Sunday, February 3, 2019

Legal Marijuana--Is this a good idea?

My dad sent me an article from a little magazine, Imprimus, a publication of Hillsdale College, a private liberal-arts college in Michigan. I've linked its Wikipedia entry here, but I'll summarize two points here: first, that it's a true liberal arts college, with a curriculum based on the so-called "Great Books" of Western civilization (Ref 1), and second it has "worked to establish ties to the conservative political establishment" (Politico, cited in Ref 2). This latter fact alone doesn't negate arguments Hillsdale publishes, but it provides context.

The writer is a journalist, formerly of the New York Times, and more recently an author of spy and corporate thrillers. The article is from a speech he gave at Hillsdale this year.

In it he shares how he shares what he learned from his wife, a psychiatrist who formerly worked with severe mental illness among incarcerated inmates at a hospital for the criminally insane in New York. In a discussion, she off-handedly notes that all of the inmates smoke marijuana, and the conclusion to be inferred was that marijuana use led to their insanity. 

The author--a libertarian who admits that he was generally pro-legalization of drugs--investigated and came to the conclusion that marijuana use causes violence, and a lot of it, and he implies that the "elite media" (whatever that is) conspires to keep this fact out of the news, and further, that legalization moves us toward a more violent society. It's a pretty nicely written piece.

Except that like a lot of opinion pieces about cannabis, it cherry-picks data and draws unsupported conclusions from available research. So what's really the case?

Marijuana and Schizophrenia

As early as 1977 a scientific review by Ernest Abel published in the APA's Psychological Bulletin found that while the majority of people using cannabis are not prone to violence, a few susceptible individuals, and subject to certain situations of set and setting (Ref 3), marijuana use may result in violence. More recently a number of studies have found a correlation between marijuana use and schizophrenia, a condition in which people's brains falter, leading to psychosis. Psychosis includes hearing voices, hallucinations, and disturbances of thought that can include paranoia, altered perception of reality, and catatonia. It's a pretty serious psychiatric illness, and in some it does lead to violence, either reactive violence (acting out when feeling threatened) or proactive violence (homicide, suicide).

More recently there have been a number of studies that confirm an association but not a causation between marijuana use and schizophrenia. That is, yes, it does seem people with this illness use marijuana more, but does that cause the problem, or is it merely part of a multi-factor stage upon which this problem is built? Some researchers admit that those with schizophrenia may be using marijuana to self-medicate. Others note that the complex factors that can precipitate schizophrenia are simply also associated with marijuana availability and use. An example would be a poor person from a violent neighborhood where drugs are plentiful: Did the plentiful marijuana cause the disease, or was it caused by the surrounding violence and resulting fear, or is it a combination of several factors, including a local lack of mental health services?

A more recent article in Scandinavian Journal of Public Health found that for every 10% increase in cannabis use, they can project a 0.4% increase in violence. That's not the disease schizophrenia, but hey, we're probably all on the same page and agree that more violence in society is undesirable. On this argument, maintaining marijuana's status as illegal makes sense. 

But What Is It Really?

Is this all the just the interaction of a chemical--or chemicals--in marijuana causing a direct and predictable violence reaction in all humans? 

I'll begin by saying the author of the Imprimus article, Alex Berenson, is not equipped by background or education to decode scientific studies. That doesn't mean he can't read them and begin to draw some conclusions, but to be fair he should be more sensitive to his own level of training in this before drawing what end up being pretty dire conclusions. His wife, a physician, should know better, but as a clinician myself who has dealt with many people using drugs and also having mental illness, I'll admit that--in the trenches--it's easy to start seeing the whole world in one color.

Next, I'll note that almost all of the sound research out there on this freely admits that there's a lot we don't know. One example pertinent to this topic is a 2018 study in Molecular Psychiatry that demonstrated a link between variants in the serotonin 2B receptor gene and risk for psychotic reactions to THC, the psychoactive chemical in marijuana that gets people high.

I teach a class on drugs and drug abuse at Penn State, and one of the things I try to get across to my students is that yes, drugs have predictable effects, but only to a point. Some people will experience untoward effects, unpleasant symptoms, or even permanent damage from certain drugs. In my pharmacology class, I teach my students that pharmacogenetics--the science of studying genetic variations in how people respond to drugs--is still a very young science, but one that will certainly influence their future careers as nurses.

