Methadone maintenance treatment (MMT) is a harm reduction approach for persons who wish to stop using opioids and is rather effective if used for a minimum of 12 months. Notably, research demonstrates that many persons enrolled in MMT programs discontinue care before this time, limiting its effects. To better understand this process, we undertook an exploratory descriptive qualitative study and interviewed 12 men and women who were using MMT. Using the theoretical work of Foucault and Hardt and Negri, the (...) interview data highlighted that MMT continues to be strongly stigmatized, and that it is a system of care that involves rewards and penalties, based on if patients behave according to prescribed norms. These results suggest that MMT is a disciplinary mechanism, albeit one that impedes its own access. We consequently recommend that healthcare providers work to facilitate access to MMT, which means altering care delivery. (shrink)

Opioid agonist treatment, including methadone, is the safest and most effective method for treating opioid use disorders and reduces opioid overdose deaths. While access to methadone is highly regulated by federal law, a substantial portion of states impose stricter barriers.

Heroin use poses a significant health and economic burden to society, and individuals with heroin dependence are responsible for a significant amount of crime. Owing to its efficacy and cost-effectiveness, methadone maintenance therapy (MMT) is offered as an optional alternative to imprisonment for drug offenders in several jurisdictions. Some object to such 'MMT offers' on the basis that they involve coercion and thus invalidate the offender's consent to MMT. While we find these arguments unpersuasive, we do not attempt to (...) build a case against them here. Instead, we explore whether administration of MMT following acceptance of an MMT offer might be permissible even on the assumption that MMT offers are coercive, and in such a way that the resulting MMT is non-consensual. We argue that non-consensual MMT following an MMT offer is typically permissible. We first offer empirical evidence to demonstrate the substantial benefits to the offender and society of implementing non-consensual MMT in the criminal justice system. We then explore and respond to potential objections to such uses of MMT. These appeal respectively to harm, autonomy, bodily and mental interference, and penal theoretic considerations. Finally, we introduce and dismiss a potential response to our argument that takes a revisionist position, rejecting prevailing incarceration practices. (shrink)

Methadone maintenance therapy is a cost-effective, evidence-based treatment for heroin dependence. In the USA, a majority of heroin-dependent offenders are forced to detox from methadone when incarcerated. Recent research published in The Lancet has demonstrated the negative health and economic outcomes associated with such policies. Methadone Continuation Versus Forced Withdrawal on Incarceration in a Combined US Prison and Jail: A Randomised, Open Label Trial. The Lancet, 386, 350–359). This novel evidence raises questions as to the justification for (...) current policies of forced detox in American prisons. Opponents of methadone provision in prisons might offer arguments from retributivism, resource allocation and curative effectiveness to justify their position. This article contends that these arguments do not stand up to ethical scrutiny. In light of this, we hold that American policymakers should reform criminal justice policies to allow the initiation and continuation of methadone treatment in correctional settings. This would be consistent with both international recommendations and the example set by a number of other Western countries. (shrink)

Through a fieldwork study of the practice of methadone substitution at a French addiction clinic, the classic ‘theory of action’ is criticized and an alternative one proposed. A sketch of the debates among French drug specialists, drug users and legislators shows the pertinence for these practitioners of such a theoretical question; further, the ethnographic data suggest that they can be seen as actually trying out an alternative to this ‘theory of action’.

Addiction is a central issue in a liberal society of autonomous citizens, as the nodal point of addiction is self-control - or rather the lack of it. By looking at different ways of problematizing and working upon addiction, one might also get some idea of different ways of conceptualizing and practicing freedom. The point of departure for my paper is practices of methadone maintenance in different regimes of drug treatment. The article illustrates how treatment practices produce different forms of (...) subjectification of drug addicts, depending on the discourses and technologies these practices articulate, and by implication, how they constitute different ways of problematizing freedom as something to be worked upon. My argument is based on interviews with managers of the drug treatment system in Copenhagen, documents concerning drug policy and drug treatment on a local and national level as well as addiction research. My analyses in this paper are tentative and a first report from a study currently under way. (shrink)

Medical interventions such as methadone treatment for drug addicts or “chemical castration” for sex offenders have been used in several jurisdictions alongside or as an alternative to traditional punishments, such as incarceration. As our understanding of the biological basis for human behaviour develops, our criminal justice system may make increasing use of such medical techniques and may become less reliant on incarceration. Academic debate on this topic has largely focused on whether offenders can validly consent to medical interventions, given (...) the coercive environment of the criminal justice system. Both sides in this debate share the assumption that administering medical interventions to offenders without their valid consent would be unethical. Recently, Thomas Douglas has mounted a formidable challenge to this “consent requirement”. Essentially, his argument rests on a comparison between prison and medical interventions. Douglas asks: if the state is entitled to impose a prison sentence on a criminal without the criminal’s consent, why is consent required for the imposition of a medical intervention? The most obvious way of defending the consent requirement against Douglas’s challenge appeals to the fact that incarceration merely interferes with the right to free movement, but medical interventions interfere with the right to bodily integrity. This argument rests on what Douglas calls the “robustness claim”—the claim that the right to bodily integrity is more robust than the right to freedom of movement. In other words, the right to freedom of movement loses its protective force in a wider range of circumstances than the right to bodily integrity. Douglas’s article seeks to undermine the robustness claim, by arguing that neither case-based intuitions, nor theoretical considerations support this claim. In this article, I will attempt to raise some doubts about Douglas’s challenge to the consent requirement and the robustness claim. (shrink)

