Time and Money Ill-spent on Medical Marijuana

This blog post can also be viewed where it was first published in the Denver Post on April 8, 2012: http://www.denverpost.com/opinion/ci_20335024/guest-commentary-time-money-and-medical-marijuana

I know of no one who is neutral on the issue of medical marijuana. Some claim that it is a myth. They do not believe there is anything medicinal about the use of marijuana, or if there is, it is nothing that can't be replicated by pills or shots, which are much safer and much less damaging to society. 

People may feel better, because they get intoxicated, or "high," but it does nothing positive for their medical conditions. In fact, smoking marijuana causes harm to the lungs and may lead to lung cancer. How can that be medicinal? This is the official position of the U.S. Government. In July, 2011, the U. S. Drug Enforcement Agency denied a petition to reclassify marijuana from a Schedule I controlled substance (like heroin) to a lesser schedule. In their response they stated, "Marijuana has no currently accepted medical use in treatment in the United States."

Others claim marijuana is a magic potion that is being withheld from patients who are in severe pain and distress. Not only does it combat the pain, nausea and vomiting, poor appetite, intraocular pressure, muscle spasms and seizures of those conditions for which it has been "approved" in the Colorado Constitution, it also helps those with asthma, atherosclerosis, bipolar disease, Crohn's disease, diabetes, anxiety, hepatitis, hypertension, opiod dependence, arthritis, depression, Tourette's syndrome and post-traumatic stress disorder.

They believe it is a travesty of justice that an influential but small-minded group of puritanical government officials can keep it from those who are suffering with these debilitating conditions.

I believe that medical marijuana is at best a misalliance, and at worst is an oxymoronic name used in the manipulation of voters by the political, economic and social proponents of the legalization of marijuana. By playing on the humane sympathies of the Colorado electorate for those who are obviously debilitated by their conditions, and by claiming a medical benefit that is questionable at best, the proponents were able to weave together a constitutional amendment that aligns marijuana and medicine in a relationship that is truly a shotgun wedding. 

Nothing about the way marijuana has been studied, produced, distributed or used in any way resembles the normal pathway of an approved medication. Research on the medical benefits of marijuana is scarce, and reported studies usually include questionable methods and small populations; there is no standardization of dosage or regulation of "prescribed" amount; the "medication" is not obtained at a pharmacy with a licensed health care provider's prescription, but is grown at home or "handed out" at a dispensary to those whose names have been registered based on a physician's certification that they have a qualifying debilitating condition; and instead of taking a prescribed dosage at a prescribed periodicity, the users self-medicate to their own level of symptom relief on their own time schedule.

I believe that the time, money, and emotions that have been spent trying to wedge marijuana into a medical model have been ill-spent. There are already FDA-approved medications available that are chemically identical to the active ingredient in marijuana that have gone through the approved medical pathway to legitimacy. For numerous reasons, though, (time to response, level of response, inability to control level of response, etc.) most qualifying "patients" prefer smoking the plant to taking the medication. 

But smoking the plant, even for the relief of symptoms, falls outside of most physicians' acceptable range of appropriate medical modalities. No respectable doctor would encourage patients to start smoking cigarettes, even though there are some scientifically proven benefits, (very few, and not worth the risk), and most doctors in Colorado are reticent to encourage patients to start smoking marijuana. There's something about that "first, do no harm" mantra that seems to get wired into our DNA somewhere in our years of training.

There are clearly some individuals who deserve and get comfort from smoking marijuana. For the most part, they are those who are described in the constitutional amendment we approved in 2000. They are so severely debilitated that they require a caregiver for most of their daily needs, and they have found no relief in the available treatments or prescription medications. Most of them have diagnoses that can be objectively validated. If asked on a ballot to once again approve the use of marijuana for the relief of their symptoms, I would be sorely tempted to vote "yes." 

But the roller coaster ride on which we as a state have been, mostly for the past four years, with zealots on both sides of the issue doing their best to manipulate the legal and medical systems in their favor, and the fact that currently 94 percent of the registered medical marijuana users have been certified with only the diagnosis of "severe pain," the one qualifying condition that cannot be objectively validated, has finally made me nauseated. 

