The Rosenthal Report - February 2017

Rosenthal Reports

The High Cost of Not Knowing

With the launch of its new website, the Rosenthal Center makes available key findings of its initial survey. The Survey of Perceptions of Drug Use in America, now in the website library, studied how drug abuse (the use of illicit drugs and illicit use of prescription drugs) has remained a critically negative aspect of American life for more than half a century despite the efforts of law enforcement, the healthcare community, and the full spectrum of social services. What has kept drug abuse alive and well, we learned, is in large measure how little and how poorly average men, women, and their children understand drugs, drug use, and addiction. 

What do Americans know and, more importantly, what do they believe?  These are the questions that prompted the Perceptions Survey, conducted for us by Schoen Consulting, since what people know and what they believe profoundly influence behavior. They are also the raw material of public opinion, shape public policy, and largely determine how drug abuse is regarded and how drug abusers are served by society.

Two Families in Five Must Deal with Drug Abuse

Focusing sharply on drugs and the family, the survey found two in five Americans have dealt with drug abuse within their families, but barely one in three sought outside help or support. Most striking was the disparity between what parents recall about drug use by their children and what today’s young adults recall doing in their teens. Twenty one percent of parents reported their children had used drugs, while nearly half as many young adults (30 percent) remembered using drugs as adolescents.

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Parents were generally aware that their children smoked cigarettes, less aware of marijuana use, and surprisingly unaware of how many of their children drank alcohol. The greatest disparity, however, was between parental awareness of non-medical use of opioid painkillers and the actual level of teen use. Just 8 percent of parents believed their children had used these life-threatening drugs but 28 percent of young adults said they indeed had done so. 

Most Parents Disregard Marijuana’s Greatest Dangers

Most discouraging was discovering how lightly parents take marijuana use by their teenage children.  There is growing evidence that regular use of marijuana during the adolescent years can have profoundly damaging consequences later in life.  Although two out of three parents agree that teen marijuana is a real concern, barely one in five (22%) claimed to be “very familiar” with the greater vulnerability of teens to marijuana addiction and the threat of lasting brain damage. So, it was not surprising that, when asked which toxic substance—cigarettes, alcohol, or marijuana—they would rather their children indulged in, it was marijuana, at 44 percent, that was chosen by the greatest number of parents.

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In a set of clearly conflicting opinions about addiction: survey participants split almost evenly over whether or not addicts were “powerless before their addiction;” slightly more than half (53 percent) believed relapse was a part of the addiction disorder; more than two out of three (67 percent) called addiction “chronic;” and yet a shade short of three out of four (74 percent) said addiction was curable.

Little of what we learned was surprising.  In the age of the Internet and 24/7-news cycle, there is no shortage of information, facts, factoids, and opinions.  But what the military call “intelligence,” the hard, cold, indisputable facts that commanders count on, is difficult to find among the welter of material on the Internet and in the increasingly partisan press and parochial media.  This reality defines the mission of the Rosenthal Center. It is the search for truth and revelation of error in what Americans believe about issues that influence behavior, public opinion, public policy, and what we do and fail to do to arrest the spread of addiction and care for its victims.

Physicians Deeply Divided over Opioid Prescribing Practices

In the face of the nation’s opioid addiction crisis, there is a growing debate within the medical and substance abuse treatment communities over the prescribing of painkilling drugs. At issue are both federal agency guidelines and state government efforts to control opioid use through prescription monitoring programs and legislation limiting how much, how often and for whom opioid medication should be prescribed.

“There’s a civil war in the pain community,” according to Daniel B. Carr, M.D., president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing,” he says. “The other group looks at the disability, the human suffering, the expense of chronic pain.” 

