02/27/19 Richard Andrews

Dr. Richard Andrews is a Houston family doctor who is co-chair of the National Task Force on Hepatitis B. He has a particular interest in the overlap between drug use, drug policy and hepatitis. + Matt Simon of Marijuana Policy Project regarding progress on drug laws in New England.

Cultural Baggage Radio Show
Tuesday, February 26, 2019
Richard Andrews
Marijuana Policy Project
Download: Audio icon FDBCB022719.mp3



FEBRUARY 27, 2019


DEAN BECKER: Hello, my friends, welcome to this edition of Cultural Baggage. I am Dean Becker, the Reverend Most High. This past Sunday I went to church, or rather to The Oasis to hear my doctor, Doctor Richard Andrews, give a talk about addiction.

RICHARD ANDREWS, MD: One of the definitions of addiction is that it's a chronic relapsing brain disease with compulsive drug seeking and use despite harmful consequences.

Now that's a key part of the definition, and typically that is in fact part of the definition, and so that kind of raises the interesting philosophical question: if you have compulsive drug use without harm, is that still an addiction?

And I'm not saying I have the answer to that, I've just -- it's something that I'm trying to figure out also.

Now, if you, sometimes it's highly contextual, though, you know, whether something is harmful or not is highly contextual. Whether you even are compulsively using it or not is highly contextual, and this has been shown extensively in the scientific literature, in fact.

But if you're rich versus poor, are you more likely or less likely to have harmful consequences? Well, again, it depends on the circumstances, you know, but, I would say that in general the poor are perhaps more likely to have harmful consequences.

And, in diabetes, is compulsive insulin injecting a disease? You know, it's an interesting question, and, so now here is, and I apologize for the slide being a little bit too busy and the letters are a little bit too small, but I'll review it.

So, and you see in parentheses there, or perhaps you can see it, the older terms for these phrases, in other words, loss of control, there are three different categories, loss of control, physiology, the effects on the body, in other words, and consequences. Those are the three areas in which you may have, you know, you can describe certain things about the person who has come to you for assistance with this.

They are using more drug than they intended, they're unable to cut down. Giving up certain activities that they used to enjoy, craving.

On the physiology side, experiencing tolerance. Now tolerance, unlike the tolerance here at Houston Oasis, in this case tolerance refers to the need to increase your dose of the substance in order to keep experiencing what you were experiencing before.

This is a natural phenomenon with some drugs, and with some people. Even with opioids, it does not occur universally. Sometimes it occurs and sometimes it doesn't. I've, you know, one of the most common reasons people go to doctors is for pain of one kind or another, and there are various different ways to approach pain.

I like to start with what are called non-pharmacologic approaches, which is to say, are you getting enough sleep? Do you need to get some more exercise? Issues like that.

And, but, you know, occasionally, the most effective medication to use is an opioid medication, and when used appropriately and monitored, they tend to be extremely safe, and I've had a number of patients go for years at a time on the same exact dose of an opioid and never change the dose, and they do fine, and it's still helping with their pain.

So, unlike what you might hear, it is not the case that everybody has tolerance with opioids and with other medications. That simply isn't the case.

Now, you do sometimes see that, especially in the case of euphoria, which is of course the most popular side effect.

And then you have withdrawal, in which you have the opposite effects on your body of the drug itself, when you're withdrawing from the drug, you know, instead of feeling calm and having euphoria, you'll have the opposite of euphoria, which is called dysphoria, or in other words feeling bad. Instead of constipation with the drug, you'll have diarrhea. Instead of feeling calm, you'll feel agitated. So that's withdrawal symptoms.

And then on the side of consequences, you may have unfulfilled obligations, interpersonal problems, or find yourself in dangerous situations or having medical problems.

The current definition, then, of substance use disorder is that you have two or more of the things listed, and you feel distressed or you have impairment. And all of those elements are important as part of the diagnosis.

So, why does addiction happen? Well, as you might expect, this is a complicated story that is still not all that well understood. But one of the ones that I wanted to focus on, because I think it's quite relevant and it's fascinating, is adverse childhood experiences, sometimes abbreviated, or the acronym is ACE.

