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The Rosenthal Report - September 2016

Rosenthal Reports
A Proper Place for Pot

When the Drug Enforcement Administration (D.E.A.) turned down petitions to drop marijuana from the Schedule 1 of the Controlled Substances Act last month, there were cries of anguish and outrage from the pro-pot crowd, plus a plea from The New York Times to “Stop Treating Marijuana Like Heroin.” But this was no hard-hearted rejection of the current reality—widespread decriminalization and quasi-legalization by prescription, plus actual legalization in two states (with upcoming votes in five more come November).  It was simple recognition that, no matter how prevalent the acceptance of toking becomes, pot is still a mind altering substance and, as such, falls under the Controlled Substance Act.

So, legislators clamoring for a category change are stuck with the strictures of the Act’s “eight factor analysis.” It’s not the degree of “actual or potential abuse” that keeps pot in the top category. It’s the lack of any “approved medical use.” That's what's required of drugs in the lower categories.

Although a downgrade of marijuana to a lower category is not in the cards, the D.E.A.—in an even-handed action by the Obama administration—opened wide the doors to marijuana research, allowing universities and even private companies to secure agency approval to grow their own pot for research purposes.  Only the University of Mississippi now enjoys this privilege.

Marijuana’s current clinical credentials, however, are not too impressive. Despite a plethora of anecdotal reports and reputable work on the drug’s ability to alleviate nausea, improve appetite, and ease painful spasms, there is little in the way of hard scientific data to support prescription of smokable marijuana for all the many maladies now being treated with pot in the medical marijuana states. Serious research on components of marijuana, however, is now under way, and the new regulations should accelerate this process.  The Food and Drug Administration has already approved two drugs—Marinol and Casamet that contain synthetic versions of a substance found in marijuana. Both are prescribed for the nausea and vomiting of cancer patients and Marinol is given to aid the appetite of AIDS patients.

It’s true that marijuana is no heroin, but it’s no benign indulgence either.  While most—but far from all—adult users appear to avoid serious consequence, the same is not true of kids.  Adolescents are twice as likely as adults to become addicted to marijuana (and, yes, pot is addictive). More significantly marijuana impairs perception and judgment, shrinks attention span and compromises the ability to learn, all of which impedes the maturation and socialization that should be occurring throughout the adolescent years. 

The most recent and disturbing discoveries about marijuana have found heavy use in adolescence resulting in lasting changes to “working memory,” altering brain structures critical to memory and reasoning, impeding problem solving and the retention of information needed for everyday tasks.

What I find particularly troubling, if predictable, is how casually many parents now regard marijuana use. Our recent survey of public perceptions of drug abuse found that more parents would rather see their children smoking pot than smoking cigarettes.

Today, it is legalization that gets the headlines, but the real issue is society’s increasing acceptance of marijuana use and the burden this places on families. Parents now, more than ever, need be aware of just how dangerous and damaging marijuana can be for their kids and must deal with the threat without the level of support from law, society, and the community that they once enjoyed.

Take the Pledge & Turn the Tide

That’s the message that Vivek H. Murthy, M.D., the U.S. Surgeon General, sent to 2.4 million physicians and other health care professionals at the end of August, urging them to go online to the Turn the Tide website, sign up, and commit themselves to the campaign’s three-point program:

Educate ourselves to treat pain safely and effectively.
Screen our patients for opioid use disorder and provide or connect them with evidence-based treatment.
Talk about and treat addiction as a chronic illness, not a moral failing. 

There’s no doubting the impact of the opioid addiction epidemic that has been growing since the start of the current millennium. Between 1999 and 2014, as prescription of opioid medications (such as Percocet, Vicodin, and OxyContin) quadrupled, more than 165,000 Americans died from opioid-related overdoses.  And today, more and more addicted men and women who can no longer secure the drugs they crave by prescription are turning to the more accessible and less costly option of heroin.