I use pharmacogenetic testing in my practice now, but there's still a lack of consensus on when and how it should be used. Indeed the vast majority of our allopathic drug prescriptions are written on the basis of a vague faith that most patients will respond as predicted. Only a handful of drugs in US have genetic testing routines that guide what we will prescribe, and the fastest-growing class of drugs in which this testing has been studied is among cancer treatment drugs.

Then Why Is Marijuana Legalization Expanding?

THC is a chemical very similar to the neurotransmitter anandamide, which is naturally occurring in humans, and bonds to special receptors in the brain--cannabis receptors! (CB1 and CB2) "Anandamide" comes from the Sanskrit word for bliss. People use cannabis because it makes them feel good, blissful, happy, whatever. Roughly a hundred years of tightening restrictions on all psychoactive drugs, marijuana included, have not led to significant declines in drug use or the criminality that defines its black market. I show my class a couple of diagrams, based on the science, of drug use harms. 
From: w:de:Benutzer:Dosenfant [Public domain], via Wikimedia Commons

From: Pmillerrhodes [Public domain], from Wikimedia Commons
As one can see from the above diagrams, none of these drugs is harmless, and none comes without some risks to society, but there is a definable scale of harms. Interestingly, caffeine, the most widely used drug on the planet (Starbucks, anyone?) isn't listed in either diagram, but does cause dependence and in some people causes physical symptoms, and rarely actual danger (mostly cardiac).

Marijuana legalization is expanding for several reasons.
  • It's fun, and people--voters--like to have fun. But this is nothing without the second reason.
  • It's not harmless, but demonstrably less harmful than other, legal, drugs in ours and other cultures.
  • It's not especially deadly--in fact no case of direct fatal overdose from cannabis alone has been reported. (This may change with novel delivery systems, and increasing cannabis potency.)
  • And as I tell my students: "Don't tell people drugs will kill them. If they try a drug, and it doesn't kill them, then they'll just think you're a propagandist and liar." Marijuana simply didn't live up to it's hype as "deadly" and "a gateway" to other drug use. 
  • And of course, there's the money. I put this last because for a long time, the money was there. It's why there was a multibillion dollar black market in cannabis. If the other reasons didn't obtain, we wouldn't be having this conversation.
In the textbook I use to teach my "Drugs of Abuse" course, the authors propose a theory of holistic self-awareness, which argues that the best way to be in the world is drug free, open and tuned in to all the sensations, thoughts, and experiences the world has to offer. I think this is an admirable argument, but ignores the tremendous variety in human bodies, human experience, and human potential. It is an ascetic argument. That's valid on its face, but only if one accepts it as so. It does not logically follow that it must be the only way to exist in the world.

I try to get my students to understand that the use of mind-altering drugs is very personal. I also try to help them understand that regulating a society is more complicated than simply saying "drugs are bad" or by arguing that all drugs are equally harmful, or that even the small harms from some drugs outweigh the benefits of particular drugs to some people. 

There is commonsense regulation available. Young brains are more adversely affected by cannabis than older brains. Driving while intoxicated is hazardous. And some people using drugs might benefit more if we redesigned our health care system such that people didn't feel compelled to self-medicate. Would a legal market improve the drugs we use (a wider variety of marijuana potencies, rather than the only very potent stuff on the black market now)? Could regulation and product testing improve safety?

As I tell my students, all mental health drugs can cause weird, unpredictable reactions in some patients. If they didn't, medical psychiatry would be way better than it is now. All mental health drugs come with a downside--which is why some people stop taking them (sometimes with tragic results!) but we don't outlaw those drugs. In a similar vein, why must we treat all, currently-illegal, mind-altering drugs with the same level of fear, disdain, and criminal sanction? 

Recreational marijuana is coming now. Almost a century of restriction is one cause of our relative lack of good, impartial data about how now-illegal drugs can be harmful and helpful. A century of political coddling and regulatory exclusivity given to the pharmaceutical industry has come with its own disappointments. I look forward to the new age of openness and hope that we can have a productive conversation about how to balance personal freedom and social safety, how to balance the possibilities in psychopharmacology and ethical regulation. 

