A Toxic Weed

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It was 1978 and I was a third year medical student when my friend was slowly dying of metastatic breast cancer.  Her deteriorating cervical spine, riddled with tumor, was stabilized by a metal halo drilled into her skull and attached to a scaffolding-like contraption resting on her shoulders.  Vomiting while immobilized in a halo became a form of medieval torture.  During her third round of chemotherapy, her nausea was so unrelenting that none of the conventional medications available at the time would give her relief.  She was in and out of the hospital multiple times for rehydration with intravenous fluids, but her desire was to be home with her husband and children for the days left to her on this earth.

Her family doctor, at his wit’s end, finally recommended she try marijuana for her nausea.  My friend was willing to try anything at that point, so one of her college age children located a using friend, bought some bud and brought it home.

Smoking, because of its relatively rapid effects, didn’t do much other than make her feel “out of it” so that she was less aware of her family,  and she hated that the entire house reeked of weed, especially as she still had two teenage children still at home.  Her nausea prevented her from eating marijuana mixed into food.

Desperate times called for desperate measures.  I simmered the marijuana in a small amount of water to soften it, then combined it with melted butter.  That mixture was chilled until it was solid and I molded multiple bullet size suppositories, which were kept in the freezer until needed for rectal administration.  Although we never could warm up the suppositories to a temperature that was comfortable for her without them melting into unusable marijuana mush, she found that she could get relief from the nausea within twenty minutes of inserting the frozen marijuana butter rectally.  It worked, without her feeling as stoned as the smoked marijuana.

My actions, though compassionate, were also illegal and if my medical school had found out I was acting as an apothecary, preparing an illicit drug for use for a non-FDA approved indication, I could have lost my student standing and future profession.   I don’t regret that I did what I could to help my friend when she needed it. Subsequent studies have confirmed the efficacy of marijuana, in various forms, for nausea from HIV and chemo, muscle spasm from multiple sclerosis and quadra- and paraplegia, some types of chronic pain, and glaucoma, yet it has never been seen by the medical community a first line drug for any of those conditions.  During my professional career, I have prescribed Marinol, the FDA approved pill form of cannabis in a few cases where it was warranted because of the refractory nature of the patient’s symptoms, for indications that are supported by controlled clinical studies.    This made sense and like most medications, it worked for some, not for all with varying degrees of side effects.

And now, nearly 40 years later, marijuana is readily available everywhere in every imaginable form — smokeable, vapeable, edible, drinkable — in states like ours with legalized recreational use, the shops are on nearly every corner as ubiquitous as the coffee stands.  Our society is split into the users and the abstainers and those who can’t stand the stuff as they know what it has done to their lives.

If you believe the growing number of vocal marijuana promoters, marketers and profiteers, cannabis can ease almost any condition under the sun and make life liveable again.  It is a fine example of not so modern snake oil, as it has been around for thousands of years, except now we have state legislative bodies and through initiatives, the voters, putting their stamp of approval on it for recreational purposes, and as a medical therapy without the regulations or scrutiny we require of any other substance.  For a mere $5 gram, relief is as close as the corner store thanks to the collective wisdom of our citizenry.

As a physician working daily with adolescents and young adults in a college health center, there is no question retail marijuana is now the cannabis equivalent to the  growing market for artisan beers and local microbreweries.  There are distinct brands and strengths to attract users of all types and needs.  Yet one thing hasn’t changed with legalization: marijuana is not for everyone,  particularly not for young developing brains, particularly not for the mentally ill nor the pregnant.

Patients who have enormous antipathy for the pharmaceutical industry or for government agencies responsible for studies of drug safety and effectiveness seem to lose their skepticism when confronting the for-profit motivation of marijuana growers, brokers and storefront sellers. After all, isn’t this a free market system now happily unconstrained by the need for proof for safety or efficacy?  The most attractive product at the best price to the consumer wins.  We are now revisiting the devastation to our societal health and well being thrust upon us decades ago by the tobacco industry.  And we thought we were winning that battle of making cigarettes socially unacceptable and unwelcome.

Cannabis use has become as normalized as tobacco or alcohol to the point of some parents smoking or ingesting THC with their adolescent and adult children as part of holiday gatherings, special family events (Super – Bowl, anyone?) and evenings-at-home  “wind-down” routines.  It is a challenge for a clinician to question the judgment of a parent who sees no problem in their 18 year old using marijuana to help sleep or reduce their stress level or ease the pain of their knee injury, especially since that is exactly what the parent is doing themselves.