This paper seeks to understand the treatment effect of Prescription Drug Monitoring Programs on opioid prescription rates. Using county-level panel data on all opioid prescriptions in the U.S. between 2006 and 2015, we investigate whether state interventions like PDMPs have heterogeneous treatment effects at the sub-state level, based on regional and temporal variations in policy design, extent of urbanization, race, and income. Our models comprehensively control for a set of county and time fixed effects, countyspecific and time-varying demographic controls, potentially (...) endogenous time-series trends in prescription rates, and other state-level opioid interventions such as Naloxone Access and Good Samaritan laws, Medicaid expansion, and the provision of Methadone Assistance Treatment. We find that PDMPs are only effective in reducing prescription rates if they obligate doctors to check for patients' history prior to filling out a prescription, but the frequency at which a state requires its PDMP to be updated is irrelevant to its effectiveness. Moreover, the significant treatment effects of PDMPs are almost exclusively driven by urban and predominantly white counties, with the relatively more affluent regions showing greater responsiveness than their less affluent counterparts. (shrink)

The regulation of narcotic medications used in narcotic addiction treatment is unique in medical therapeutics. Physicians who want to use narcotics for this indication must obtain a separate annual registration from the Drug Enforcement Administration. Annual registration is contingent on compliance with both the DEA's security regulations as well as treatment regulations jointly promulgated by the Food and Drug Administration and the National Institute on Drug Abuse.During the last decade, a number of events have occurred that persuaded NIDA that it (...) is time to reevaluate the current method by which the Department of Health and Human Services regulates methadone treatment. As a result of research during the past twenty years, we have learned about the effective components of methadone treatment. In comparison to other available treatment modalities for opioid addiction, methadone treatment is uniquely effective when administered by well-trained medical staffs. (shrink)

The regulation of narcotic medications used in narcotic addiction treatment is unique in medical therapeutics. Physicians who want to use narcotics for this indication must obtain a separate annual registration from the Drug Enforcement Administration. Annual registration is contingent on compliance with both the DEA's security regulations as well as treatment regulations jointly promulgated by the Food and Drug Administration and the National Institute on Drug Abuse.During the last decade, a number of events have occurred that persuaded NIDA that it (...) is time to reevaluate the current method by which the Department of Health and Human Services regulates methadone treatment. As a result of research during the past twenty years, we have learned about the effective components of methadone treatment. In comparison to other available treatment modalities for opioid addiction, methadone treatment is uniquely effective when administered by well-trained medical staffs. (shrink)

