column entitled Even Heroes Can Struggle With Addiction, Timothy McMahan King offers convincing evidence that the great British abolitionist and statesman, William Wilberforce, responsible for ending the slave trade within the British Empire in 1807, was an opium addict for much of his adult (and productive) life. Because of the stigma attached to addiction, most historians and biographers have hidden, ignored, or buried that fact.
Similarly, few of us who rely mainly on the history lessons we received in high school are aware of the regular and (by today’s standards) excessive use of alcohol, opium, and other drugs by our nation’s founders.
Even many in my profession do not know that the great William Halsted of Johns Hopkins University Medical School,

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Washington Post Revelation of Pain Pill Distribution Only Helps to Fuel the False Narrative

July 18, 2019

The Washington Post recently received access to a database maintained by the Drug Enforcement Administration that tracks the manufacture and distribution of every prescription opioid in the country. It reported that 76 billion pills were distributed throughout the US between 2006 and 2012, with higher volumes shipped to the areas that were most hard hit with opioid-related overdose deaths. 
This is being offered as proof that the overprescribing of prescription opioids caused the overdose crisis. But this flies in the face of other powerful evidence. Research reported in the Journal of Pain Research last February that examined data from the National Survey on Drug Use and Health as well as the Centers for Disease Control and Prevention show there is no correlation between the number

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Will Congress Finally X-Out the “X” Waiver?

July 16, 2019

Members of Congress are growing more appreciative of the benefits of Medication Assisted Treatment in addressing the overdose crisis. Two bills presently under consideration—one in the Senate and one in the House—are the latest evidence of that awareness. 
Medication Assisted Treatment for opioid use disorder is one of the most widely-accepted and least controversial of the tools in the harm reduction tool box. The strategy involves placing the patient on an orally-administered opioid that binds with enough opioid receptors to prevent painful withdrawal symptoms while, at the same time, not producing cognitive impairment or euphoria. The approach has been around since the 1960s and has greatly reduced overdose deaths as well as the spread of deadly infections from dirty needles.

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Senators Manchin and Braun Are Attempting to Practice Medicine Without a License—And Fighting the Wrong War

July 12, 2019

Senator Joe Manchin (D-WV) and Mike Braun (R-IN) are still trying to address the fentanyl and heroin overdose crisis—soon to be joined by a methamphetamine and cocaine overdose crisis—by denying chronic pain patients access to pain relief. They have just introduced a bill they call The FDA Opioid Labeling Accuracy Act, which would “prohibit the Food and Drug Administration (FDA) from allowing opioids to be labeled for intended use of ‘around-the-clock, long-term opioid treatment’ until a study can be completed on the long-term use of opioids.”
Set aside the fact that most pain specialists agree that, in some cases, long-term opioid therapy is all that works for some chronic pain patients. The 2016 guidelines on opioid prescribing put forth by the Centers for Disease Control and

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New Evidence From British Columbia Provides a Strong Case for Harm Reduction Strategies

July 8, 2019

A study published last month in the peer-reviewed journal Addiction by researchers at the British Columbia Centre for Disease Control and the British Columbia Centre on Substance Use found that harm reduction strategies were responsible for the province’s opioid-related overdose death rate being less than half of what it otherwise would have been between April 2016 and December 2017.
The researchers noted that 77 percent of opioid-related overdose deaths during that time frame involved illicit fentanyl. Vancouver has long been a major port of entry for fentanyl and fentanyl analogs, produced in China and other parts of East Asia, often using historic seaborn drug trade routes. 
During the 23 months ending December 2017 there were 2,177 overdose deaths in British Columbia, according to

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CDC Provisional Drug Death Numbers Show Slight Improvement. Credit Harm Reduction.

June 26, 2019

Provisional data released by the Centers for Disease Control and Prevention suggest the annual overdose death rate may be levelling off or even slightly declining. The data predict a drop in the death rate to 69,096 for the 12-month period ending November 2018, down from 72,300 predicted deaths for the 12-month period that ended November 2017. These provisional findings represent a 4.4 percent drop in the national overdose rate. 
The drug overdose death numbers include deaths due to natural and semi-synthetic opioids, synthetic opioids other than methadone (fentanyl and its analogs), methadone, methamphetamines and other stimulants, cocaine, and benzodiazepines. For example, opioid-related deaths accounted for 47,600 of the 70,237 overdose deaths reported by the CDC for the year 2017.

