Monthly Archives: February 2012

Local Crisis

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My local community is currently undergoing a massive addiction crisis.
A large pain management clinic was recently shut down because the physician overseeing it lost his license. It was suspended last week on an emergency basis because an investigation revealed that many of the patients there were being over-treated, undoubtedly because of an addiction they had developed to the narcotic pain medications. The physician himself is under investigation for dispensing excessive quantities of controlled substances out of his office, and he was felt by the investigating body to be a danger to the community. With his center closed,there are four or five hundred poorly-managed chronic pain patients in this community who have suddenly lost access to their source of drugs. Some of these people surely have chronic pain issues that need to be addressed, while many probably have primary addiction problems, but either way, all are physically dependent on massive doses of methadone, Percocets, and Oxycontins. Without these medications, or any managing therapy to replace them, these four or five hundred people will be horribly sick, in great pain, and possibly driven to unacceptable behavior (theft, etc.) in order to find new sources of the drug they feel they need.

Physicians in the area are not excited about taking on new patients with poorly maintained or spotty medical records and poorly managed, poorly documented pain issues, especially since all these patients need immediate refills of their massive amounts of narcotics. The addiction doctors in the area, the few of them that there are, are not really qualified to evaluate these patients for the true status of their pain condition, and so have no real way to separate the primary pain patients from the primarily addicted patients. Most addiction-based physicians are at or near their 100 patient Suboxone limit in any case, and do not routinely prescribe other narcotics.

We also can’t forget about the ERs, where physicians are also wondering how they will handle this massive crisis. ER doctors will ultimately become the last resort for many of these patients who cannot get their prescriptions filled in a more controlled manner. The ER will be flooded with people with a multitude of pain complaints and withdrawal symptoms, trying desperately to get their narcotics filled. I cannot begin to imagine how much time and money will be wasted doing unnecessary testing for complaints of abdominal pain, back pain, and headaches — not to mention the delay in attending to others who will be competing for ER time with many of these patients.
This is not the fault of these patients — it is primarily the fault of the physician who so badly mismanaged their care, and his staff who were clearly not trained to recognize or deal with the addiction problems that so often attend pain management. (I very much doubt that he knew that he might want to be on the lookout for addiction problems.) Due to his recklessness and carelessness, the medical systems of this community are very shortly going to be overloaded with patients who desperately need to be managed and are extremely difficult to correctly diagnose.
A harm reduction model would suggest that somebody just needs to open up an office and provide all these people with the narcotics they want to keep them from flooding and incapacitating the rest of the system. That is essentially the role that the suspended pain management center was playing, and while it was logistically effective, no plan like that will ever be sustainable. Not to mention, of course,  that it is a gross violation of the goals and ethics of medicine.
I don’t know how this situation will resolve. I will do my best to take on excess patients when I can be sure that their problems are primarily addiction-related, and I’m going to make an effort to educate my fellow medical practitioners about this issue. If nothing else, I hope this can serve as a warning of what can happen even when we do the right thing by closing down a poorly-run pain management center. Maybe soon we will be able to move forward to find a more sustainable solution.

Casualties in the War on Drugs

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Demi Moore was reported as having had “convulsions” after smoking an undetermined substance (probably “Spice”) late last week. Spice and K2 are both generic names used to refer to a wide range of synthetic cannabinoids, designer drugs intended to mimic the effect of marijuana on the brain. Many varieties of spice boast that they are made of “legal herbs”, which is always almost untrue — and even when the substances involved are legal, they are not intended for smoking, and tend to have severe adverse effects. A physician quoted in the linked article above states that spice usage can often lead to “prolonged seizure and seizure-like activity”, and that the lack of quality control makes purchasing these compounds a potentially lethal form of gambling with the amounts of chemicals involved.

Yet one of the most stunning things about this story is how little attention it’s getting. If Demi Moore had collapsed from a new flu strain, the public health resources of the entire country would be focused on dealing with the issue in a major way; people would be lined up to buy their hand sanitizer and get their flu shot. Because her collapse was addiction-related, and we see addiction as being “not a public health problem” or just a natural price of stardom, it is essentially ignored  — despite the fact that the same condition is epidemic in almost every community in the nation. Where are the people lined up to buy lock boxes for their prescription pills? Where is the public education campaign asking people to do this? Where are the resources of the CDC aggressively pursuing an answer? Where are the parents boycotting those stores that sell stuff like this to our kids? Where is leadership from the addiction treatment community to get any of this done? There is a bill currently in Congress to outlaw Spice, K2, and other compounds, but the designer drug industry will only continue to flourish, pushing more and more dangerous compounds that have been carefully engineered to evade the strictest legal rules, regardless of what effects that engineering has on the health of those who use it. Without widespread public education and public health resources available to everyone, substance-seeking and addictive behavior will just move on to more and more lethal experiments.