In July 2014, the roboticist Ronald Arkin suggested that child sex robots could be used to treat those with paedophilic predilections in the same way that methadone is used to treat heroin addicts. Taking this onboard, it would seem that there is reason to experiment with the regulation of this technology. But most people seem to disagree with this idea, with legal authorities in both the UK and US taking steps to outlaw such devices. In this paper, I subject (...) these different regulatory attitudes to critical scrutiny. In doing so, I make three main contributions to the debate. First, I present a framework for thinking about the regulatory options that we confront when dealing with child sex robots. Second, I argue that there is a prima facie case for restrictive regulation, but that this is contingent on whether Arkin’s hypothesis has a reasonable prospect of being successfully tested. Third, I argue that Arkin’s hypothesis probably does not have a reasonable prospect of being successfully tested. Consequently, we should proceed with utmost caution when it comes to this technology. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:It's Not Always Just a RashAdam BossertI looked at the emergency department track board and saw a patient waiting for a provider who was "roomed" in a hallway stretcher with a chief complaint of a rash. I briefly considered his ultimate disposition, "He's probably fine. He can't be that sick if he was triaged as safe for the hallway." I was tired and close to the end of an (...) overnight shift and thought he would be a quick turnaround, likely discharged, since rashes are typically benign. I walked over to his stretcher after a quick chart biopsy that highlighted his mildly increased heart [End Page 24] rate on arrival as well as his history of polysubstance use and homelessness."Hey doc, I don't feel so good.""I'm sorry to hear that. What's specifically bothering you?""I am itching all over with these bumps. My skin is red, and I also think I'm withdrawing since I have body aches and chills."The interview continued.I discovered his last heroin use was approximately eight hours prior to arrival. I thought he was an ideal candidate for buprenorphine since he was actively withdrawing. I was recently licensed to prescribe this medication and excited to use my license for the first time. He declined the suggestion, however, preferring methadone instead. Buprenorphine can precipitate withdrawal if not given long enough after opioid use or if an incorrect dose is given; thus, many patients are hesitant to take it. He also stated he was predominantly here for his rash and did not want rehabilitation placement. I ordered our initiation methadone dose as well as a screening COVID-19 test and a urine drug screen test, which are both needed for rehabilitation placement in case he changed his mind.His rash was highly suspicious for scabies. He was covered with red bumps that spared only his face, some in linear distributions, and was actively scratching his arms and legs during the interview. I prefer oral ivermectin over topical permethrin for the homeless population simply for ease of administration, lower cost, and increased compliance. He received ivermectin for his scabies and knew he could return to the emergency department for a repeat dose if he was unable to fill a prescription.What happened next is, in my experience, an all-too-common scenario.The patient told me that the methadone is "doing nothing." I explained he could no longer take buprenorphine since he already received methadone, which only made him more frustrated. Unfortunately, I am restricted with the amount of methadone I can give in the emergency department, largely due to the drug's long half-life, and thus I was unable to give him more, let alone attempt titrating to his tolerance.Opioid withdrawal is not a life-threatening diagnosis; these patients are not typically admitted to the hospital. The management consists of initiating either methadone or buprenorphine, symptomatic treatment and then outpatient referral or rehabilitation placement. I explained the options to him, and he requested to be discharged since he was deferring rehabilitation. He was discharged. I was able to treat his rash but his chronic illness, opioid use disorder, was not controlled.I discharge a patient in opioid withdrawal or who has opioid use disorder almost every day, and I think most emergency medicine physicians would echo that statement. The disposition is not wrong from the perspective of the individual physician, but it feels like the system has failed these patients when I think of the frequency that they return and their baffling risk of overdose. The latter can be reduced by giving patients Narcan, the drug to reverse opioid overdose, upon discharge but this is just placing a bandage over the problem and not all emergency departments can fund this risk-reduction tool.I saw my patient's COVID-19 result return as I wrapped up my shift. It was positive. And, of course, he was in our department's hallway the whole time, only intermittently using his mask. I suddenly realized that while yes, he was withdrawing, he also may have had a symptomatic COVID-19 infection! I quickly reopened his chart, only to... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:When Is Enough, Enough?Megan HomsyThis was a case that stuck with many members of our transplant team for a long time. The patient was a 44-year-old Caucasian male evaluated for a liver transplant with a diagnosis of hepatitis C virus (HCV), originally diagnosed 11 years before the transplant evaluation. The patient met the criteria for the following substance use diagnoses: alcohol use disorder moderate in sustained remission, in a (...) controlled environment, opioid use disorder, severe, in sustained remission, on maintenance therapy, in a controlled environment, stimulant use disorder, amphetamine-type, severe, in early remission, in a controlled environment and stimulant use disorder, cocaine-type, severe in early remission, in a controlled environment.The patient had been living in a sober living housing program for approximately ten months prior to his transplant evaluation with me, his social worker. He had also been diagnosed with depression and bipolar disorder. He had been intermittently linked with mental health services and had participated in numerous detox and substance abuse programs over the last ten years, with varying degrees of success. He was in dual diagnosis treatment (i.e., treatment for co-occurring substance use and mental health disorders) through his Suboxone clinic and was completing toxicology screenings on a biweekly basis.After concluding the minimum three months of drug and alcohol treatment set forth by the state's Organ Transplantation Consortium, the patient graduated from his sober living program, moved in with his sister, and was listed for a liver transplant.The patient was transplanted five months after his clinic evaluation. At the time of the surgery, the patient's Suboxone was abruptly discontinued and replaced with IV Dilaudid. Within days of his transplant, the patient frequently expressed concerns about his pain. Several medical services attempted to manage the pain medications, resulting in his pain management plan being changed repeatedly and much confusion over his current medication regimen. During his liver transplant hospitalization, the RN found the patient with a needle in his arm, and after a search of the patient's hospital room, the hospital police found drug paraphernalia and illicit substances. The patient was eventually discharged to an inpatient substance abuse program, which he left before completing the program and against medical advice.During his first year post-transplant, I attempted to arrange other various treatment programs for him (most of which he did not follow through with) and to find housing for him (as he had been forced to leave his sister's home after his relapse). Eventually, the patient was incarcerated on drug-related charges. Numerous times, the patient missed completing his labs and his post-transplant appointments. He did not refill his immunosuppressant medications, and for lengthy periods of time, he was unreachable by the transplant care team, which resulted in my team members and I calling the patient's family, other providers, and the police for safety checks.In the aftermath of these issues, my colleagues and I had to reckon with the realization that we had failed the patient. As a team, our transplant center created a task force to review this case and what to do in the future to prevent such breakdowns in patient care. We created protocols for managing patients who, at the time of their transplant, are on Medication Assisted Treatment (MAT) such as Suboxone and methadone. Staff across the multidisciplinary team attended trainings regarding addiction, pain management, and best practices for MAT services. Additionally, our transplant center collaborated with our hospital's addiction treatment program for a streamlined referral process for transplant patients to addiction services.This patient's case and its sensational nature resulted in many conversations, both professional and unprofessional. Members of the social worker department became aware that personnel within transplant, though not involved in patient care, were inappropriately discussing this patient's case and engaging in unprofessional behavior. Said actions led to the termination of a member of the transplant team. I was placed in the unenviable [End Page E3] position of having to report this behavior to hospital management and legal teams to protect a vulnerable patient.The ethical challenge behind this case really stems from the transplant team attempting to balance two... (shrink)