PTSD is sort of, it can happen to an adult or a child, and it would tie in with the, at least for the childhood part of it, tie in with the ACEs or even just a lack of positive experiences, especially in your formative years.

And there was a fascinating study done a number of years ago by people from the CDC together with the Kaiser Group out in California, where they collected data on a huge number of their patients, and they looked at certain things. You can take the study, oh by the way, anybody who would like to have a copy of the slides you can email me at sciencelover@gmail.com, and I'll send you a copy of the presentation.

But if you had childhood trauma, neglect, or abuse, an incarcerated parent, there's a whole variety of different things that constitute Adverse Childhood Experiences, and if you have a certain number of these, and certain kinds of experiences, then that correlates quite well with certain problems, health problems, that people develop, including a risk of addiction or substance use disorder.

A lower income all by itself, you know, can predict a higher ACE score. A higher ACE score predicts earlier drug use and more likelihood of having a substance use disorder, and some studies indicate that a half to two thirds of illicit drug use is explained by a, again, that would be problematic illicit drug use, not necessarily non-problematic.

I'm fascinated by the idea of evidence based policy. Now, there's a nice Wikipedia article on that. Increasingly in medicine, and this did not use to be the case, increasingly in the medical field, if you don't present evidence for your position, your position is automatically deemed weaker.

Now, sometimes good evidence doesn't exist for certain things. If good evidence doesn't exist, then sometimes you do have to fall back on other things, like expert opinion, but it would be nice, increasingly, if we would have evidence based policy.

For roughly a hundred years now, we've had prohibition against drugs, you know, and so, and yet, drug use is not going down, problematic drug use is not going down, to put it mildly. Overdose deaths are rising, and so, despite a hundred years or more of prohibition against drugs, the evidence suggests that it isn't working.

Even proponents of prohibition admit that it isn't working, but they feel the solution is even more prohibition. So, I suggest that rather than having an emotional attachment to one view or another, we look at the evidence. Just like we do in the medical field, or at least the way we should.

And should policemen, should cops be the ones who are dictating health and social policy? Again, I don't have a position one way or the other. We need to look at the evidence, and if the evidence suggests that that really was the best way to go, that putting drug users in jail for simple drug use, if that really was good, then I would be in favor of it.

When I spoke to the Portuguese police about this when I was over there, because I tried to find people who disagreed with the policy, and I, so I ended up talking to, I was able to arrange an interview with the top narcotics interdiction person in the country, and he said, look, when this decriminalization law in Portugal first passed, in 2001, I was opposed to it. A lot of my police colleagues were opposed to it.

But at this point, most of us support it. And he said, look, as a cop, I have to enforce whatever the legislature says the law is. I'm not the one who decides what the law is, that's what the legislature does.

And he said, but I'm also a citizen, and as a citizen, as a member of the community, as a neighbor, I support the law, because I have seen the benefits. And the cops, in other words, are frequently, they frequently discover that they really aren't enjoying being the, you know, the drug police.

You know, that, in other words, and I'm not talking about drug dealing, I'm talking about drug using here, but, you know, they're really not well equipped to handle addiction and overdose and stuff like that. And so frequently, police appreciate no longer being in that realm.

In Portugal, once you're deemed, if you're picked up with drugs in Portugal, and in some other places, once they determine, and they have criteria for this, once they determine that you're a user, not a dealer, then you're automatically shifted over to the health and social sector. Automatically, just automatically.

There's no decision made, all you have to do is decide user or not. If they're a user, they're automatically no longer a police issue. Drug crops are always far more profitable than any other crop, and so when you're dealing with a number of poor farmers, and they have a choice between feeding their family or not, then they're frequently going to choose the very profitable drug crop.

I remember when I went to a tobacco museum at one of the tobacco companies in Virginia, when I lived there, and I was fascinated to see a comment there that in the Virginia colonies, a few hundred years ago, you know, growing tobacco, because it was so profitable, was so popular among the farmers that the colonies started to starve to death, because no farmers were growing food.

And so the Virginia governor had to pass, they had to pass a law saying that the farmers had to grow at least five percent of their territory for food crops. They had to set aside at least five percent for food crops.

