Weighing in on the Medical Marijuana Issue

I have witnessed and thought long and hard on the medical marijuana issue and debate for decades. I was a too young college student, precocious and underage for a college student but more worldly wise than my “Doogie Houser” like age and circumstances would convey. I had lived in nearly half the states in the Union and over a dozen foreign countries and had many experiences than the usual late middle school aged youngster growing up in a well educated professional, college emphasizing family of my time. I had lived in countries that even in the 1960’s were paralyzed by national endemic drug use to such an extent that my father, a mining engineer had trouble finding sober, not stoned underground miners for his projects; those drugs were opiates, pot/hashish and khat. I went to college and medical school in one of the hot spots of the latter hippie years and centers of the drug revolution, Ann Arbor at the University of Michigan. I saw people all around me smoking dope, dropping acid, and experimenting with the early designer drugs, DMT etc. I was curious and observed all this just like I did the radical, anarchist white student power movements of those times, attending SDS and Weathermen meetings, hearing Tom Hayden, Rene Davis, Eric Chester, Abbie Hoffman and other lesser known student radicals of that tumultuous era give speeches at rallies and in small groups, talking about “kidnapping Kissinger,” and other idiotic things. Sitting in on some of the small group meeting-cabals, given that I came from a military family, I could look around the room, and silently count the FBI agents in disguise in attendance, chuckling and thinking to myself ‘how dumb can these people be?’ I became so interested in the student radical movements that enveloped my world in Ann Arbor, I did the scholarly thing, and did a dissertation that compared them to the radical anarchist movements in Russia before the Bolshevist Revolution of 1917 that brought Vladimir Lenin, Trotsky and the Communists to power, and have looked at radicals in those terms ever since.

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Calling OxyContin Out Yet Again

If there was ever a corporate sponsored scourge as great as American Tobacco’s unleashing of tobacco products upon this country over a century ago (from Durham NC) where I trained, or the famous beer monopolies in every town in America in the late 1800’s as documented in Daniel Okrent’s landmark book, The Last Call,  on the history of alcohol, the temperance movement, Prohibition and the rise of the Mafia, as well of all things, the Suffragette Movement for Women to Vote, it has been the last 20 years of marketing of OxyContin.

This date I read a superb

article published in the Pacific Standard, by a brave author, a man in recovery, Mr. Daniel McGraw, on the history of the “Rise and Dominance of OxyContin,” [my phrase] and I cannot let it pass without commenting upon it and referring the reader to it. It is entitled “How Big Pharma Gave America Its Heroin Problem.” It is more than well worth reading. It is jarring and appalling in its history and backed up by multiple references to such unimpeachable sources as the National Institute of Drug Abuse among others. It also diligently references one of the seminal recent public health articles of the rise of opiate abuse in this country, “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction,” published in the Annual Review of Public Health 2015. 36:559–74 [sorry I could not get this reference to make a link as this is a pre-publication edition, but search using the title and you will find it easily enough].

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Heroin We Go Again, Deaths are Up, Up, Up

It seem to the casual observer, and I will include myself in that category on questions much bigger than me often, that in the War on Drugs, it is like the county fair “Whack-a-Mole” game, where you hit on pop up mole head down into its hole and another pops up over and over. With drugs we have still a plethora of illicit more damaging than every agents available, but as soon as we may progress on one drug of abuse’s “front,” another bounces up into increased availability to take its place for a while. And so  it goes with marijuana and meth, interdiction has been seizing more and more in the last few years and now heroin supplies have surged again becoming every  more obtainable again on the streets. One factor sadly is that a few years ago the American military had to make the tactical decision to stop the eradication effort on the poppy plant on the growing high planes of Afghanistan to save that country’s local economies, and to “win the hearts of the people,” the old concept from many previous wars, made most ‘popular’ in the Vietnam Conflict/War. Heroin is showing up again everywhere, the streets, points of interdiction and seizure, and in the ERs across the country.