continent. 2.1 (2012): 22–28. Jeroen Mettes burst onto the Dutch poetry scene twice. First, in 2005, when he became a strong presence on the nascent Dutch poetry blogosphere overnight as he embarked on his critical project Dichtersalfabet (Poet’s Alphabet). And again in 2011, when to great critical acclaim (and some bafflement) his complete writings were published – almost five years after his far too early death. 2005 was the year in which Dutch poetry blogging exploded. That year saw the foundation (...) of the influential, polemical, and populistically inclined weblog De Contrabas (The Double Bass), which became a strong force for internet poetry in Dutch in the years to follow. In the summer of that year, a lively debate raged in the aftermath of Bas Belleman’s article “ Doet poëzie er nu eindelijk toe ?” (“Does poetry finally matter now?”), on a blog specifically devoted to this question. Up to that point, the poetical debate in the Netherlands had largely been confined to literary reviews (which were often subsidized), having become mostly marginalized in more mainstream media, where poetry could be covered by only a small number of so-called authorities. As a result, literary debate had acquired a rather placid quality. Though a variety of camps with different aesthetics could be discerned, most poetical positions shared a general acceptance of poetry as a form of art somewhat apart from fundamental political concerns. Late modernists would pursue subtlety and density of reference. Others would insist poetry was best understood as a form of entertainment that should ideally be accessible and work well on the stage. Still others would insist that poetry is mostly a play with forms. Linguistically disruptive strategies were valued highly by some, but mostly for their aesthetic effect. Values of disinterested playfulness reigned supreme everywhere. Any idea that poetry could be a field in which one confronts politics and the world was decidedly marginal. This led to a climate in which most attempts at polemics were DOA, often based on far too superficial positioning and analysis. The greatest polemical debates were revolving around the question of whether poetry should be difficult or easy, with both camps defining their ideas of difficulty and accessibility in ways that were so utterly shallow as to make the entire point moot. Debates were performed, rather than engaged with. It was a postmodern hell of underarticulated poetics. Half-consciously, people were yearning for new forms of criticism that could put the oomph back into poetry. Weblogs provided for ways to explore debate directly outside of the clotted older channels of the reviews and the newspapers. Belleman’s essay and the resulting online activity had shown that there was a widespread eagerness to take poetry more seriously as a social art form. It was in this environment that Mettes started his remarkable project Dichtersalfabet . At that moment, Mettes was active mostly in academic circles, having become noted at Leiden University as a particularly gifted student of literary theory. Within the Netherlands, the field of literary theory has a very odd relationship to literature as it is practiced in the country. Academic theory tends to have a mostly international view and engage with international debates of cultural criticism, literary theory, and philosophy, with academics often publishing in English and attending conferences around the world. Literature itself however is much more concerned with domestic traditions. Consequently, in the Netherlands, there exists a language gap between academic theoretical practice (as it is studied in the literary theory departments) and literary practice (which, academically, gets studied in specialized departments of Dutch literature). The Dichtersalfabet can be seen as Mettes’s attempt to close this gap. It is also an attempt to bridge the divide between theory and practice, in which he could apply his theoretical knowledge in a very unorthodox and unacademic critical mode that moreover could reach far beyond the domain of conventional criticism. Mettes’s goal was to trace a diagonal through Dutch poetic culture, to “strangle” what he perceived to be its dominant oppressive traditions of agreeable irrelevance, in order to see whatever might be able to survive his critical assaults. But he could only do so by means of a very serious engagement with poetry itself. To this end, he would go systematically through the poetry bookshelf of the Verwijs bookshop (part of a mainstream chain of booksellers) in The Hague, buying one publication per blog item, starting from A and working his way through the alphabet, reading whatever he might encounter that way in the restaurant of the HEMA store (another big commercial chain in the country). He would subsequently write down his reading experiences, refraining however from trying to write a nuanced book review. Rather, he would write about anything that caught his attention and sparked his critical interest. This way of working would yield vast, at times somewhat rambling, dense, lively, and generally brilliant essays, in which he held no punches. He never hesitated to pull out his entire arsenal of concepts from the international theory traditions, while never degenerating into mere academic exercise and pointless intertextualities. The attempt was rather to live the poetry that he read, and to engage it with the full range of political, academic, cultural, and personal references that he had at his disposal—all that composed the individual named Jeroen Mettes as a reader. Often what he wrote would not be according to the standards of what we usually think of as a critical review of a book of poetry. Sometimes he would even be a little sloppy in his judgments of poets or representations of the books he read, for example by basing an entire essay on the blurb of a book rather than its poetry content. But what he did was always brilliant writing nonetheless—virtuoso riffs on poetic fragments randomly found within capitalist society, exposing an incisive and insistent poetical sensibility. Mettes read poetry for political reasons, to see whether poetry could offer him a way to deal with a political world he detested. The right-wing horrors of the Bush years, the Iraq war, and the turn of Dutch public opinion towards ever more conservative, narrow-minded, and xenophobic views alongside a complete failure of the political left to present any credible alternative, were weighing heavily on the times in which Mettes reported on his reading. Poetry was to measure this world, diagram it, to lay bare its inconsistencies and faults, to indicate where lines of flight might be found. Amid the ruins of a world wrecked by imperialist policies, corporate capitalism, and doctrinal neoliberalism it would have to show the possibility of a new community. And it was, through its rhythmical workings, to release the reading subject from his confinement to ideologically conditioned individuality and lead him into the immanent paradise of reading. The stakes were high. Much higher than anything Dutch poetry had seen for many years. Mettes’s blog was widely read from the start. His posts sparked lively debates. Some of these subsequently led to the publication of extensive essays on a few key poets in some literary journals, particularly Parmentier and the Flemish journal yang , for which Mettes would become a member of the editorial board, a few months after starting the Dichtersalfabet . This could have been the start of a brilliant career, but this was not to be. The initial manic energy that fueled the blog gradually subsided. The Alfabet was updated less and less regularly. Mettes sometimes just disappeared for many weeks, then suddenly returning with a brilliant essay. Until, on September 21, 2006, he posted his final blogpost, consisting of no text whatsoever. That night I learned from his mentor at Leiden University that he had committed suicide. Mettes and I had had some fruitful exchanges on poetry, rhythm, music, and form, mostly on the blogs, but also by email. Three weeks before his death was the last time I heard from him: a very sudden, uncharacteristically curt note saying “My old new sentence epic.” Attached to that message I found a DOC-file of a work so major that I felt intimidated. This was N30 , a text he had been working on for over five years. After his death, it took me a long time before I dared to read it in its entirety. In the meantime, the work of preparing the manuscript for publication was entrusted by his relatives to his colleagues at yang magazine. It took them a few years to brush up the text and to edit the Dichtersalfabet -blog (which, apart from the Alphabet project itself, incorporated many other fragments of political, polemical, and theoretical writing) into book form along with the essays. The result of this labor was finally published in 2011 as a two-book set, and Mettes burst onto the Dutch poetry scene for the second time. The work was widely reviewed, on blogs, in journals, magazines, and newspapers. Many critics who had not followed the blogs in 2005 showed themselves surprised, baffled even, by the intensity of Mettes’s critical writing. But for those who had read the blog, the main surprise was in the poetry. During Mettes’s lifetime, some of his poems had already been published in Parmentier . Although these were strong texts by themselves, in no way did they prepare readers for N30 . Nothing like it had been written in Dutch before. Instead, N30 explicitly follows the American tradition of Language Writing, directly referencing Ron Silliman and his concept of The New Sentence. However, it would seem that much of the poetical thinking around his use of this technique puts him closer to a writer such as Bruce Andrews. For Mettes, using non sequiturs as a unit of poetic construction was not only a way of reinventing formal textual construction, but it was another way of finding the fault lines in the social fabric. From the perspective of the Language tradition, one may put N30 somewhere between Silliman and Andrews. N30 shares an autobiographical element with Silliman’s New Sentence projects, and as in Andrews, there is a concern for mapping out social totality within text—what Mettes refers to as a “textual world civil war.” Again this shows a formal textual strategy for allowing the person “Jeroen Mettes” to be absorbed by the world, which here appears as a whirlwind of demotic and demonic chatter, full of violence, humor, intensity, beauty, disgust, sex, commerce, and strife. Influenced as it may by American precursors, Mettes’s tone and form end up quite different from his American counterparts, consistently referencing a world that is Dutch, all too Dutch, taking on the oppressive orderliness of Dutch society with its endemic penchant for consensus by introducing chaos into its daily life and laying bare its implicit aggressions. The work’s 31 chapters each have a different feel and rhythmical outline, but none of them follow a predetermined pattern. Rather, Mettes would consistently edit and reedit the text, randomly rewriting parts of it, as he explains in his poetical creed Politieke Poëzie (Political Poetry). N30 – referring to the 1999 antiglobalist protest in Seattle – was to be the first text of a trilogy. The work itself was written “in the mode of the present.” A second text was to be written in the mode of the future, and a third one, in the mode of the past, was going to be an epic poem about the Paris Commune, and to form an alternative poetic constitution for the European project. I still deeply regret that Jeroen Mettes never got to complete those projects, just as I would be very keen on knowing what he might have had to say about more recent political developments. Instead, in 2006, he remained stuck in the horrors of the present, that ended up consuming him completely. He left Dutch literature with some of its most piercing criticism and its most profoundly