Dr. Carr makes the case for compassion and the physician’s obligation to alleviate suffering. Reducing the nation’s extraordinary level of prescriptions for opioid painkillers (e.g. Vicodin, Percocet, Oxycontin) is the agenda of Physicians for Responsible Opioid Prescribing, (PROP) who contend that today’s addiction crisis is the result of:

  • The promotion of a high-potency, time release opioid painkiller (OxyContin) in the late 1980s and early 1990s;
  • The notion that addiction due to prescribed opioid pain management is rare;
  • The then guiding principle of pain management, which was “titrate to effect” or keep raising dosage until the medication provides sufficient relief as measured on a pain intensity scale.

Rules for Opioid Use Now: “Go Slow and Low”

What replaced this approach, in addition to state legislated limits, are the guidelines for pain management issued by the Centers for Disease Control and backed by the surgeon general. The CDC guidelines 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 and, not the extended release, long-acting kind.  

The guidelines are voluntary, intended primarily for primary care physicians and aimed specifically at non-cancer chronic pain. But a recent article on STATNews, the health news website of the Boston Globe, reported how emergency room doctors across the country are cutting back on narcotic painkillers for acute pain and prescribing them only as a last resort.   The effort, says Dr. Jay Bhatt, chief medical officer of the American Hospital Association, is “to stem the tide of the opioid epidemic.”  

So far, there is no evidence that this is occurring. Opioid prescribing was in decline well before the guidelines were issued last March, yet overdose deaths continued to rise.  Heroin has replaced more expensive and harder to find prescription painkillers pills for many addicted users, and the Drug Enforcement Administration warned this summer of high-powered fentanyl in counterfeit painkiller pills flooding the black market. A counterfeit fentanyl-laden pill was responsible for the death last year of the singer/record producer, Prince.  

Opioid Restriction Lobby Discounts the Severity of Pain

PROP justifies wholesale reduction of opiate use not only because the use of prescribed narcotics can lead to addiction and a host of other distressing consequences—from depression and anxiety to respiratory impairment and sleep apnea—but also, they contend, because too much attention is given to how severely a patient’s chronic condition hurts. This perception of pain was described most vividly in a 2015 commentary in the New England Journal of Medicine by the organization’s president Dr. Jane C. Ballantyne and Dr. Mark D. Sullivan, titled “Intensity of Chronic Pain—The Wrong Metric?” the commentary asked, “Is a reduction in pain intensity the right goal for the treatment of chronic pain?” Their answer was “No.” They maintained that, “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity.”

PROP’s position on pain is not without support within the pain treatment community. “The American culture has grown intolerant of pain,” psychiatrist Anna Lembke of Stanford University’s medical school told STATNews. Lempke, who practices at the school’s pain clinic and heads Stanford’s Addiction Medicine Dual Diagnosis Clinic, feels we just make too much of a fuss about pain. “Whether it’s surgery or women going into childbirth, there’s an almost alarmist reaction to pain, and it’s contagious and makes people more anxious, which makes the pain worse,” she said.

The Institute of Medicine’s latest estimate is that that roughly 100 million adult Americans suffer incurable pain from disease, injury or nervous system malfunction. They use a broad array of medications and therapies to find relief, and opioids are only one option—and not necessarily the first one. 

“Opioids absolutely harm some patients, but they absolutely help some patients”

“Opioids absolutely harm some patients,” Dr. Daniel P. Alford told the Boston Globe, “but they absolutely help some patients.” An addiction specialist at Boston University’s School of Medicine, Alford directs the school’s Safe and Competent Prescribing Education program. He is no fan of what he called “opioid phobia” or “blanket regulatory changes that treat everybody the same.” Many of the patients he knows, who function well on opioids and can safely use them for years, no longer can get the medication they have been using or get enough of it.

At Stanford, Dr. Sean Mackey, who heads the pain management program, is no happier with blanket regulations. “The thing is we all want black and white,” he told STATNews. “We don’t do well with nuance. And this is an incredibly nuanced issue.”  He described a patient on opioids whose foot was crushed in an accident and had undergone surgery ten times for “the burning, terrible pain” of the injury. “People will say, ‘this guy’s on way too much opioid medication,” Mackey said. “But guess what: He gets up every morning and goes to work and does his job, and he’s been on the same regimen for years and years and tried everything else first.