What we are experiencing now in the “War on Drugs” bears many similarities to what the country experienced during Prohibition. Outlawing alcohol did little to decrease drinking; instead, people moved on to bootleg methanol, which caused seizures, blindness, and death. What we are seeing in the proliferation of spice compounds is the same pushback against ineffective and harmful legislation. Marijuana is safer, less addictive, and less likely to cause violence than alcohol; it has been grouped in with other, much more dangerous drugs like cocaine, and been outlawed along with them. For those who claim it is a “gateway drug”, I would like to note that the marijuana substitutes being produced now are, technically, legal – those who want to smoke marijuana are very interested in staying within the bounds of the law. No one bothers with “legal” synthetics of heroin or cocaine, because those drugs cause a potent addiction that makes the drug a priority over all legal or moral concerns. Marijuana does not do the same.

If we believe that all mind-altering substances should be forbidden and illegal, then it makes no sense at all to have alcohol freely available and encouraged throughout our society. If we agree that some mind-altering substances can be taken recreationally, when well-controlled and in safe circumstances, then legalizing marijuana becomes a sound health and economic choice.

I do not personally endorse anyone taking mind-altering substances, or breaking the law. But I think it’s foolish that we seem willing to sacrifice countless people to harmful synthetic drugs rather than legalize a substance that wouldn’t even be the most damaging or addictive substance a 21-year-old could purchase anywhere in the country. Demi Moore is a highly visible personality, but for every celebrity whose drug use makes the news, there are millions of others who are being harmed out of the public eye. That’s an epidemic, and it’s time we worked towards stopping it.

Fear and Education

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It’s clear that more adults, including physicians, need further education about the causes and consequences of addiction, but it may be even more important to educate our children before they make decisions that can end up tearing apart their entire lives. Drug education in schools is mandatory and ongoing, but it’s clearly inadequate, for much the same reasons that health and sex education standards are inadequate.

The approach most schools take to drug education is a unilateral, completely straightforward “Just say no!” campaign. They struggle to paint all use of any substance, even one sip of alcohol or one cigarette, as a horrifying and potentially lethal act of self-destruction. While it’s true that beginning to drink or smoke at a young age can have horrible long-term effects on health, painting the situation with such a broad brush just sets education up for failure, because it creates an illusion that can’t be maintained. Kids — especially pre-teens and teenagers, who are the target of most drug education — are immature, but they aren’t stupid. They will see adults having a drink, or smoking, in their everyday lives. They may see their friends trying a beer or a cigarette, and when that adult or that friend doesn’t immediately crash a car, vomit, or suffer some other horrible comeuppance, the kid who has been through that style of drug education will conclude that they have been lied to. They will also realize, possibly just by going home in the afternoons, that not all people who are addicted to substances are bad, dirty people. By refusing to deal with any of the nuance or complication of addiction, much of drug education sets itself up as a lie — a lie that will be easily disproven. And the worst thing is that, once a kid has realized that official education sources may exaggerate or lie, that kid may never trust an official source of education again. Any future attempts to correct the bad drug education will fall on deaf ears.

If we are going to have any hope of reaching kids, we must show them the basic respect they deserve, and tell them the truth. They have to understand that a large number of people want to get high, or feel an altered state of consciousness, and that there are safe ways to do it — drinking in moderation with friends (without driving afterwards), for example. Kids need to know that some things, like marijuana, are almost infinitely safer than others — like the “legal” marijuana analogues that use things like toxic bath salts and tar, and can cause seizures.

The drug education standards prevalent today are not strictly “education”, in my opinion. Education is a process designed to give people true and useful information with which they can make decisions and keep themselves safe. The statistics and medical consequences discussed in drug education are certainly true, but they are not presented in the context of giving useful information; they are presented in the context of propaganda and scare tactics. While I understand the deep concern and fear for the safety of children that is behind this style of teaching, I also feel certain that it does not work, nor will it ever work, the way it was intended. Giving students information you swear is true, which will be contradicted by their real-world experience, will only set them up for lifetime distrust of education. It may also lead to them throwing out the legitimate warnings along with the trumped-up fear tactics, and put them in a worse position than before.

Drug education, like health and sex education and all other important topics, must be discussed with children in a way that is serious and straightforward, but it must also take into account the complexities that that child will face as they attempt to make their way in a nuanced adult world. “Just say no” has some valuable aspects to it as a campaign, and I would certainly rather that no one under legal age used any substances at all, but a lack of proper education will only lead to more addicted people living more self-destructive lives.