moving, exciting and powerful poetry. Excerpts from N30 Translated by Vincent W.J. van Gerven Oei from Jeroen Mettes. "N30." In N30+ . Amsterdam: De wereldbibliotheek, 2011. Published with permission of Uitgeverij Wereldbibliotheek, Amsterdam. Chapter 1 1999. A day is a space too. And another man, who had chained himself, had his ribs crushed, and a motor has driven over somebody’s legs. Dutch health care system spends ±145 million guilders per year on worriers. A spiderweb vibrates as I pass by. Randstad renovating. She slaps her bag against her ass: “Hurry up!” OPINION IS TRUE FRIENDSHIP Your skin. It doesn’t express anything. “But the use of the sword, that’s what I learned, and you’ll need nothing more for the moment.” Just try to interrogate a guy like that. Gullit in Sierra Leone. Codes silently lying all around. But that’s simply what belongs to “that it’s just allowed”: that sigh of “world” (a word expressing that the trees are now standing along the water like black men with white bags in their hair); that’s nothing else right? And you see how everything has to move, and first of all what cannot do so. Without Elysium and without savings, barbarians lashing out, horny for an enemy, staring across the water, staring into the air—staring to get out of it. “You’ve never showed me more than the mall,” she said. All those “dreams” in the end—and now? It was lying on the stairway, so I picked it up and took it upstairs. Chapter 3 “You know what?” Telecommunication. For love… I don’t really like that cheap cultural pessimism, but… The holy city is on pilgrimage in the earthly bodies of the faithful until the time of the heavenly kingdom has come. The end of an exhausting autumn day behind the computer, my eyes filled with tears of fatigue. KITCHEN / INSTALLATION / SPECIALIST. Network integration. In the sun, stretched out on a sheet. (…) I don’t believe what I’m reading, because I want to believe something else. An illusion? Suits me. There’s a variety of shapes and tastes… “So what?” you may think. 102 dalmatians can’t be wrong. But I want more, dear… A feel good movie. I’m smashing the burned body. So what? We continue to save the European civilization. What’s there to win? Plato with poets = Stalin without gulag? Ball against the crossbar. No wonder. She comes straight to her point. She’s standing in the kitchen eating an apple. (…) The godless Napoleon had used her as a stable and wanted to have her taken down. “Our” Rutger Hauer. Ready or not here I come. Psst… are you also wearing a string? Nobody understands our desire. Cliffs breaking the waves and shattering the sunset. I used to be a real romantic (as a poet). A typical fantasy used to be the one in which I brutally raped mother and daughter Seaver from the sitcom Growing Pains . Nevertheless you only contain bad words. Eyelashes. Automatic or manual? That your skin always in the afternoon. Integration. The air is empty. Too bad! Hand in hand on their lonely way. Alaska! Chapter 12 May 5, 2001 [10:00-10:30] A dust cloud on a hill. Globe. Indian (British) (tie) / pope. Damascus. Rape. We’re carrying the ayatollah’s portrait through the streets. At the moment the girl is mostly suede jacket with white ribbons on her sleeves. A small explosion flares up/impact. Camouflage. Close up. We’re analyzing the situation. He’s dead right? Dead dead. Dead. Everything without, these, and only with the body. Indices signal death. Dollar bills are printed in factories. Holes. Light patch. Globe in a box. Microphone. What’s the situation? Grey impact on a green hill (field?). The water is blue. He has no lips. Interns on the background with skirts that are too long. This is an example of a sonnet. An Islamic woman pushes against the door of an electronics shop. Arrows (percentages (prices)). Is this what awaits the American? Touch screen interface. The word, an island, can only be a sign in that situation. We pull up a chair, join in on the fun. On the shelves only books about computers. One glance in the distance is enough to lighten up a luna park in the distance. She’s really desperate, especially when she laughs. Click. Ah. Next. And now it’s raining, but that’s ok. Yellow stains sliding over the south. Shallow caves light: clothes, boots, electrical equipment. 45. 22:10. Nothing gives you the right to eat more than people starving to death. The Hague. Slam dunk. Traffic light. Two H’s, one L (standing for the L (little prick)). We’re happy to say something. Clouds, small suns, temperatures, cities. The truth is never an excuse. Yellow. Yellow. Green. Yellow. Yellow. Yellow. Yellow. Green. Green. Yellow. Will you email me? Skeleton: “No.” Ex-nerds in brand-new and brightly red sport cars. $$$. I love. Shihab. Hooves in the sand. Skinny senior with over-sized sunglasses; old jockey (cap, trophy) smiling in slow motion. And there I am again, flashback, crying with my head in between my hands. Sometimes I’ve got the feeling that cannibals. Eyes: blue. Cancer. Why would I wait until tomorrow? Golden beams protruding from the lifted/lit earth. May 5, 2001 [11:30-12:45] You’ll remember this for the rest of your life. Graphs, diagrams. Bu$ine$$. Blue shirt, white collar, no neck (porn star). A name lights up. I’m hysteric. Will you join us? Letters falling in their words. Fingers set up a tent and start to dance. Young entrepreneurs from poor neighborhoods (read: black) guided by Microsoft. Kinda makes me happy, that sort of kitsch. A sense of exhaustion/impotence to see anything but the present. (…) Wouldn’t you like to? Orange explosion in an industrial zone. YOU’RE DOING THIS FOR AMNESTY INTERNATIONAL. Would you. A familiar face. Clouds and blossom. Sunflowers. Supermodels. Mountainous area in a rectangle: shades of brown, from dark to beige, more green toward the south. Tents and next to them (it’s all a blur) people. Plane. Stadium. Geometrical block of people. No, I ain’t crying. I don’t speak no more. I just want. Quote + photo. (Positive:) screaming crowd. Three-piece suit, seen from the back, before entering the arena. On the back: “Daddy abused me.” Oh, bummer. State of emergency has been declared and everyone has to cooperate. She’s cut her wrists. What we do know (…) is that there’s never been a unique word, an imperative name, nor will there ever be. [Click here for work that suits you.] Barefooted children are watching it (coherent pieces revelation of what’s lying below). Who knows how she’s changed during those two years. “Everything used to be better” + sigh. And here we are. An empty field of parquet. A city lying behind it. Explosion. Blue. A rain drop falling in my coffee. May 5, 2001 [14:30-15:30] A young Arafat on video speaking with raised finger. “I’m calling from my convertible.” Names on walls, victims, numbers… Tourists. Yellow. Yellow. “Your own child! Really, what kind of human are you?” I don’t want to hear it no more. A woman jumping out of the water in a yellow bikini against a background of fireworks and the Cheops pyramid. Thy sorrow shall become good fortune, thy complaints laudation. All planets will float and wander. Wo die Welt zum Bild wird, kommt das System (…) zur Herrschaft. It is something, but is it? May 5, 2001 [18:30-19:00] Iris. Leaves. NASDAQ. Open / and white and. For the one who’s doing nothing, just waiting. (…) NO DEFEAT is made entirely up of defeat -- since / the world it opens is always a place / formerly / unsuspected. October 2002. “Jeroen, I’m leaving for the cemetery, byeeee.” The rise of the middle class. My entire oeuvre is an ode to the. My entire head is a fight against the. God always demands what you cannot sacrifice. You may take that the easy way, but… “The state hasn’t made us, but we make the state” (Hitler). A stork exits the elevator. Skeletons of. Moscow. Helsinki. Palermo. Paris. Chapter 30 Like your paradises: nothing. United Desire, as only remaining superpower. And even though the sea is now calmer and the wind is blowing pleasantly in my face… Heart! Who determines whether a tradition is “alive”? The yellow leaf or the white branch? Mars. This sentence is a typical example. Most Dutch people are happy. No consolation. When I see a girl sitting at a table with a book, a notepad, a pen, a bottle of mineral water, her hand writing in the light—then I consider that one thing. “Presents,” “poetry,” “classics.” We are what we cannot make from ourselves. “Left”: mendicant orders, missionaries. Saint-Just: “A republic is founded on the destruction of its enemies.” She crosses the street with a banana peel between her fingers. (…) We chose our own wardens, torturers, it was us who called all this insanity upon ourselves, we created this nightmare… But “no”? Girl (just like a beach ball) talking rapid Spanish (Portuguese?) in a mobile phone. Do I have a chance now that her boyfriend is getting bold? CLIO, horny bitch. What else do you want? An old woman, between the doors of the C1000, is suddenly unable to go on; her husband stretches out his hand, speaking a few encouraging words. Selection from. Der Führer schenkt den Jüden ein Stadt. How can it reach us if we haven’t been already reached somehow? It doesn’t “speak.” No problem. Each word she uses is a small miracle, as if she doesn’t belong to it, to language, but wanders around with a pocket light looking for the exit; she’s never desperate (maybe a little nervous), lighting up heavy words from the inside. But indeed, we’re free. But the predicate is not an attribute, but an event, and the subject is not a subject, but a shell. That’s why also samurai, knights, and warriors raised the blossom as emblem: they knew how to die. Locked up in a baby carriage with a McDonald’s balloon. Blue helicopter, the blue sky. Whether you want to refer? The point is. How / Motherfucker can I sing a sad song / When I remember Zion? You’ll feel so miserable and worthless that you think: “If only I were dead!,” or: “Just put an end to it!” “So you’re an economist?” Her card—two little birds building a nest, her handwriting shaking—is still on the mantelpiece. Guevara: “No, a communist.” A straw fire, such was our life: rapidly it flared up, rapidly it passed. I’m fleeing, coming from nowhere. (…) Eazy-E drinking coffee with the American president. If I’d scream, would that be an event? Drown it: the cleaner it will rise up from the depths. No! The night, so fast… As if there’s something opened up in that face. Come on, we may not curse life. He shows me his methadone: “If you drink that all at once, you’ll die instantly.” The last one dictates how we should behave to deserve happiness. One shine / above the earth. “I want to go to Bosnia,” I said bluntly. I don’t even know the name of the current mayor. Let’s despise our success! “There is no future; this is the future. Hope is a weakness that we've overcome. We have found happiness!” Sun. Sushi. Volvo. I feel like a bomb about to explode at any moment. Makes a difference for the reconstruction right? The decor moves forward. Daughter of Nereus, you nymphs of the sea, and you Thetis, you should have kept his tired head above the waves! Alas! This sentence has been written wearing a green cap. I receive my orders from the future. A frog jumps into it. Her husband has turned the Intifada, which he follows daily on CCN, into his hobby, “to forget that he doesn’t have his driver’s license yet." Suddenly the sun slides over the crosswalk. Her (his?) foot is playing with the slipper under the table. Is this how I’m writing this book now? I’m not a fellow man. I hate you and I want to hurt you. These are my people. Their screaming doesn’t rise above the constantly wailing sirens which we've learned to ignore. My whole body became warm and suddenly started to tremble. Unfortunate is he who is standing on the threshold of the most beautiful time, but awaits a better one. Arafat’s “removal” is contrary to American interests. Jeep drives into boy. What you can do alone, you should do alone. A food gift from the people of the United States of America. Two seagulls. [...]. (shrink)