“There’s almost a McCarthyism on This, Silencing so Many people”

The schism in the pain management field is deeply troubling to authorities like Mackey. He finds physicians being trained at the Stanford pain center increasingly fearful of prescribing opioids. “There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared.”  

Dr. Carr is neither silenced nor scared. The Academy president says only about 10 percent of patients using opioid drugs are at risk of addiction. He finds CDC’s guidelines dictate dosages or limits that ignore the needs of the individual patient, “Many appropriate and compliant patients, already stigmatized and marginalized by virtue of having pain and using opiates to treat it, are finding it impossible to continue therapy from which they derive benefit.” Indeed victims of chronic pain, who came to opiate pain management after every other medical intervention failed, now find themselves, as they will tell you, “being treated like addicts or criminals.”

In his first President’s Message, Dr. Carr focused on the victims of today’s guidelines, regulations, and physician monitoring programs. The patients who are “now denied treatment that has long worked for them,” he called, “collateral damage in the war on opioid abuse.”

Marijuana Update

Weed Market Grows 

Marijuana legalization and the introduction of new pot products are having a broad impact on the marijuana market. Cannabis sales totaled $53.3 billion in 2016 across legal, medical, and illicit markets in North America, according to Arcview Market Research. Most of those sales – 87 percent – were from illegal channels. Still, legal market sales climbed 34 percent over 2015 to $6.9 billion, due to the easing of state regulations prohibiting medical or recreational use. The report forecasts legal cannabis sales growing 26 percent annually to $21.6 billion by 2021, as more states approve legalization. Meanwhile, consumers’ buying habits are changing, and concentrated marijuana products with high levels of THC are now more popular than traditional dried leaf. In Colorado, according to Arcview, concentrate sales quadrupled to $80 million by the third quarter of 2016 compared to $20 million in 2014, when legalized adult-use was launched in the state. 

Doubts on Pot for Anxiety and Depression

For those suffering depression and anxiety, using cannabis for relief may not be an effective long-term solution. Colorado State University researchers found that, while marijuana can initially help relieve symptoms of anxiety and depression, chronic use may prove detrimental, according to a report published in PeerJ. The CSU study examined the relationship between pot users’ habits and neurological activity, including the processing of emotions. “There is a common perception that using cannabis relieves anxiety,” study co-author Jeremy Andrzejewski said, but so far research has yet to fully support this claim. 

More Cases of Marijuana “Mystery Illness”  

Emergency room doctors in Colorado have seen an influx of patients suffering from cannabinoid hyperemesis syndrome, or CHS, a little known disease associated with regular and prolonged marijuana use. A 2015 study published in the journal Academic Emergency Medicine found that ER admissions for CHS at two urban Colorado hospitals nearly doubled between 2009 – the year medical marijuana was legalized – and 2011. CHS symptoms include severe abdominal pain and intense cyclical vomiting, which ER doctors say can be controlled by hot baths and showers – or, of course, by reducing or stopping the use of pot.    

Rise in Pot Use During Pregnancy 

More pregnant women in the U.S. are using marijuana than did a decade ago, JAMA reported. The rate of use rose 62 percent, from 2.37 to 3.85, between 2002 and 2014, among 200,000 women ages 18 to 44 in the data group. The rate was even higher for younger women ages 18 to 25, with 7.47 of them using the drug within the preceding month. Preliminary research on pot use during pregnancy - ostensibly for morning sickness - shows a spectrum of potential risks to the fetus, including anemia and low birth weight that often requires neonatal intensive care.  In addition, maternal pot use is linked to such developmental problems as impaired impulse control and attention loss during school years. Laws legalizing medical marijuana do not list pregnancy-related conditions among allowed uses, but also don’t prohibit use or carry warning labels. “Doctors must be aware of the risks involved and err on the side of caution by not recommending the drug for pregnant patients,” Dr. Nora Volkow, director of the National Institute on Drug Abuse, wrote in a JAMA editorial. 

2nd February 2017
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