And, then, you know, in the middle of the 1800s, of course, you had the opium wars, which are fascinating on so many different levels, but, and that was England growing opium in India in order to sell it to China, and then China saying, well, we don't think that's such a good idea for our population to have all this huge amount of opium coming in, and so the Chinese tried to restrict it, and the British said, no no no, you can't restrict it.

And so England went to war with China to force them to continue to import their Indian opium, you see. And that's where -- that's why Hong Kong was in British hands for all this time, that was part of the loot from winning the opium wars. That's why it was British.

But what's interesting, too, if you go back even further than that, the reason England felt like they had to grow opium in India and send it up to China was because England got addicted to another substance, which was tea, right? The British love tea, as you know, to this day, and that's mildly addictive, and so the balance of payments with China was terrible, you know.

So China was, I mean England was buying all this tea from China, and so they decided to get another drug, and so the whole thing is interesting to me.

So, and then a little bit more, I mean, if you look at the stock market, you'll see all this, you know, breathless discussion of the best stocks to buy and stuff like that, including for the anti-overdose drug naloxone. There are a few different brands, which we'll talk about here.

Drug treatment is a huge industry, and then you have private prisons, of course, you know, one in five Americans are incarcerated because of drug use, and there's been a huge increase in private prisons and private inmates just in the last 20 years.

Very briefly here, I know I'm getting off track, is the first documented hypodermic syringe used was the guy who was the architect of Saint Paul's Cathedral in London, who apparently did a little bit of everything, and in the 1600s, he injected dogs with opium using an animal bladder and goosefeather quills, and I'm not sure if you went to this guy as your doctor, if you had to pay more for a clean bladder or, you know, or not, I'm not sure.

And then shortly after that, a German scientist tried injecting various things into humans, and that didn't go very well, and so, and since I grew up in Spain, I have to mention that the modern two-piece needle syringe combination was invented by a Spaniard.

I strongly recommend, if you're interested in this topic, that you look at the Rice University drug charts. There's a drug policy institute right here in Houston at Rice University, and that has some of the best data, I mean, it's data that is collected by the federal government, where the federal government every year collects survey data on about 120,000 Americans of all different ages, to find out how many drugs are being used and what's the pattern of drug use.

It's absolutely fascinating. I mean, you can go to the federal government website, but it's not as user friendly, and so that's why they are, they make them more user friendly here.

And so it turns out that the evidence is quite clear. This is some of the largest databases in the world for this. Turns out that the vast majority of drug use is in fact casual, occasional, non-problematic drug use.

How many people are addicted to heroin in this country? And there certainly is an increasing problem with all kinds of opioids, with unsafe use of opioids, but in terms of the actual percentage, and now this was up until 2016, was 0.3 percent of the young adult population, you know, one of the -- that's one of the key ages for addiction, is in your 20s, because the brain is still developing and what not.

And by comparison, Portugal before they decriminalized was up to around 1 percent of the population using heroin, or having used heroin, which is considered a huge percentage.

This is a picture of the opium poppy flower itself. There's actually a purely ornamental version of the flower [sic: even poppies grown in household gardens in the US are opium poppies], and opioids versus opiates, what's the difference? Well, opioids includes, is the broader term that includes both natural and synthetic products.

We have our own opioids, of course, every person here is producing opioids on a regular basis. If you twist your ankle, and then after a while you find the pain subsiding, that's your own opioids that are attaching to the parts of the brain that govern pain perception, and that's why the external opioids have an effect on our brain, is because our brain is already set up to experience pain reduction and to a certain extent euphoria.

The opiates in the plant itself, the opium poppy plant, include opium, morphine, and codeine, and as we've discussed, bagels and muffins. When you eat a poppy seed bagel, that really is from the poppy seed, from the poppy plant, and yet it does contain morphine. Okeh? That's why I asked earlier.

So sixty percent of you have had morphine in your bloodstream from eating a poppy seed bagel or poppy seed muffin, but don't worry, the amounts are tiny. Yes, it can cause a positive result on a drug test. Okeh, that's why you have to be a little bit careful about that.

And, semi-synthetic opioids include heroin and oxycodone. That's where you take the morphine molecule itself, from the poppy, and then you modify and create a different product. Heroin by the way was first created by Bayer corporation.