The opioid epidemic has claimed the lives of more than 183,000 individuals since 1999 and is now the leading cause of accidental death in the United States. Meanwhile, rates of incarceration have quadrupled in recent decades, and drug use is the leading cause of incarceration. Medication-assisted treatment or MAT is the gold standard for treatment of opioid use disorder. Incarcerated individuals with opioid use disorder treated with methadone or buprenorphine have a lower risk of overdose, lower rates of hepatitis (...) C transmission, and lower rates of re-incarceration. Despite evidence of improved outcomes, many jails and prisons do not offer MAT to individuals with opioid use disorder. This seems partly due to a scientifically unjustified preference for an abstinence-only treatment approach. The absence of MAT in prisons and jails results in poor outcomes for individuals and poses a public health threat to communities. Furthermore, it disproportionately harms poor communities and communities of color. Health care providers in prisons and jails have an ethical obligation to offer MAT to individuals with opioid use disorder to mitigate risk of infectious diseases, opioid overdose and health disparities associated with incarceration. (shrink)

... We will turn our attention to the current state of pain relief technology and the ethical questions surrounding the use of advanced technology, otherwise referred to as "high-tech," pain relief. It is obvious that pain may decrease the quality of life for cancer patients. The availability of long-acting narcotics, such as MS Contin or methadone, affords cancer patients long-duration pain relief at minimal cost. The use of adjuvant medications may also be important. Clinical examples of the effective use (...) of adjuvant medications include the addition of a nonsteroidal, anti-inflammatory agent to help patients cope with bone pain and the use of a serotonin blocking agent to reduce the transmission of pain impulses in the spinal cord. Only a small percentage of patients are good candidates for high-tech delivery systems for narcotic administration. In our pain management clinic, all patients are initially placed on oral medications. When the side effects of oral medications become excessive, or the patient becomes unable to take oral medications, high-tech modalities are considered for use. (shrink)