Although I see marijuana as the “least” of the problem recreational drugs, not as physically devastating nor fatal in overdose as nicotine, alcohol, benzodiazepines, methamphetamines, or opiates, I’ve still seen it ruin lives and minds. In its twenty first century ultra high concentrated version,  far more powerful than the weed of the sixties and seventies, it just makes people so much less alive and engaged with the world.   They are anesthetized to all the opportunities and challenges of life.  You can see it in their eyes and hear it in their voices.  In a young person who uses regularly, which a significant percentage choose to do in their fervent belief in its touted “safety”, it can mean more than temporary anesthesia to the unpleasantness of every day hassles.  They never really experience life in its full emotional range from joy to sadness, learning the sensitivity of becoming vulnerable, the lessons of experiencing discomfort and coping, and the healing balm of a resilient spirit.  Instead, it is all about avoidance and getting high.

Marijuana often exhibits paradoxical effects and is unpredictable even in experienced users.  It is a common factor in the history of adolescents and young adults with persistent depressive and anxiety disorders, paranoia, recurring dissociative episodes and psychosis.  Beyond the mental health impacts,  there is frequent morning anxiety, irritability, nausea and abdominal discomfort in some regular users, sometimes to the point of vomiting, which prompts the user ingest even more marijuana to “help improve appetite”.  This is part of the symptom spectrum of cannabinoid hyperemesis syndrome as GI workups, antiemetics and other meds fail to help until marijuana use is discontinued completely.

So, as in most things, buyer beware.  Don’t be snowed by the marketing and promotion designed to sell the most product to the most people.  The profit motive is still alive and well in this country, no matter the cost to the individual.

Even when — especially when– selling a potentially toxic weed.  After all, what’s the matter with a little paranoia among friends?

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The Real Driver

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I heard an old man speak once,
someone who had been sober for fifty years,
a very prominent doctor.
He said that he’d finally figured out a few years ago
that his profound sense of control,
in the world and over his life,
is another addiction and a total illusion.
He said that when he sees little kids sitting in the back seat of cars,
in those car seats that have steering wheels,
with grim expressions of concentration on their faces,
clearly convinced that their efforts are causing the car
to do whatever it is doing,
he thinks of himself
and his relationship with God:
God who drives along silently,
gently amused,
in the real driver’s seat.

~Anne Lamott from Operating Instructions

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Taking a Share of the Blame

This week brought news of yet another high profile death from an uncertain cause in a star with addiction history.   Media accounts included reference to the “27 club” –a lengthy list of famous artists who have perished by their own hand, often unintentionally, at the age of twenty seven.

The reality is that too many fatal overdoses responsible for the deaths of the famous and not-so-famous are from medications that were dispensed by a pharmacist in response to a physician’s legal prescription.  The Who’s Who list of “dead in their prime” celebrities in the headlines is long, many because prescription medications were determined to be the cause of death.   In our county, the medical examiner will routinely notify the physician whose prescribed medication is found at the scene of a drug related death.  It can be a sobering call to receive–as it should be.  It should cause the physician to think twice before they sign their next controlled substance prescription.

It is time for those of us who vowed to “first do no harm”  to share in the responsibility for these deaths.  Without our implicit cooperation –our prescription pads, our signatures and our willingness to please patients, especially the rich and famous, by offering up a hand full of pills for every expressed concern and complaint, there would not be so many empty pill bottles sitting next to corpses, and not so many corpses.  We prescribers, including those professionals with prescriptive authority other than physicians,  need to be accountable for the clinical decisions that place combinations of potentially lethal medications in their patients’ hands and mouths.

In the twenty years I have managed medical detox for addicted patients, I have learned how frequently physicians overprescribe for complaints of anxiety, stress, sadness, insomnia as well as the everyday pain of living in the modern world.   Too many pills per prescription, too many unquestioned refills, too many times written without regard to what another physician may have prescribed a week before, too oblivious to what recreational self medication/beverage may be routinely consumed.  Addicts know well who the easy touches are in the physician community, know exactly what they need to say and do to get the drugs they seek.  Addicts also know to rotate emergency room and pharmacy visits and how to  “borrow” from a family member’s medication supply, as well as where to buy “on the street” when all else fails.