An October 3, 2014 report “Increases in Heroin Overdose Deaths–28 States, 2010 to 2012,”  from the venerable CDC’s weekly mortality and morbidity report, the MMWR showed the increase in heroin to be quite real with data covering 56% of the country’s population showing in the first line that the prescription drug abuse and overdose epidemic 1999-2010 has been massive, stating: “Nationally, death rates from prescription opioid pain reliever (OPR) overdoses quadrupled during 1999–2010,” but then subtly noting that heroin OD death has increased at a slower rate during that period of time. The report then goes on the document step by statistical step, that heroin use and rate of overdose deaths increased after 2010 dramatically. It showed from data solicited from all states with responses from 28 states for just the two year period from 2010 till 2012, that “The death rate from heroin overdose doubled in the 28 states from 2010 to 2012, increasing from 1.0 to 2.1 per 100,000 population,” effectively doubling in that short of a period of time! Further the report found statistically and accurately that heroin overdose deaths increased nationally in every age demographic, not just the young adult segment of typically the early 20’s to mid thirties, and that the OD death rates increased also in females a trend not always seen. The report goes on the compare in effect time periods of heroin high rates of use with the current period and states telling: ” In a sample of heroin users in a treatment program, 75% of those who began opioid abuse after 2000 reported that their first regular opioid was a prescription drug. In contrast, among those who began use in the 1960s, more than 80% indicated that they initiated their abuse with heroin (8). Persons who initiated heroin use after 2000 have reported that heroin often is more readily accessible, less expensive, and offers a more potent high than prescription opioids.”

There was a national increase in heroin overdose deaths of at least 45% in the years 2009-2012; states had increases in the time period 2010-2012 of from 74% to 300%!!!

So it is clear the heroin scourge is with us again, proving sadly and tragically that history repeats itself,” that addictive waves of old drugs “come around again,”

I fear that each generation must learn its developmental lessons all over again for itself, such as how to study in school, how to get toilet trained, how to share with other kids in the sandbox, dropping out of school means economic serfdom or condemning yourself to the illegal underground economy, tattoos are hellishly painful and expensive to have removed by your friendly expensive dermatologist even with a laser when you realize they are dumb and keep you from getting hired sometimes, that binge drinking really is bad for you and not worth the pseudosocial rank it seems to afford you in your equally stupid peer group who fail their exams just like you did because of it, that prolifigate sex will eventually teach you an unwanted lesson, and working in a low level service job will not pay for all your “Tunes” and the expensive Nikes your mom and  pop used to buy for you in the old days, that your friend and apartment roommate will not pay the rent and steal you blind when you throw him out and then realize you cannot afford the rent by yourself…And that heroin will addict you and can very well kill you like it did Jerry Garcia of the Grateful Dead in 1995, who as bright as he was, was an absolute idiot when it came to heroin and speedballs, dying IN a treatment center and betraying his fan base to boot. [As an aside yesterday I viewed his last interview in ?August 1995 very shortly before his death, and he was high, loose, disorganized, funny but pathetic, an old man who had not learned anything…] At least David Crosby came to his senses reportedly when he needed a liver transplant and realized what he had done to himself, and Robert Downey so far has demonstrated the power and benefits of sustained recovery.

So our public education efforts on heroin will have to ramp up again at all levels, and the War on Heroin specifically will increase once again targeting the cartels and gangs and God knows who else. And hopefully the greedy legislators in this country in order to fulfill their mantra of renewed Voodoo economics so ably and foolishly tried again by Governor Sam Brownback in Kansas, will not seizure upon legalizing and taxing heroin to make up for their moronic self deluding state revenue reducing policies that result in the chaos now repeating itself in Kansas, the land of sucker legislators, disappearing revenues, huge new budget deficits in the cautious Heartland of America (Crazy California yes, but not rock steady sensible Kansas. And if the “good Governor’ destroys the economy there and sends it into bad bond rating territory because now deficit borrowing, self induced tax raises (oh my what the Republican Governors’ caucus think of him now?), no more best buddy status for him…then he can count himself as stimulating the underground economy and drug i.e., meth manufacture and sales, increasing sales and distribution of heroin, if the marginal folks have no where else to turn to work and we will replication of what has happened in white Appalachia repeats itself in the Heartland, which stereotypically and simplistically thinking, is almost “unthinkable.”

