Sex, Drugs, and Public Health

October 29, 2022


Filed under: Uncategorized — cbmosher @ 7:30 am

When I was finally old enuf to count, I counted years. “Wow,” I thought, “I may see the 1900’s become the 2000’s. We’ll learn so much more by then.” But then another thought hit me. “That’s 50 years. A half century. Heck, I’ll be dead by then.”

            And so it is that the words “wisdom” and “children” are seldom used together.

            Over time, experience brings knowledge that can sometimes grow into wisdom. We add to that knowledge by sharing experiences. Schools do this.      And so it is that, in Med School, the professors discussed Pain. It’s subjective, they said. Some writhe and whimper from slivers or stubbed toes. Others shrug at cuts or when they hit a fingernail with a hammer. It’s difficult to know which drugs to use to relieve “pain.”

            How, I wondered, can a powder in a capsule make pain go away? Ice decreased the soreness of bruises. Aspirin evaporated my headaches. But I never had enuf pain to test other analgesics – pain relieving drugs. Then one day (as the story tellers say) I had a serious injury in South America. I sliced open my hand, severing the main nerve that allows fingers to feel and operates the muscles in the hand.

            As I lay in the hospital bed, my bandaged hand suspended above my head and the rest of me and my glitching brainstem writhing in unrelenting pain, they injected something into the IV line. Then they moved me onto a gurney. I recall the lights in the hallway ceiling flowing past like marching soldiers. I became aware of a strange feeling: I was relaxed for the first time in three days.

            I looked at my bandaged hand. The pain was still there. All of it. My hand was in a vice, being slowly crushed. My fingers were being ripped away from each other like drumsticks from a cooked turkey. A blowtorch was blasting against my palm. Everything was the same since leaving South America.

            “That’s a lot of pain,” I thought. “I bet it must hurt.”

            But it didn’t.

            Not gone, like some headache after aspirin. I still felt the pain, but it was no longer – – – mine.

            I leaned over to vomit. Small price to pay for such relief.

            Learned a lot from that experience about the connection between Pharmacology (the study of how various drugs – including herbal extracts – effect the body) and Neurology (the study of how the brain and nerves function). More than I could ever learn from a textbook.

            Other experiences added to the knowledge. Judges in Mariposa asked me to evaluate people arrested for offenses related to the use of illegal drugs. The drugs that these folks were using were often different. Some used opioids (known medically as “narcotics” from the Greek meaning “to make numb”). Some used meth or “speed” (stimulants, not narcotics). Others used benzodiazepines (sedatives, drugs that  decrease awareness and response to stimulation). Not surprisingly, each person described both the effect of their drugs and the reason for using it very differently.

            And over the years, many patients I’ve treated have been dealing with a complicated relationship between the pain of their problems in life (some, but not all, medical problems) and their use of drugs, both legal and illegal.

            And so it is that I’ve learned three major things thru all these experiences:

  • – just because a drug is legal does not mean it’s free of hazards; conversely, just because a drug is illegal does not mean it is hazardous;
  • – each drug – legal or not – has a very different effect on the human body;
  • – the way some drugs are used can cause harm.

When we say (or hear) “drugs,” many folks have a powerful emotional reaction. This may be due to some tragic personal experience with a loved one or maybe is just integrated into a belief system. We think of the psycho-active chemicals, often, those purchased on the street. We don’t think of medications. But in addition to the drugs called Antibiotics, Blood Pressure modulators, Hormones etc. there is a long list of psycho-active drugs available to physicians. 

            All these can do positive things – otherwise, no one would use them. But they also have potential to harm if used incorrectly. And a couple of them are notorious.

  • – Blood-borne Diseases. Hepatitis, AIDS, and bacterial sepsis can result from injecting with dirty needles. These are devastating diseases and the reason that some jurisdictions have needle exchange programs for those who use IV injection of drugs.
  • – Social Destruction. Loss of family, loss of job, and the cost to society of medical and psychological care can be extreme.
  • – Crime. Because several of the psycho-active drugs are illegal, criminals get involved. Violence has ripped thru more than one country because of the money. Reminds us of the Prohibition era (1920 to 1933). Thousands are imprisoned , often for mere possession.
  • – Death by Overdose. Those who obtain their opioids from pharmacies rarely overdose. They know exactly how many milligrams of morphine or hydrocodone they are getting, and the drug is “clean” of contaminants. Thus folks like healthcare workers or patients who are addicted can function for years without detection. But those who use street opioids never know the exact dosage, and often the heroin (a drug that is prescribed in Britain) is contaminated with fentanyl (a very powerful synthetic opioid) or with benzodiazepines. So  you can see how easy it would be to overdose accidentally.