Fully synthetic products are methadone, fentanyl, and carfentanyl. Fentanyl and carfentanyl, because they're so incredibly potent, are causing a lot of the overdose deaths these days.

And, for medical opioids, are they safe or are they deadly? Well, a little bit of both. It's kind of like insulin. It's actually quite similar to insulin, in the sense that, if you're opioid naive, meaning you've never had opioids, external opioids, then a high dose or even a moderate dose can be quite deadly, because one of the effects of these drugs is that it reduces your respiratory drive, and then people stop breathing, and that's where the overdose deaths typically come from.

But if it's increased slowly, this is remarkable because there are very few medicines for which this is true. I remember once a few years ago I had a cancer patient come see me. Now, I wasn't a cancer doctor, I was going to help her with other issues. She was already seeing a cancer doctor, and she had cancer all over her body, as is very common.

She had a lot of pain. And, she was already on fentanyl, because her oncologist, her cancer doctor, had prescribed it, and a month earlier, the cancer doctor had said, you need to increase your dose of fentanyl.

Now, fentanyl, when it's increased slowly, there's a safe way to increase fentanyl dosage, and it's quite safe. But she was afraid, here she was with cancer all over her body, and miserable, and she was afraid to increase the dose because I might get addicted.

And so I increased her dose, I convinced her that it was okeh, she wasn't going to suffer any harmful consequences, and she needed to increase her dose. And so we did that. So, but I decided before, I had used fentanyl once or twice before, in my patients, in other words, and I decided to go back to the books, not that anybody uses books anymore, but I decided to go back to the references and reviewed safe use of fentanyl in terms of increasing the dose appropriately.

And I was reminded right there in the description of how to use fentanyl safely that there is no known upper dose limit. And this is true for opioids in general. In other words, when it's increased slowly, it's not clear, there probably is an upper dose limit, but because, when it's increased slowly and you're under medical supervision, it's a very, very safe class of drugs.

Obviously, if you're buying it on the street, as Dean Becker often says in his radio show, you don't know what's in that bag. If you're buying it on the street and it's not regulated, then you have no idea what's in the bag, and it may well contain fentanyl or carfentanyl, and that's where the deaths come from, because when people don't know what they're taking.

DEAN BECKER: Doctor Andrews went on for quite some time. We'll use some of it for 420s next week.

It's time to play Name That Drug By Its Side Effects! Agitation, paranoia, hallucinations, face chomping, lip eating, heart devouring, brain slurping, ecstasy, suicidality, zombieism. Time's up! The answer, according to law enforcement, from some crazy ass chemist somewhere: mephedrone, otherwise known as bath salts.

MATT SIMON: Yeah, my name's Matt Simon. I live in Manchester, New Hampshire, and I work for the Marijuana Policy Project, trying to make cannabis legal for adult use in New England.

DEAN BECKER: Now, and that's right, you're not just focused in one state, you kind of have a few, you're adjacent to a few states there and you're trying to maneuver things along in several states. Right?

MATT SIMON: That's right. I'm registered to lobby in five states this year, and I keep up with them the best I can. Really, the action so far has been really hot in New Hampshire, where I've lived for twelve years, so, so far that's consumed a lot of my time.

Committee I've been lobbying, the House Criminal Justice and Public Safety Committee, for 12 years, for the first time just recommended passage of a bill that would legalize cannabis for adult use. It was a 10 to 9 vote, but it was quite history making, and it's been a very difficult committee, so, that goes to the House floor on Wednesday, and it looks like it's going to pass by a good margin, and proceed.

So, we've got a lot stacked up against us in New Hampshire. Our governor is totally opposed to legalization. But, so far so good for this bill. It passed its first committee and goes to the House floor this week.

DEAN BECKER: Well, and I want to bring up the fact of the matter is, this is a result of not just work you've done this year, or last year, or, it's over the years. This is a cumulative effect, that you got, finally got 10 to 9, because those people in that committee are probably the hardcore proponents, or opponents, am I right?

MATT SIMON: It's been a very difficult committee for a long time. We've been fighting in that committee, trying to educate, for a long time, and as we've realized that some of them can't be educated, you know, some of them have been replaced over time.