It is time for decisions about the use and legalization of marijuana to once again be made by the whole community, based on the political, economic and societal arguments for and against it, instead of continuing to hide the issue behind the white coats of medicine.

Swimming Upstream with the Salmon: Analogies of the U.S. Health Care System

“… It’s in the nature of the human being to face challenges. We're required to do these things just as salmon swim upstream.”

Neil Armstrong

Our health care system is a very complex, complicated and expensive structure which nobody really understands. I certainly don’t claim to understand it, even though I have been schooled in it and have lived and worked in various portions of it for the past thirty-five years. But not understanding something and thinking you can’t explain something are two completely different things. I am more than happy to explain the U.S. health care system to you, even without understanding it.

I believe the best way to explain something that is extremely complex, is to make it mind-numbingly simple. This is one of my gifts.

I would like to use three analogies to describe the U.S. health care system: the example of beached whales; the story of starfishes on the beach; and the heroic journey of the salmon swimming upstream to spawn. I believe these analogies describe the three main categories of individuals that we have in our health care system.

Beached Whales

Almost every year we hear a story about a whale, or a group of whales, who have stranded themselves in shallow water and have subsequently been beached, or left up on the sand out of the water. The reasons why they do this are not well-understood, but there is some thinking that it has to do with sick or diseased whales, who are accompanied by other sympathetic whales, particularly in whale species that are very social. Most beached whales die.

The human response to beached whales is very interesting. Almost no expenses are spared in trying to keep these animals alive, when possible, and to rehabilitate them so that they can be set free. One effort earlier this year in the Florida Keys included hundreds of volunteers, including veterinarians, college students, an Olympic swimmer and a movie producer, who donated thousands of hours to help move the whales back into the water or get them to safe places for rehabilitation.

The people in our health care system that remind me of beached whales are those individuals who apparently take little interest in their own or anyone else’s health. They choose to smoke despite health problems or physicians’ recommendations; they are abusive in their use of alcohol and drugs; they ignore all dietary guidelines, hate fruits and vegetables and choose to overeat on a high fat, high cholesterol, high sugar, high salt diet; they refuse to partake in physical activity; they scoff at seat belt usage and won’t wear helmets when motorcycle riding, or bicycling, or skateboarding or hang-gliding; and they ridicule the use of condoms in their sexual escapades.

I personally think these “beached whales” represent less than 10-15% of our population, but they disproportionately raise the cost of the entire health care system. There also may not be any one particular individual who exhibits all of these characteristics in their life, but there are plenty of Americans who “beach” themselves by consistently falling prey to two or three of these unhealthy behaviors despite the availability of resources and tools to help them change. And almost no expenses are spared in trying to “save” these folks.

Stranded Starfish

You may have heard or read the story by Loren Eisley, about the older man walking on the beach and discovering a young boy almost frantically throwing starfish back into the ocean at low tide. When told that he cannot possibly save all of the starfish, the young man picks up another starfish, throws it into the ocean, and replies, “I saved that one!” In the original story, the older man then joins the young man and starts throwing starfish back into the ocean himself.

I think this analogy is a good one for the vast majority of folks in our health care system. Although they are much more passive and less reckless than the beached whales, they too find themselves ill and in need of help to get back to health. One by one, physicians, dentists, nurse practitioners, physician assistants, chiropractors and other health care providers try to help as many of them as they can, but there is no way that they can reach all of them. Still, they do their best as they methodically work their way down the beach one starfish at a time in their heroic attempt to save every starfish.

Swimming Salmon

Salmon have a very active and amazing life cycle. It begins when they are hatched from eggs in stream gravel beds far upstream and inland from the ocean. For some time they grow here, learning to catch food, and avoiding predators. They fiercely guard their territory, and imprint the scent of their home. As they grow, they eventually migrate downstream to estuaries, where they adapt to salt water and develop their characteristic scales and color. When large enough, they migrate to the ocean, where they spend about half of their life, increasing in size and mingling with other salmon. They then begin a long migration back to their place of birth, often overcoming tremendous hazards on route, where the female salmon lays up to 3,000,000 eggs, which the male fertilizes, and then they die.