One of the most recent news reports, from NBC News, June 17, 2105 entitled “Drug Overdoses Spur Rise in Accidental Deaths,”  On the general level even, its statistics are startling: “drug overdose deaths have doubled in the last 14 years”; “drug overdoses killed 44,000 people in 2013” [more can car accidents!]; “more than half of these deaths, 51.8%” were related to our now well known prescription drug abuse  epidemic, “with more than 16,000 deaths related to prescription painkillers…” West Virginia, one of the chronically poorest and of recent years with the downturn in the coal and timber industries, has topped the list consistently for accidental drug overdoses in this country. Suicides, are still the second leading cause of injury deaths, accounting for 41,000 annually, while motor vehicle accidental related deaths are third with 33,000 but noticeably continue to decrease over time. I can remember when I was in my youth that MVAs killed on average 55,000 annually consistently UNTIL the great organization MADD, Mothers Against Drunk Driving, identified the main cause as drunk drivers, especially recidivist drunk drivers, and started the national pressure campaign and hastened the long needed legal and enforcement crackdown on drunk drivers, with longer prison sentences even without death involved, for repeat offenders. Well into this report comes the subtle point that heroin now again is making up a large part of accidental drug overdoses, and that again “Heroin use [is] on the upswing again.”

The Narcotic Prescription Epidemic–Part III

One additional monumental regulatory national policy mistake made in this country in the early 1990’s accelerated the easier access to prescribed narcotics. This came from the organization, the JCAHO, that certifies hospitals to stay open and operate through every three year or so on site reviews, “inspections,” made the ‘adequate treatment of pain,’ a national priority and requirement. This is when the “smiley face” pain quantification chart came out. Suddenly if you are old enough to recall those days, your medical practice’s nurse or physician began asking you at EVERY contact if you had any physical pain and if so to rate. The “Joint Commission” as the above mentioned hospital accreditation body, made it clear the so-called “undertreatment” of pain had to be corrected. Physicians reacted defensively and began to drastically change their opioid prescribing practices and the veritable floodgates opened. Again many many physicians who lived through that time felt that opioid prescribed was at least somewhat more rational but after the machinations of the Joint Commission (JCAHO or “Jayco”) in the have felt this was one of the most misguided bureaucratic maneuvers in modern American medical history. The informal consensus is that this helped wrongly educate patients to expect narcotics as more regular interventions and helped to form the ‘perfect storm’ along with all the other opioid facilitating developments discussed in this series.

The emerging subspecialty of pain management specialists arose to try to fill the need along with physical medicine specialists, both of which specialists there are woefully too few. Consider that just a few years ago the pain management fellowship programs graduated less than 300 such physicians a year in this country. Their rise to recognition coincided and in essence was a result of new technology of invasive spinal column endoscopy in which we could fairly safely insert these wondrous flexible minicathter tubes with little tiny camera lenses on their ends, much as had been done in gastroenterology used to visualize the insides of stomachs to see ulcers, colonic polyps and cancers, etc. This was a giant boost to the diagnostic and treatment potentials and approaches of GI medicine. It started to be applied a few decades ago in investigative learning efforts all over the country in big medical centers to spinal cord pathology. At first of course it was applied to the simpler, VISIBLE conditions such as fractures of the pedicles (like Cam Newton recently had in his truck accident), to bulging disks that were physically accessible to the threading of these “photographic catheters.” Thee had had decades of safer and safer experience in “invasive” or “interventional cardiology” in which these miniature cameras on a catheter had displayed for medical science the insides and blockages in coronary (heart) arteries, permitting “clot busters” therapy in strokes, placement of coronary artery stents or aid in determining that coronary artery bypass graft surgery was the proper next therapeutic step.

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