So, it's an issue that's come up in this committee year after year, and through the efforts of, you know, a lot of people over a long period of time, people calling and mailing and, you know, helping turn the tide against prohibition.

We've won enough of them over to be able to get it out, with a positive recommendation, so ...

DEAN BECKER: And if I'm hearing you right, you have a governor who might be the blocker, who, and we have a similar situation in many states, Texas in particular, our governor and lieutenant governor are, you know, nineteenth century, you know, marijuana doctors, if you follow me.

I mean, they think they know everything, but, this is an example, though, that there is potential for progress, that your governor can just embrace the idea that it's good for the state. Right?

MATT SIMON: Well, our governor's not embracing that idea. It's incredibly frustrating, the governors of Rhode Island, of Connecticut, of New York, of New Jersey, of Illinois, are all asking their state legislatures to pass legalization bills, and Chris Sununu's going the other direction. He's actually invited Kevin Sabet and Project SAM to come to New Hampshire and fight us tooth and nail.

Kevin's going to be here later this week, actually. So, our governor's declared war on us, and the only thing we can do is try to override his veto in the state legislature. So fortunately we can do that, if we can get two-thirds of the House and two-thirds of the Senate, we don't need the governor's support. If he wants to be stuck in 1985, that's his business.

So, that's pretty much where we are.

DEAN BECKER: Well, folks, once again we're speaking with Mister Matt Simon. He's with the Marijuana Policy Project up there in New England. Matt, you say you, I guess, in the smaller states, you can work with three or four or five of them within a given year. Right?

MATT SIMON: Yeah. Yeah, I spend a lot of time in Vermont, over the years, and, you know, they passed the legalization of just limited cultivation and possession last January, and the Vermont Senate, this year, is going to pass a bill, this week, the House will -- sorry, the New Hampshire House will pass legalization on Wednesday, and then probably on Thursday, the Vermont Senate will pass a bill that would create a regulated market.

So, those two have been pretty busy, and then Connecticut, I think we're going to see get real busy in the coming weeks and months. You know, the legislature, the mood's really on to do this, and the new governor is very supportive, but, we haven't seen a lot of action just yet, but it's coming.

DEAN BECKER: And, this is, you know, I hear great news coming out of New York. I know that's, I guess, not your bailiwick, but the point there is that the governor and the mayor and all kinds of important folks are kind of standing tall for marijuana.

It's, I didn't know how to say this, that we can have this tide shift to impress or compel elected leaders like governors and mayors to stand forth, and others can just be so recalcitrant, and back pedaling. It's really puzzling at times. Your thought there, please.

MATT SIMON: Oh, it's certainly puzzling, and it can be incredibly frustrating, but, you know, we, we're not powerless in this, and especially as the polls continue to go our way, we have more and more leverage.

So, if we can't educate a governor or a legislator, we probably can replace that person, and, you know, it's, as long as people are patient and, you know, we're going to have rocks thrown at us, we're going to have lies told about our issue, about us sometimes, but we're right, and if we continue to present accurate arguments and data about how we're right, we will win hearts and minds over time.

And the people we can't convince, we might be able to replace. And that's how it's played out, one place after another. So, I think someday it will be obvious. Someday we'll have ended this crazy prohibition of cannabis and we'll look back and wonder why it took so long.

But, it would have taken a hell of a lot longer if it hadn't been for all the hundreds of thousands of people, hundreds, thousands, I don't know how many, but people who have written, emailed, called their legislators, people who've published letters and op-eds, people that host radio shows, people that do what they can to get the message out.

So, the tide is turning. The boulder has topped the mountain and is now starting to roll down the other side, but we've still got our work cut out for us, and particularly in state legislatures, where so many of the members are in their 70s and 80s, and just really need to be educated on this issue, in a way that isn't stuck in the 1980s.

DEAN BECKER: Oh, you're so right, and I like that thought, that the boulder has made it to the top and it's just starting to go over the edge, but it's going to pick up steam, and some of these politicians better get out of the way. That's for sure.

Well, once again, friends, we've been speaking with Mister Matt Simon, Marijuana Policy Project. Closing thought, website, Matt?


DEAN BECKER: Just enough time to urge you to please visit our website, DrugTruth.net, and because of prohibition you don't know what's in that bag. Please be careful.