It is not the “spawn and die” analogy I wish to highlight here, although it may well describe the life cycle of some in the U.S. health care system. Instead, it is the “swimming upstream” analogy that I think fits. “Moving upstream” is a phrase that is often used in the medical community to describe primary prevention, which means getting to the root cause of a problem and preventing it before it occurs. There are a number of stories, or fables, that have been used with this analogy. Here is one of them:

A small fishing village was situated near the mouth of a large river, where it entered the ocean. One day, as the villagers were fishing in the river, they heard the screams of someone coming down the river, pleading for help because they couldn’t swim. The villagers rescued the drowning victim, but soon another person came down the river, once again screaming for help. Before long, the villagers found themselves spending the entire day rescuing drowning people from the river. This gave them little time to fish, but they found that the rewards, or presents, that were given to the village by the drowning victims more than made up for their lost fishing revenue. Most of those who were rescued also stayed in the village for they said it was too dangerous to return home, so the village grew in both wealth and population.

The villagers soon became experts in the art of rescuing drowning people. They eventually broke the job of rescuing down into areas of specialization for which the children of the village could be trained. While it was true that some of the people drowned before they reached the village, and some were swept by the village on the strong currents in the river, for the most part the villagers were able to save the victims. And the village grew very rich.

Then one day, a visitor to the village asked a question that shook the very foundation of the village’s economy. “Why are so many people drowning in the river and from where do they come?” he asked. (He spoke very grammatically correct English!) This deeply disturbed the village elders! No one had ever asked such questions before! This visitor was obviously an intellectual and would cause a great deal of trouble, so they drove him out of the village.

It turned out that he was, indeed, an intellectual, and his curiosity was aroused to such a degree that he hiked up the river to see if he could answer his own questions. What he found was rather startling. He discovered a second village a number of miles up the river that had been severely damaged by a violent earthquake several years previously. The damage had altered the pathway that led into the village so that it now ran along a beautiful, but steep and slippery cliff that overlooked the wild river below. It was here that so many of the second village’s inhabitants were slipping over the cliff into the river, never to be seen again. The second village was a very depressed, and dwindling, place.

“I am a builder of fences,” the visitor told the elders from the second village, “and I believe if we build a fence along the pathway into town, it will keep your people from falling over the cliff and into the river.” The village elders conferred. This visitor was obviously an intellectual who might be able to save the village, so they hired him.

The fence did as he predicted. People soon came from miles around to look over the beautiful (but protected) cliff into the raging river below and to buy souvenirs from the villagers. The visitor was made the chief of the second village, which flourished and became very prosperous.

The river rescuers in the village downstream noticed a precipitous drop both in the number of victims to be rescued and in their income. Eventually they began to get hungry. Before long they all went back to fishing.

Members of this third group in the U.S. health care system are searching for ways to improve their health and to prevent death and disease. They are swimming upstream, like the salmon, and are learning that their dietary habits, and their exercise activities, and their refusal to use tobacco or abuse alcohol lead to positive health consequences downstream. They are flourishing, whether or not they become very prosperous.

There are many problems with the U.S. health care system. But most of us won’t be able to do much to change it. Each of us, however, can choose whether we end up beached like a whale, stranded as a starfish, or swimming upstream with the salmon.

The Promise and Potential of Automatic Public Health
by Dr. Mark B. Johnson, M.D., M.P.H.

One of the lessons I learned in an Injury Control course I took in graduate school was that the fewer intentional steps an individual has to take to protect him- or herself from a potentially harmful situation, the greater the likelihood that an injury will be prevented. It’s a principle that has applications in many arenas of prevention. For example, the fewer steps that one has to consciously take to make sure their water is potable, the less cases of cholera there will be. I like to call this concept “automatic public health.”

Automatic prevention is a term that is used in computer science, but it has not been frequently used to describe public health activities. I am not talking about habitual activities that one might learn through repeated practice, like always fastening your safety belt in a car without even thinking about it. I’m talking about unobserved, behind-the-scenes public health activities that protect you without your conscious involvement, and potentially without your awareness or knowledge.