Drugs other than opioids that can kill by overdose include alcohol (a sad consequence of “hazing” at some colleges) and Tylenol. CDC reports six alcohol overdose deaths per day and 500 Tylenol / acetaminophen deaths a year.

If a person wants to avoid the harm, why don’t they just quit?

In 1875, the medical syndrome of addiction was described, associated

 with morphine. Addiction has these characteristics:

  • – an overwhelming urge to use the drug, in spite of the risk of harm
  • – the phenomenon of Tolerance, whereby the patient uses increasing doses to get the same effect. Often, people use doses that would be lethal to others.
  • – Physical Dependance where the body incorporates the drug into its normal chemical balance.
  • – Withdrawal symptoms when the drug is stopped – a very painful and sometimes fatal process.

Several legal drugs can cause addiction, which increases the likelihood of harm. Alcohol is notorious for a withdrawal syndrome that can be lethal. Even without the withdrawals, alcohol kills 140,000 a year in the U.S. (CDC). Tobacco is extremely hard to quit because of addiction to nicotine. This drug kills 480,000 a year (CDC). Caffeine, when daily users (like me) stop for a few days often punishes us with headaches that are a withdrawal symptom.

But it is the opioids (morphine, heroin, codeine, fentanyl) – the classical drugs of addiction – that has grown into a horrendous epidemic. Even if the initial doses were prescribed by a physician, patients, once addicted, have a much bigger problem than pain (physical or psychological). Snagged by the claws of addiction, they have fallen into a catastrophic quagmire of harm or accidental death. Just how extreme this can be is exemplified by James Fisher, a man who, like me, rode a gurney to an O R. But for very different surgery.

James had become addicted to opioids a decade earlier and tried to escape its clutches multiple times. He had been yanked back from the brink of death from contaminated drugs several times and had tried every addiction therapy available. He always relapsed. Desperate times, desperate measures.

And so it was that a neuro-surgeon implanted electrodes into a very specific part of James’ brain and attached these to a pacemaker-like electronic stimulator implanted under his skin. This artificial modification of his brain has allowed him, so far, to remain off opioids. This case shows how desperate people can be to escape the clutches of opioid addiction.

Here in the U.S., the response to this major Public Health epidemic was to make certain drugs illegal. This approach grew into the War on Drugs. “War” requires a military, and that’s where tens of BILLIONS of your tax dollars have gone in the attempt to cut down the supply of drugs. More money was poured into the law-enforcement / judicial system, chasing after those who possessed the illegal drugs. A small, inadequate amount went to treatment of addiction.

How well has this “War” worked out since 1971?

In 1986 and again in the 1990’s, the government contracted with the RAND corporation to look at that question. RAND reported that the “armed forces had little to no effect” on drug supply except to increase prices. They recommended moving billions from law enforcement to treatment which they assessed as “23 times more effective.” In 2001 the National Research Council reported that the “War” had shown no evidence of success. The journals “Foreign Policy” and “Journal of Crime and Justice” deemed the War on Drugs “a failure.”

On the human side, there are an estimated 21 million people addicted in the U.S. per the Association of American Medical Colleges. The Federal Bureau of Prisons reported that 45.3% of all criminal charges were drug-related. And thru all this, the opioid death rate has kept climbing. It hit an all-time high in 2021 at 108,000 deaths, up 15% from 2020 and 53% from 2019. (CDC).

These disappointing results should not be a surprise. We’ve done this before. Prohibition made alcohol illegal between 1920 and 1933 and the result was a dramatic rise in crime (remember Al Capone?), the creation of illegal speakeasies (an estimated 100,000 in New York alone), increased harm from bad moonshine (blindness) and an increase in the price of alcohol. If, as a kid, I was wrong about what we would learn over 50 years, this failure to learn over the course of a century speaks poorly of human wisdom.

Isn’t it about time we looked at this Public Health epidemic from a different angle?  Shouldn’t we invest the money wasted on the “War on Drugs” into Treatment of the victims of these drugs (legal and illegal) and Prevention measures against future addiction? 

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