PurposeThe aim of this study was to investigate and compare impulsiveness, negative emotion, cognitive function, and P300 components among gamma-hydroxybutyrate -addicted patients, heroin-dependent patients, and methadone maintenance treatment subjects.MethodsA total of 48 men including 17 GHB addicts, 16 heroin addicts, 15 MMT subjects, and 15 male mentally healthy controls were recruited. All subjects were evaluated for symptoms of depression, anxiety, impulsiveness, and cognitive function through the Patient Health Questionnaire, the Generalized Anxiety Disorder 7-item, the Barratt Impulsiveness Scale version II, (...) the Beijing version of the Montreal Cognitive Assessment, the behavioral test, and event-related potential P300 detection.Results The mean scores of BIS-II in the GHB addiction group, heroin dependence group, and MMT group were significantly higher than those of the HC group. The total scores of BJ-MOCA in GHB addiction group was the worst among the four groups, followed by heroin addiction, MMT group and HC group. The response time in the GHB addiction group was the longest among the four groups, followed by the heroin addiction, MMT, and HC groups. The amplitude and latency of P300 in GHB addiction subjects were significantly lower and longer than those of the MMT group and the HC group. For the three types of addiction, the P300 amplitudes at Fz, Cz, Pz, T5, and T6 were negatively correlated with the scores of GAD-7, PHQ-9, and BIS-II; the P300 latencies were positively correlated with the response time and negatively correlated with the scores of the BJ-MoCA.ConclusionPeople with an addiction were likely to have increased impulsiveness. The cognitive function of the GHB and heroin-addicted subjects, including the heroin detoxification and the MMT groups, was severely impaired, especially for the GHB-addicted patients. The impairment manifested as abnormalities of BJ-MoCA, response time, and P300 components. (shrink)