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New Genetics Evidence Should Help Quell “Reefer Madness”Mongering

June 24, 2019

A team of Australian and Dutch researchers (Gillespie et al), writing in the June 2019 issue of the British medical journal The Lancet, criticized a March 2019 study by British researchers (Di Forti et al) in the same journal that suggested variations in cannabis use and potency may be responsible for variations in psychotic disorders. Opponents of cannabis legalization have used the Di Forti study as evidence to support their position. 
The criticism rests on the fact that the authors of the March study “assume that cannabis causes psychosis or psychotic symptoms without acknowledging compelling, alternative hypotheses.” 
Gillespie and colleagues point out that most studies looking at associations between cannabis and psychosis don’t adjust for “confounding” that arises from

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The War on Meth Is Back. Big Time

June 18, 2019

Today’s Seattle Times reports on the surge in methamphetamine-related deaths, noting there are more meth-related deaths than at the height of the last “meth wave” in the early 2000s. 
The era of the American meth lab is over a decade gone, yet pure, cheap meth is back and bigger than ever in Western Washington. When Seattle residents point to needles proliferating on sidewalks, they usually say heroin’s to blame; however, a bigger proportion of those needles in recent years is actually from people injecting meth, according to King County syringe exchange surveys.
Death rates in King County have increased four-fold between 2005 and 2017. As I have written here, this is a nationwide phenomenon. In 2005 Congress passed the Combat Methamphetamine Epidemic Act, which moved

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Will “Internet Addiction” Be Our Next “Crisis?”

June 17, 2019

A report on National Public Radio’s Morning Edition today discusses growing concerns about “internet addiction,” especially among adolescents. The reporter mentions that “internet addiction,” sometimes called “social media addiction,” is not recognized as a mental health disorder in the US, where the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association categorizes it as a “condition for further study.” This is not insignificant in light of the strong economic incentives for the psychiatric profession to medicalize behavioral problems. 
The World Health Organization recently recognized “internet gaming disorder” as an addiction in its eleventh revision of the International Classification of Diseases (ICD-11), and China, South

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Toward a Healthy Relationship with Opioids

June 17, 2019

In the June 14th Wall Street Journal, Johns Hopkins University bioethicist Travis Rieder, in an excellent essay, shared with readers his battle with pain resulting from a devastating accident, the effectiveness of opioids in controlling the pain, and the hell he went through when he was too rapidly tapered off of the opioids to which he had become physically dependent. Like most patients requiring long term pain management with opioids, he developed a physical dependence, which is often mistakenly equated with addiction by policymakers and many in the media. 
The aggressive schedule launched me into withdrawal, and I learned viscerally, firsthand, what the absence of opioids can do to someone whose brain has become accustomed to them. Those symptoms include increased sensitivity to

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The Coming “Stimulant Crisis?”

May 21, 2019

Earlier this month the Centers for Disease Control and Prevention, in the Morbidity and Mortality Weekly Report (MMWR), reported that from 2015-2016 deaths from cocaine and psychostimulants (such as methamphetamine, Ritalin, dextroamphetamine) increased 52.4 percent and 33.3 percent respectively. In 2017, the CDC reported a total overdose rate of 70,237, and cocaine was involved in 19.8 percent of those deaths while other psychostimulants were involved in 14.7 percent. Opioids, primarily synthetic (fentanyl and fentanyl analogs), were found in 72.7 percent of the cocaine deaths and 50.4 percent of the other psychostimulant deaths. The report mentioned that provisional 2018 data indicate deaths involving cocaine and other psychostimulants are continuing to increase.
As I have

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An Encouraging Sign for Harm Reduction Advocates

May 13, 2019

A New Hampshire high school student who is remarkably knowledgeable about the various harm reduction strategies that are underused to address the overdose crisis engaged Senator Cory Booker (D-NJ) in a discussion of the subject during a campaign stop in Littleton, NH. The video of the exchange is here.
Senator Booker, who is seeking the Democratic nomination for President in 2020, is a former mayor of Newark, NJ, a city with major drug overdose problems. He had a sophisticated conversation with the student and agreed with her on the need for safe syringe programs. At about 1:50 into the video Booker was asked if he would support needle exchange programs and safe injection sites. He responded that as mayor of Newark he established the needle exchange program in that city and “fully

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The Secret Safe Injection Facility That Is Saving American Lives

May 1, 2019

I have written here, here, and here about efforts by a nonprofit in Philadelphia named “Safehouse” to establish a Safe Injection Facility in the neighborhood of Kensington, where IV drug use is rampant and out in the open, and overdoses are soaring. That effort is being impeded by threats from the Department of Justice that it will enforce federal law prohibiting such sites. The specific law at issue is known as the “Crack House Statute,” passed in the 1980s. Leaders in other major US cities who also want to set up Safe Injection Facilities, including Seattle, San Francisco, New York, and Boston, are closely monitoring the situation before proceeding with their own plans.
In my Policy Analysis on harm reduction I wrote of the impressive results that Safe Injection Facilities (also

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As Seattle Reels From An HIV Outbreak, Safe Consumption Sites Make More and More Sense