The surgeon general is hardly the first to sound the alarm.  By 2008 more Americans were dying from drug overdose than from motor vehicle accidents. The Center for Disease Control designated the spread of addiction as “epidemic” in 2010 and issued guidelines for a far more restrained approach to the prescription of opioids this past March.  (The surgeon general’s letter includes a pocket card copy of the CDC guidelines). It was also in 2010 that my colleague Andrew Kolodny, M.D. and his Physicians for Responsible Opioid Prescribing organization began advocating for restraint and controls in the use of opioids. 

Although I don’t argue with the need to respond aggressively to the addiction epidemic and to address the over-prescription of potent painkillers, I am concerned about over-responding.  After all, much of the problem we face today came about because of over-responding to the under-treatment of pain.  It was not only aggressive marketing of prescription opioids that led to over-prescription. It was also a newfound concern about patient satisfaction in the 1980s. That’s, when patient pain came to matter, as patients were recognized as “health care consumers,” physicians as “providers,” and the federal government started keeping track of patient satisfaction.  When I turned to the Turn the Tide website I was struck by one of the factoids that crossed the screen in the site’s numerical display. It read: “As many as 1 in 4 receiving long-term opioid therapy (in primary care settings) struggle with opioid addiction.”

What, I wondered, about the other three? What, for that matter, about all the patients with chronic pain whose caregivers will now feel pressure to follow the CDC guidelines that encourage such alternatives to opioids as exercise, cognitive behavioral therapy or the use of aspirin, ibuprofen and other anti-inflammatory medications. (Other sources also recommend acupuncture and meditation). When opioids are to be used, the rule is go slow and low—low dosage, and a strictly limited number of pills—only immediate release pills too, not the extended release, long-acting kind.  Will this reduce the incidence of addiction and overdose?  It certainly should, but I suspect there’ll be a world of hurt that goes untreated as well.

There is a wry twist to one aspect of Surgeon General’s pledge. It’s the requirement of those who sign up to connect patients with opioid use disorders with evidence based treatment. Since the overwhelming majority of new treatment capacity authorized by Congress (but yet to be funded) is specifically for medically assisted treatment (MAT), we can be fairly certain that these patients will have ready access to buprenorphine, suboxone and similar semi-synthetic opioid derivatives.

When the Enemy is Us

Yes, former drug users are stigmatized. That’s true. It is also true that stigma flourishes, in part, because of efforts by the very folks who protest most ardently against it. Whether or not it inhibits addicts from seeking treatment, stigma has profound and negative effects on the lives of men and women in recovery.  A recent survey of public perceptions of addiction and drug abuse conducted by Schoen Consulting for the Rosenthal Center, found that three quarters of Americans find social drinkers trustworthy enough to hire, while barely half consider recovering addicts that trustworthy. When it comes to approving a potential husband or wife for their children, our survey respondents put the totally abstinent at the top of their list, with social drinkers close behind. Barely 30 percent would bless the union of their son or daughter to an addict in recovery.

What the survey also revealed was widespread misunderstanding of addiction. Seventy percent of respondents agreed that addiction was a disease, 67 percent that it was a chronic condition, and slightly more than half that relapse was a built-in aspect of the disorder.  They split almost evenly over whether or not addicts were powerless to resist their addiction (with a slight edge on the pro-powerless side). Nevertheless three out of four maintained that this chronic relapsing condition is curable. 

As for stigma, close to two-thirds of Americans hold it to be a useful social tool, and stigmatization they agree might well reduce the use of marijuana, as it has the use of cigarettes. A key finding about stigma, however, is the belief by better than two thirds of respondents that defining relapse as integral to addiction contributes to stigmatizing people in recovery. There is a lesson in this for those vested most firmly in the “chronic relapsing” disease model. Rather than bowdlerizing the language of addiction (banning the use of “addicts,”  “abuse,” or “abusers”) what is more likely to destigmatize recovery is ceasing to insist that addiction is incurable, and indeed the evidence is mounting that, for most (if not all) addicts, this is not necessarily true.                            

1st September 2016
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