Now go out and enjoy this glorious(ly not too freezing) day!
Reference 1: "Great Books", at Wikipedia, accessed on February 3, 2019 at
Reference 2: "Hillsdale College" , at Wikipedia, accessed on February 3, 2019 at
Reference 3: "Set" is the mental state the user is in at the time of drug use. "Setting" is where and when the drug is used. Example: A person using cannabis to calm down before a stressful event has the mental set "This will calm me down" in the setting "before my stressful event." I'm not stating whether this is healthy or not, but as a way to understand the way mind-altering drugs work.

Sunday, January 13, 2019

Ethics & Medicine: A Philosophy Lesson

Ok, the title sounds a little pedantic, but the lesson doesn't have to be. Anyway, thanks to all who follow this, for your patience while I've been taking care of some business during the holiday break. The semester just began, so I'm back!

Photo credit CDC/Judy Schmidt
The inspiration here is an article I read online back around Thanksgiving Update on the Ethics of Mandating HPV [human papilloma virus] Vaccination. HPV is a virus that comes in many strains, and a few strains can increase risk for cervical cancer. Women, especially, will appreciate it as a concern that has driven regular check-ups--"Pap tests"--over their adult lives. Catching the cancerous changes early has a 100% cure rate, and numerous studies over the decades showed that regular Pap tests reduced the rate of cervical cancer to a rarity. HPV vaccines were introduced in 2006, and public health experts pronounced that this was "the first vaccine that prevents cancer" and that it should be used throughout the population.

In the following 12+ years there have been arguments pro and con. I shared the former above. The con arguments ran to these...

  • Use of the vaccine would lead young people to conclude that sexual activity outside of marriage is ok.
  • The vaccine probably had hidden dangers that would not be known for years "and my kid's not going to be a guinea pig!"
  • Big Pharma was making up reasons to sell us more pharmaceuticals.
  • The vaccine was too expensive.
  • Once again we're targeting women's sexuality for "treatment"--a feminist argument.
...and so on. Use of the vaccine languished for a number of years. Some state legislatures tried to mandate that HPV vaccine be included in the required immunizations for attendance at public school. That didn't always go over well with parents who were also voters. Since then, the Centers for Disease Control report that immunization rates have increased. There's more acceptance of it, and its use has been expanded to include boys. (After all, girls have to get the virus from somewhere!) 

From Merck, Inc.
Advertising helped. Check out this ad from Merck in which adorable young people ask their parents if they knew about this vaccine that can "prevent...cancers". I mean, what parent wouldn't feel guilty about not paying whatever it costs to immunize their kid against cancer? (In fairness: many insurance companies now cover the cost of HPV vaccination.) But this article is about the ethics of medical technology and medical decision-making, so let's go there next.

Ethical Theory

Our sense of right and wrong is governed by two things: ethics and morals. Morality is a personal framework for the determination of right and wrong, and guides us in how we should act in society. It may include our religious or spiritual beliefs, and so its application may be limited by some circumstances. For example, some Christians believe that God rules against abortion, and so for those folks, abortion is wrong. Someone who doesn't subscribe to that religious view may believe that abortion is a suitable choice in some circumstances, and what circumstances permit that choice may also vary among individuals based on even more specific values. Morality is determined by culture, religion, psychology, and a variety of other factors.

Ethics has a similar dictionary definition, but more precisely it's a body of theory that attempts to help people choose right from wrong using broader social and historical bases. It's a branch of philosophy and so it's unbound by any specific religion. Here are a few examples of ethical theories, some of which the reader may be familiar with, but this list is not exhaustive--just some examples!

Utilitarianism: the theory that suggests that we should do the thing that does the greatest good for the greatest number of people.

Duty: philosophers will recognize this as "deontology", the theory that suggests that formal rules of conduct--the laws of a society--determine what is right or wrong.

Contractarian: and if you recognize the word "contract" in there, you can see that this would be the theory that argues that what is right and wrong is based on what everyone involved agrees is right or wrong.