As a prescriber, I’ve learned there are ways to responsibly prescribe chronic opiates and benzodiazepines under a patient/prescriber medication contract.  I prescribe small amounts of certain medications that I know can be a problem and never automatically allow refills.   There are never “after hours” or weekend refills.  When I am concerned about potential abuse, I say “no more”  and mean it, when it is clear the medication is no longer justified for the symptoms.  If a taper is necessary, it is done on a daily dispensing basis through a pharmacy.   I insist on random urine drug tests if I’m not sure if the patient may be self-medicating or possibly diverting the drugs I prescribe.   I check the community pharmacy database if I’m not certain I’m the only prescriber for the patient and I check the hospital medical record system for recent drug-seeking emergency room visits.  With the help of modern collaborative electronic medical record systems,  shared information about a patient’s prescriptions can prevent the tragedy of sharing the blame for a patient’s unnecessary overdose.

No prescriber wants to get the call that the medications they prescribed in good faith, in a spirit of healing and compassion, caused an overdose death.   We can do better, and before the next celebrity’s name hits the headlines, we must do better.

Slow Down and Reduce Speed

‘Twas the week before finals and all through the dorm, few students were sleeping, since Adderall is the norm…

What is the state of academic performance and achievement in the age of adult ADHD?   Recent media publications feature “neuro-enhancement” sought by college students and stressed professionals through the use of prescribed and non-prescribed medications, particularly stimulants, to guarantee focus, concentration and alertness when needed for studying and work demands.    It’s as easy as bargaining with a roommate for one of their prescribed stimulant pills for $5.  Some campus studies suggest as many as 40% of college students self medicate with non-prescribed stimulants during their college years–in certain settings like fraternities and sororities, it can be much higher.  Graduate students certainly partake as well, and that includes medical students.

Approximately 15% of students entering university now have been diagnosed (some very cursorily) with Attention Deficit Disorder and the majority of those students are medicated for their illness.   This is a significant increase from twenty years ago when I first started working in a university health center.  At that time a diagnosis of adult ADHD was extremely controversial and the incidence of ADHD diagnosis for entering freshmen was less than 1%.   In 1991 I attended a college health conference where a Harvard Medical School professor flat out called treating adults with stimulants for ADHD a “clear case of malpractice.”    Since then, the diagnosis has gone mainstream in the DSM IV and the criteria are likely to be even more liberalized in the upcoming DSM V revision.  Some estimates suggest one in seven adults meet criteria for ADHD.  That is a lot of inattention and impulsivity out there.  That results in a lot of stimulant out there.

Amphetamines are hardly the new drug on the block.  In the 50’s and 60’s they were routinely prescribed for “tired housewives” and became the go-to diet pills to suppress appetite and aid weight loss.  My paternal grandmother was one of those tired overweight housewives.  She kept a large jar on her kitchen table full of multi-colored capsules that she would pop prior to meals.  The appealing looking pills appeared very much like a candy jar to her grandchildren.  I remember being warned many times that “those are Grandma’s diet pills and you kids can’t take them because they would stunt your growth”.   They didn’t seem to do much for Grandma’s weight problem, but they certainly contributed to her moodiness, anxiety and chronic insomnia, a problem that resulted in prescriptions of sedatives to counteract the stimulant effects.   She wasn’t alone in her doctor-prescribed addiction to then uncontrolled substances–thousands of patients were treated with similar drugs that worked at cross-purposes,  handed over by well meaning physicians who truly believed they were doing their best to prevent suffering in their patients.

Does that sound anything like the well meaning physicians of today who prescribe stimulants based on “evidence based standards” and “best clinical practices”?   Currently the diagnosis of ADHD is difficult to standardize and easy to fake for an adult desperate for that extra edge in a competitive world.  No imaging studies have become the gold standard and would bankrupt an already overstretched health care system if they did.  Indeed, there are many patients who have legitimate need for the benefit that stimulants offer them–I’ve seen the difference it makes in their chaotic lives.  But I know there is no way 40% of college students have legitimate need for stimulants–they are self medicating solely for the extra boost they get from speed.  This is no different than the pill popping dieters from the 60’s.  And I don’t accept 15% of adults warrant prescribed controlled substances for the rest of their lives.   When I see these young adults struggling with insomnia, poor appetite, hypertension, and rapid pulse all thanks to the side effects of their stimulants, it is time to look at other solutions for their learning issues besides amphetamines.  Sadly the response from too many doctors is to add on the antianxiety drug, the sleeper, the medical marijuana, the anti-hypertensive.   Once again these are well meaning physicians who truly believe they are doing their best to prevent suffering in their patients.  It seems we haven’t come far in sixty years.  Same overprescribed dependency producing drugs, different diagnostic indications.