Drug overdose has recently surpassed motor vehicle accidents to become the leading cause of unintentional injury death in the United States. The epidemic is largely driven by opioids such as oxycodone, hydrocodone, and methadone, which kill more Americans than heroin and cocaine combined. The demographics of overdose have changed over the past few decades as well: according to the latest data, the average overdose victim is now a non-Hispanic white man aged 45-54.These deaths — over 16,000 per year — (...) are almost entirely preventable. Opioid overdose kills by slowly depressing respiration, a process that can take several hours. It can be quickly and effectively reversed by the timely administration of naloxone, an opioid antagonist that works by displacing opioids from the brain receptors to which they attach, reversing their depressant effect. Naloxone, also known as Narcan, has many benefits and minimal risks. Although it is a prescription drug, it is not a controlled substance and has no abuse potential. (shrink)

In this study, we examine the accounts of 30 white middle- and upper-class female heroin/methadone users. Using a resistance framework, we note that these women recall their initial heroin use in ways that suggest rejection of restrictive gender and class expectations. Using a dynamic view of resistance, we begin to understand how these women attempt to resist the dominant discourse through their heroin use and to reinterpret their experiences with heroin.

This chapter sets the scene for the subsequent philosophical discussions by surveying a number of biological interventions that have been used, or might in the future be used, for the purposes of crime prevention. These interventions are pharmaceutical interventions intended to suppress libido, treat substance abuse or attention deficit-hyperactivity disorder (ADHD), or modulate serotonin activity; nutritional interventions; and electrical and magnetic brain stimulation. Where applicable, we briefly comment on the historical use of these interventions, and in each case we discuss (...) the evidence that they are effective, or might become so with further refinement. The chapter concludes with a comment on some potentially significant differences between the varieties of intervention that we canvass. (shrink)