Making an argument on ethics means making an argument within a theoretical framework, and there are parts to that framework. Autonomy is something that most of us in America feel is an important feature of our personhood. Being able to "be ourselves", to pursue "life, liberty, and...happiness" is a thread that runs through medical decisions. We should be able to choose medical therapies based on what we want, not what we are told to do by a doctor or a nurse. In mainstream American ethical thinking, autonomy is very important. In some cultures, not so much. For example, some of my colleagues at Hershey Medical Center work with many Amish, and in some situations Amish families may decline life-saving medical treatment because the "greater good" (utilitarianism) is better served by foregoing expensive treatment that seems to go against God's will and can cost the community a lot of money, when that money could better used elsewhere. You get the idea.

Ethical Tension in the Immunization Debate

As I've suggested elsewhere in this blog, a lot of the passion about whether or not to immunize comes down to different ethical approaches to this issue of what's right and wrong. In the article I referenced above in Infectious Disease Advisor, lawyer and professor of medicine at Georgetown University, Lawrence Gostin, states "I think that mandating the vaccine has public health benefits far beyond the small intrusion on individual rights. Thus, a mandate should be in place for all recipients recommended by the CDC unless there is a genuine religious objection — that exemption should be quite narrow." 

Gostin is making a utilitarian argument. What's better for all should be chosen over what's thought by some to be better for themselves. He argues that giving up a little bit of personal autonomy is more right than wrong because it is in the "best interest of the children receiving it"--although I'll be quick to note that neither Gostin nor the article's author provides statistical estimates of just how many people would benefit. However, I dug around a bit and found that a team did use mathematical modeling to estimate how much disease and death could be prevented (Van Kreikinge, 2014). 

Here, I've just shared one part of one of the results they share that's relevant to Americans. Basically it says that the more people you vaccinate, the more lives are saved. I have a couple of problems with this estimation. First, I used to do gynecology and examined (literally) over a thousand women for cervical cancer surveillance. What I found was that if women were poor, without insurance, or otherwise limited in capacity for self-care, they could get full-blown cervical cancer. Women with good education, good health care, reasonable hope for a prosperous future, and so on would not get past the very early stages of cancerous change. Simple outpatient treatment was 100% effective.

Second, two of the study's authors are paid employees of Merck, Inc. Think there's any financial incentive to create a rosy mathematical model that underscores the importance of getting immunized? Do you think that the study included in its estimates the impacts of wealth inequality, war, food insecurity, unfair labor practices, or any of the host of social and economic factors that also have an effect on what kind of health girls--or boys--receive? It did not.

"Ethical" Pronouncements as an Excuse for Ethical Truth

I get it. Doctors, nurses, public health advocates and policy makers all want to believe they are doing the right thing. They take one little thing they can run with, whether that's vaccines, or medicines like statins, or healthy eating or whatever, and they use it as a pivot to make the argument that people should do this because it's the "right thing", and it may be small, but it will help.

Where this goes wrong is the argument that follows on: if you aren't doing this, then you are wrong. It's the same argument that doctors use to vilify alternative medicine practitioners. It is unethical to use homeopathy with patients, or to recommend supplements, or to suggest vaping over smoking. "There's no evidence" (well, there often is, but it's not "enough" evidence). 

Really, this is all just an excuse for moralizing over someone else's choices, when the evidence for harm from such things may be minimal. Ethical truth is a personal, moral state of thoughtful calculation that considers the autonomy of another person, and the importance of valuing imagination and cooperation, over a static moral framework and its use to dominate others in order to feel superior. 

While I am aware of the value of HPV vaccine in preventing some cancers in susceptible persons--as the author of the article I shared notes--I do not agree with the ethical calculus. I would argue that it's an excuse to avoid talking about bigger social problems that lead to the deaths they would like to prevent. Further, it's an excuse to write a prescription in a few seconds, rather than to work with people to understand and help them build upon their own health choices.

Be well!
Reference: Van Kreikinge et al., 2014 in Vaccine, Feb 3;32(6):733-9. doi: 10.1016/j.vaccine.2013.11.049. Epub 2013 Nov 26.