April 24, 2019

The US Centers for Disease Control and Prevention’s latest Morbidity and Mortality Weekly Report (MMWR) alarmingly reports a 286 percent increase in cases of HIV among heterosexual persons injecting drugs in King County, Washington from 2017 and mid-November 2018. The report recalls a similar outbreak for similar reasons in rural Indiana that took place between 2011 and 2014, and ultimately led the state to enact legislation permitting needle-exchange programs to operate there. 
As I explain in my policy analysis on harm reduction strategies, needle exchange programs have a more than 40 year track record reducing the spread of HIV, hepatitis, and other blood-borne diseases, and are endorsed by the CDC and the Surgeon General, but are prohibited in many states by local

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Latest Opioid “Sting” Again Illustrates The Power of Prohibition to Corrupt

April 18, 2019

The front page of today’s Wall Street Journal reports on a federal sting operation that led to the arrest of 31 doctors, 7 pharmacists, 8 nurses, and other health care professionals including dentists for distributing more than 32 million prescription opioid pills to patients in five Appalachian region states. 
Federal prosecutors described doctors handing out pre-signed blank prescriptions in exchange for cash. In some instances, doctors provided prescriptions in return for sexual favors. One Alabama doctor allegedly recruited prostitutes to become patients and let them use drugs at his house. Dentists performed unnecessary teeth extractions on cooperative patients so they can have a legal excuse to prescribe them the opioid pills they desired. Some doctors knowingly sold

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Fentanyl as a WMD? The War on Opioids Reaches a New Level of Misinformation

April 17, 2019

“This is like declaring ‘ecstasy’ as a WMD,” an anonymous source from the Department of Defense counter-WMD community commented incredulously. This source was quoted by a Task and Purpose reporter investigating a Department of Homeland Security internal memo discussing designating the synthetic opioid fentanyl as a weapon of mass destruction. This is just the latest example of how misinformation and hysteria inform federal and state policy regarding the overdose crisis. 
Policy makers maintain their state of denial about the role of prohibition in the overdose crisis. Denial fosters vulnerability to misinformation and “alternative facts” to prop up falsely held views. Denial that the war on drugs is responsible for most of the death and destruction surrounding illicit drug use makes

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The AG’s Position on Marijuana Legalization a Welcome Contrast to That of His Predecessor

April 11, 2019

Lost in all of the media frenzy over the Mueller Report, redactions, and alleged improprieties within the Department of Justice and FBI, was Attorney General William Barr telling the Senate Appropriations Committee yesterday that he favors a more federalist approach to marijuana laws.
In response to a question from Senator Lisa Murkowski (R-AK), Barr said that allowing the states to set their own marijuana policy and removing the federal government from the matter would be an improvement over the present situation, which he called an “intolerable” conflict between state and federal laws. Senator Murkowski is a sponsor of the Strengthening the Tenth Amendment Through Entrusting States (STATES) Act, which would give immunity from federal action against business and people engaged in the

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They Still Call It An “Opioid Epidemic.” Why’s That?

April 9, 2019

The Cleveland Plain Dealer recently reported that, while overdose deaths have come down slightly over the past year in the Cleveland metropolitan region, a new killer has emerged on the scene: cocaine mixed with fentanyl.
The Cuyahoga County Coroner’s Office informs the public that cocaine was involved in 45 percent of overdose deaths last year, the highest rate in ten years. It reports that cocaine is being found in combination with fentanyl with increasing frequency, and it is believed that many cocaine users are either unaware of the presence of fentanyl or, if they are, they are uncertain as to the amount that is present. The highly potent fentanyl (roughly 100 times more potent than morphine) causes them to asphyxiate and die.
This phenomenon was reported a year ago in

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Libertarians and Harm Reduction

March 26, 2019

Last week we held a day-long conference at the Cato Institute devoted to exploring the strategy known as “harm reduction” to address the rising rate of drug overdose deaths and the spread of infectious diseases, such as hepatitis and HIV.  
In my remarks at the beginning and at the conclusion of the conference, I pointed out that the harms afflicting the drug-using community and their intimate contacts are the direct result of drug prohibition. Cato’s Jeffrey Miron emphasized that point in a key presentation and discussed the success Portugal has had in reducing overdose deaths, HIV, hepatitis, and the heroin addiction rate after it decriminalized all drugs in 2001.
While I stated that the ultimate act of harm reduction would be to end the War on Drugs, I argued that, as a start, the

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From “Meth Crisis” to “Opioid Crisis” to “Fentanyl and Meth Crisis” to…

March 18, 2019

Today’s Wall Street Journal reports that, just as overdose deaths related to prescription pain relievers are showing signs of leveling off, officials worry that the surge in methamphetamine-related deaths is joining the surge in fentanyl-related deaths to fuel the total drug overdose rate. 
There were 1887 meth-related deaths reported in 2011. By 2017 more than 10,000 deaths were reported related to meth and other chemically-similar psychostimulants.
The Drug Enforcement Administration has seen a 118 percent increase in meth seizures by law enforcement between 2010 and 2017. The meth is cheap and abundant and flooding the US mainly from Mexico, according to the agency. The Mexican cartels have taken up the meth trade to compete with cocaine coming up from South America. 
The Journal

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