It’s time to really take a look at what we physicians are doing in the name of “best clinical practices.”  The physical and psychological toll of life long stimulant dependency is clearly understood in street amphetamine addicted patients, what few years they have left because of their snorting and shooting. But we know very little about the ADHD treated individual on routine prescribed amphetamines for thirty, forty, or fifty years or more.   In another generation, the health care providers of the future may well shake their heads looking back at our collective ignorance, just as we now shake our heads over the dexedrine- and valium-pushing doctors of fifty years ago.

First, as always, do no harm.  It is time to slow down and reduce speed.

Steaming in the Pile

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(yes, another story about manure–sorry!  Given I spend an hour or more a day dealing with it, it tends to absorb my creative energy!)

A mid-March cold snap swept down from northern Canada last week, freezing daffodils in mid-bloom, withering berry plant and orchard branch buds, and causing general mayhem in the Pacific northwest.  After a few weeks of rain and temperate weather up to the high 50’s, 17 degrees felt cruel indeed.

Our barn is fairly draft proof, but in northeasters like this, the water buckets ice up and the manure sits in cold hard piles, like so many round rocks.  It is a great temptation to put off the stall cleaning when the weather is this bitter cold and push the poop to the walls for later pick up when it is warmer.  After all, it doesn’t smell when it is frozen rock hard, and certainly loses its “squish” factor, so the horses seem to not mind too much.  So when I went out this weekend to start the digging out process, there were several days of accumulation to contend with.

As I wheeled the loads out to the manure pile, and dug into the pile to tidy it up, the steam poured out into the frigid air–there was nothing left frozen there.  It was hot and getting hotter–its destruction assured through the composting of so much organic matter.  No wonder the cats find a nice sunny spot to stretch out next to this smoldering mountain of poop.  It is as comfy as a tropical vacation spot.

How often have I similarly piled my metaphorical “poop” in piles to deal with another time?  Frozen it seems innocuous, inoffensive, not worthy of my attention, not enough to bother with.  It is so tempting to pass on cleaning up my messes, by shoving mistakes and errors to one side or “under the carpet” and trying to ignore the growing mounds in my own nest.  Admitting one’s sins and proceeding to clean up after one’s self  is not fashionable in this day and age of not wanting to be judged or to pass judgment.  All types of behavior, even some of the most self-destructive, are tolerated as freedom of expression, and referring to anything as sin is considered impossibly old fashioned.  Our pastor is doing a study series on Christian “respectable sins”, like ungodliness, discontent, pride, etc.   I have a ton of them that accumulate daily that I want to simply pile up and ignore.

Like frozen poop shoved aside and not dealt with, sin eventually warms up.  It starts to stink, and generally becomes obnoxious and overwhelming.  Once it gets big enough, it becomes its own steaming inferno, burning and destroying everything else within. The only safe place for it is to move it far away from where we dwell everyday.

I remember a young mother of three children who died three years ago as the heat of her drug addiction overcame efforts to clean up her life, though she was a Christian believer.  Many family, friends, church family and health care professionals handed her the tools to help scoop up the mess her addiction had left behind, but she chose to shove it into frozen piles around her, unwilling to admit how it was mounding up higher and higher, to the point of blocking any eventual escape.  It consumed her before she could dig free with her rescuers’ help.  It crushed her and her family is still trying to recover.

Such tragedy convinces me we must face our own messes without turning away in our shame.  We must dig ourselves out everyday from our mistakes, ask forgiveness for the harm we cause, and gratefully accept the tools handed to us that make possible the impossible job of getting clean.   We cannot do it by ourselves.  Our wheelbarrow is too small, our shovels too inadequate, our muscles too weak.

Blessed are the barn cleaners, for working together, they will find hope beyond the steaming pile.