Monday, September 8, 2014

Unintended Consequences

Years ago, there was a comedian named Sam Kinison. That name still likely resonates with some readers, positively or negatively. With the passage of many years, others may simply not remember who he was. Certainly he offended many people with his rants on religion, women and other groups. In this land of free speech, there are often statements that offend someone.

During Kinison's appearance on Saturday Night Live (SNL) in 1986, the NBC censors gave him the "electronic hook," blocking his "audio and pictures" for about 13 seconds. One edit involved one of his perspectives on drugs. He noted that there was much in the media pleading with people to stop smoking crack. That was a form of cocaine back then, it is something we have not heard much about lately as the modern trend has turned to methamphetimine and other substances. Back then President Reagan's wife, Nancy, produced some public service announcements on drug use, urging people to "just say no" to drugs, and the airwaves were crowded with other pleas to avoid crack. 

In this comedy routine, after noting the many media pleas to avoid crack, Kinison said "they've taken the pot, there is no more pot, you can't get any more pot." Then in the screaming voice that was his trademark, he said "if you give us back the pot, we'll forget about the crack." Lorne Michaels, the producer of SNL disagreed with censoring this and said of the drug comment "I thought his comment was a very smart comment." The commentary was clear, Kinison's contention was that some population was going to use drugs, and that crack use was the result of inaccessibility of pot. There was discussion back then about pot being a "gateway" drug, one whose use would lead the user to instead use other more serious illicit drugs. 

That is all ancient history of course. Kinison died at 38 back in 1992. But the commentary on drugs remains interesting. Is it possible that there is some population of people out there who are simply inclined to drug use? Whether for physical or emotional discomfort or distress, do some people simply have to turn to something? We see people we admire or enjoy like Philip Seymour Hoffman and Heath Ledger who pass from our world due to their struggles with chemicals. That brings attention to drug death, but perhaps not the magnitude of it.

In August, Dr. Gupta reported on "unintended consequences," and the message is troubling. He notes that in the 1960s heroin was popular, and that users were "usually young men" who started using this around 16 years old and "most likely from low-income neighborhoods." 

According to a Journal of the American Medical Association article cited by Gupta, heroin use in the United States has changed in the last fifty years. So, "today's heroin addict" begins using in the early twenties, and is "likely to live in the affluent suburbs," demonstrating a demographic shift. But more importantly, the article concludes that today's addict was "likely unwittingly led to heroin through painkillers prescribed by his or her doctor." In other words, there is the suggestion that prescription pain pills are a "gateway drug" for heroin. 

Heroin may be an only child, but it has many cousins. Among them are Oxycontin, Vicodin, Morphine, Oxycodone (Percocet), and Fentanyl. There can be arguments about how closely they are related, Fentanyl for example is a synthetic opiod rather than being derived from the natural poppy plant that yields most opiods. So, call Fentanyl a "cousin" by marriage if you prefer, but a cousin nonetheless. 

According to Gupta, all of these chemicals produce an increase in "pain tolerance and a sense of euphoria." That is "intense excitement and happiness." Everyone likes to be happy (except perhaps Oscar on Sesame Street who thrives on being grouchy). Unfortunately, one of the critical characteristics of these opiod chemicals is that the human body develops "tolerance" for them. That is the user needs increasing amounts over time to achieve the same result as the body becomes accustomed to the chemicals

Gupta says it is "precisely because there are so many similarities that pain pill addicts frequently turn to heroin when pills are no longer available to them." Why are the pills no longer available to them? Because doctor's ability and willingness to prescribe the pills is being constrained by the attention focused on use of Opiods. Why are governments constraining that ability? Because people are dying from pain pill overdose

Because people are dying from pain pills, we strive to better control access to them. Pill mills were shut down, regulations for prescribing were tightened, some chemicals were changed to a more restrictive "schedule" by the Food and Drug Administration, states implemented prescription drug monitoring programs to help doctors identify persons getting multiple scripts from various doctors. The result is clear improvement in decreasing Opiod use. The unintended consequence though seems to have been that they instead use heroin from the streets. I suspect that people are dying from that too. I know it killed Philip Hoffman (who can forget his manic character in Twister?) and Heath Ledger (the Joker). 

Gupta says we have been "railing about the flagrant use of pain pills" for years in the United States. He notes that at least since the Clinton administration the U.S. has been consuming about 80% of the pain pills in the world. So through legislation and regulation we constrained Opiod pill use, made them more difficult to abuse (crushing, etc.) and the overdose deaths from Opiod pain pills began to subside. But, he notes, that "heroin use nearly doubled."

Who is using this stuff? Gupta cites a study in Charlotte, North Carolina which sought to understand heroin use. They found that people seeking help in that community were "cops, lawyers, nurses and ministers who came from some of the best neighborhoods in the area." The problem is not so easily constrained or defined as to the "who," the "where," and perhaps the "why."

Why do people turn to drugs? Well, if I could crack that nut I would not be sitting here writing about workers' compensation any longer. Perhaps the reason this is such a difficult question is because there is no single answer. What seems clear to me, however, is that there must be some way to treat what ails people. Whether it is Oxycontin or heroin, there is a reason someone is putting the chemical in their body. Constraining access to the chemical has proven successful in one regard, but seems to just drive people to a different chemical. If asked, would today's heroin users tell us in the spirit of Sam Kinison "if you give us back the Opiod pills, we'll forget about the heroin?"

It seems that restricting access to some chemical is not solving the problem for people. It seems that those people still have the problem and simply look for some other chemical to fill their need. There are bath salts, methamphetamines, alcohol and more. I shudder to think of the many people over the years who testified to various efforts at self-medication with easily accessible alcohol. As Gupta says, "medication and drugs aren't the problem; it's the intrinsic behavior of human beings. We do not need to treat the drugs we are taking; we need to treat the drug addiction we are suffering."  

He concludes that "good doctors don't focus on the symptoms of a disease; they want to treat the disease itself." He suggests that we attack America's "awful drug habit" and that this would be the most productive approach to decreasing the cost, human and financial, that it is having on us as a society. With the inexorable ties between workers' compensation and injuries and pain, would any marketplace benefit more from such an approach than employers and employees? 

It is hard to believe that this is a problem that is beyond us as  a society or an industry. There is so much effort out there to attack the insidious diseases like cancer, ALS, diabetes, and more. Attacking and conquering these are priorities of various groups all struggling for limited financial resources and a limited population of great scientific minds. But is there some expertise, some resources, to focus on these chemical issues? Can America find a way to decrease heroin death without simply driving those people to the "next" tragic chemical?

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