Access to safe or potable water in most developed countries is one example of automatic public health. In the United States, public water supplies that are unsafe to drink are so rare that they have to clearly identify the fact to ensure that people don’t drink the water. Americans “automatically” assume that water coming from public faucets is safe to drink. They do not have to filter, boil, or chemically treat the water before they consume it. A great deal of unnoticed work has gone into providing this potable water to the public, but no individual consumer has to do anything to ensure that it is safe. This is automatic public health at work.

Another example of automatic public health is the addition of folic acid to cereals in the United States. There is good scientific evidence that if a woman has enough folic acid in her body before and during pregnancy, it can help prevent major birth defects of the baby’s brain and spine. Various surveys of American women of childbearing age have shown that over 80% know about folic acid and its effects and almost 90% would take folic acid supplements if their health care provider recommended it, yet only 40% of them take folic acid supplements and only 37% of the health care providers do, in fact, recommend the supplementation. The most common reasons given for not taking folic acid supplements were that they forgot, they didn’t think they needed it or they thought they were getting enough from their regular diet. Only 12% of the women took folic acid supplements before they knew they were pregnant, but many of these types of birth defects occur, and therefore must be prevented, before a woman knows she is pregnant.

In January of 1998, automatic public health was put in place. It was mandated by the U. S. federal government that cereals be fortified with folic acid. One serving of many commercial breakfast cereals now provides 100% of the recommended daily value of folic acid. During the first year of this program over 1,000 major birth defects were prevented, saving an estimated $560,000,000 (in 2003 dollars) in direct costs for the care of these infants. The women did not have to remember to take an additional pill and they did not have to wait to have their health care provider recommend the addition of folic acid to their diet; they just continued eating the diet to which they were accustomed. This, too, is automatic public health at work.

One of the areas where automatic public health has been the most successful is in the reduction of motor-vehicle crash fatalities. Numerous alterations and modifications have been made, both in vehicles themselves and in the roads and roadways on which they travel. Dashboards which used to have many sharp and rigid items protruding toward the passengers have given way to soft, molded contours with flat buttons and dials. Steering wheels have been modified to collapse and move away from drivers during impacts. Engines, too, are directed down and under the car instead of moving straight into the passenger compartment. Windshields, which were originally made of ordinary window glass that could shatter and lead to serious injuries, are now laminated with an inner layer of cellulose to hold the glass together even when it fractures. Brake lights have been added in a raised position more likely to catch the attention of those behind the vehicle. Car frames are now made with stronger, yet lighter components.

In 1989, U.S. federal law mandated automatic restraint systems with either airbags or automatic seat belts. Since that time, advanced generations of airbags have been devised, and many new cars have several airbags that protect from multiple angles. The National Highway Traffic Safety Administration (NHTSA) estimates that between 1988 and 2008, airbags, while possibly causing 175 fatalities, saved more than 6,377 lives and prevented countless injuries.

In addition to the many modifications that have been made to vehicles, modern roads and roadways have been improved. The slopes and slants of roads have been altered to help hold vehicles on the road. Guardrails crumple when hit or are the ends extend into the ground so they do not slice into cars and their occupants as many used to do. Signs and light poles are lighter and now break away when struck instead of impaling occupants or causing rapid-deceleration injuries.

All of these automatic public health alterations and adaptations have had a significant impact on motor-vehicle safety. Between 1994 and 2008 fatality rates per 100 million vehicle miles traveled in passenger cars decreased by 38%. At the same time, motorcycle fatality rates per 100 million vehicle miles traveled, which did not benefit to the same degree from the automatic public health measures taken, increased by 62%.

Automatic public health activities have the advantage of repeatedly producing positive health and safety consequences for individuals and populations who do not have to consciously and intentionally take single or multiple steps to produce the beneficial outcomes. I believe more public health research should be devoted to identifying automatic public health activities that have the potential of improving safety and saving lives without unduly increasing costs or limiting personal freedoms. Health education and behavior change, while recording numerous historical successes and having honored roles in public health’s armamentarium are severely limited when working with unmotivated, preoccupied or overstressed individuals and populations. Informed automatic public health has the potential of circumventing the common deterrents and disincentives for healthful activities, not by manipulation or exploitation, but by aligning incentives and making healthy choices and activities the paths of least resistance.