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2/23/2015 12:00 AM

Saying that police officers should not be able to search through patients’ “electronic medicine cabinets” without a search warrant, Utah state Senator Todd Weiler is calling for law enforcement to obtain a search warrant before looking up someone’s records in the 19-year-old Utah Controlled Substance Database Program, the state’s prescription drug monitoring program (PDMP).

Weiler said that physicians and pharmacists should check the database, but that law enforcement has abused it. “We’ve had a problem in Utah, because law enforcement can go to the database, put in a case number and check anybody they want,” Weiler told ADAW. “One cop in Salt Lake City checked the database for almost 500 firefighters, because some morphine that was in an ambulance went missing,” he said. “This was just a fishing expedition.” One firefighter, said Weiler, was arrested in front of his wife and teenage daughter based on the database search — but he had prescriptions for all of his medications, and all of his doctors knew about each other. “He had to spend $3,000 on a lawyer,” he said. “It was like a nightmare from a Communist country.”

In another case, a police officer who was addicted to opioids “would look up to see who had just filled a prescription, and would go to that person’s home and steal it,” said Senator Weiler. “These are the two examples I’m using, but I expect I could find a lot more.”

The only solution is for law enforcement to be required to obtain a search warrant before going into the database, said Senator Weiler. Otherwise, they are violating the 4th Amendment rights of citizens to be free from unlawful searches.

“The law enforcement community is fighting back,” he said. “But I’m not going to apologize for the 4th Amendment being inconvenient.”

Senator Weiler supports pharmacists and physicians checking the database to make sure patients aren’t doctor-shopping to obtain addictive medications.

For the bill, go to http://le.utah.gov/~2015/bills/static/SB0119.html.

2/16/2015 12:00 AM

A grant announcement issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) last month to fund drug courts contains an important new condition: drug courts funded by the grants would no longer be allowed to tell offenders to stop taking medications to treat opioid use disorders. Many drug court judges have opposed methadone or buprenorphine and required participants to stop taking them. Drug courts prefer either abstinence or Vivitrol.

A grant announcement issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) last month to fund drug courts contains an important new condition: drug courts funded by the grants would no longer be allowed to tell offenders to stop taking medications to treat opioid use disorders. Many drug court judges have opposed methadone or buprenorphine and required participants to stop taking them. Drug courts prefer either abstinence or Vivitrol.

From the SAMHSA Request for Applications (RFA): “Under no circumstances may a drug court judge, other judicial official, correctional supervision officer, or any other staff connected to the identified drug court deny the use of these medications when made available to the client under the care of a properly authorized physician and pursuant to a valid prescription and under the conditions described above.”

The grant language refers to medication-assisted treatment (MAT) and includes methadone, buprenorphine, oral naltrexone, Vivitrol (injectable 30-day naltrexone) and other medications.

Under the January 26 grant announcement, drug courts would be allowed — but not required — to use 20 percent of SAMHSA grants for MAT.

Grant language

Below is the language from the RFA:

“Recognizing that Medication-Assisted Treatment (MAT) may be an important part of a comprehensive treatment plan, SAMHSA Treatment Drug Court grantees are encouraged to use up to 20 percent of the annual grant award to pay for FDA-approved medications (e.g., methadone, injectable naltrexone, noninjectable naltrexone, disulfiram, acamprosate calcium, buprenorphine, etc.) when the client has no other source of funds to do so.

“MAT is an evidence-based substance abuse treatment protocol and SAMHSA supports the right of individuals to have access to FDA-approved medications under the care and prescription of a physician. SAMHSA recognizes that not all communities have access to MAT due to a lack of physicians who are able to prescribe and oversee clients using anti-alcohol and opioid medications. This will not preclude the applicant from applying, but where and when available, SAMHSA supports the client’s right to access MAT. This right extends to participation as a client in a SAMHSA-funded drug court. Applicants must affirm, in Appendix II: Statement of Assurance, that the treatment drug court(s) for which funds are sought will not: 1) deny any appropriate and eligible client for the treatment drug court access to the program because of their use of FDA-approved MAT medications (e.g., methadone, injectable naltrexone, noninjectable naltrexone, disulfiram, acamprosate calcium, buprenorphine, etc.) that is in accordance with an appropriately authorized [physician's prescription]; and 2) mandate that a drug court client no longer use MAT as part of the conditions of the drug court if such a mandate is inconsistent with a physician’s recommendation or prescription. If an application does not include the Statement of Assurance affirming these conditions, the application will be screened out and will not be reviewed. In those circumstances where resources such as available physicians to prescribe FDA-approved medications do not exist the applicant must include in the Statement of Assurance justification as to why clients may not be able to access MAT; however, this circumstance does not alleviate the applicant from complying with conditions 1) and 2) stated above.

“Under no circumstances may a drug court judge, other judicial official, correctional supervision officer, or any other staff connected to the identified drug court deny the use of these medications when made available to the client under the care of a properly authorized physician and pursuant to a valid prescription and under the conditions described above.”

Later in the RFA, there is the following statement, which the applicant for the funds must sign: “…for the treatment drug court(s) for which funds are sought will not: 1) deny any appropriate and eligible client for the treatment drug court access to the program because of their use of FDA-approved MAT medications (e.g., methadone, injectable naltrexone, non-injectable naltrexone, disulfiram, acamprosate calcium, buprenorphine, etc.) that is in accordance with an appropriately authorized prescribed by a physician’s prescription; and 2) mandate that a drug court client no longer use MAT as part of the conditions of the drug court if such a mandate is inconsistent with a physician’s recommendation or prescription.”

ONDCP-NADCP link

Michael Botticelli, director of the Office of National Drug Control Policy (ONDCP), was cited in a Huffington Post article as heralding in a new federal initiative banning drug courts from ordering people on physician-ordered methadone or buprenorphine to stop taking them. However, Sam Schumach, press secretary for ONDCP, told ADAW that this referred to the SAMHSA grant language. Still, Botticelli and the ONDCP are strongly in favor of MAT, including Vivitrol. “We have highly effective medications that, when combined with other behavioral supports, are the standard of care for the treatment of opioid use disorders,” Schumach told ADAW. “However, there continues to be a lot of misunderstanding about these medications. We are working at the federal level to increase education about these medications, as well as to strengthen policies and contractual language to ensure that grantees — including criminal justice and treatment programs — permit the use of medication-assisted treatment.”

West Huddleston, CEO of the National Association of Drug Court Professionals (NADCP), agrees. “No drug court should prohibit the use of MAT for participants deemed appropriate and in need of an addiction medication,” he told ADAW. He added that ONDCP, SAMHSA and NADCP “are not at odds whatsoever on MAT.” The only leverage that can be applied is through federal grants, said Huddleston — the NADCP can’t tell drug courts what to do. However, “we urge all drug courts to consult a physician who has expertise in addiction medicine and/or addiction psychiatry.”

ONDCP is reviewing the NADCP MAT publication on drug courts. It is not ready for release, said Huddleston. “Since it was developed under funding from ONDCP, it is in their possession for formal review and approval,” he told ADAW.

Huddleston added that the issue is more complicated than “Do you or don’t you support MAT?” For the NADCP, it’s not about “liking or not liking” methadone, buprenorphine or Vivitrol. Huddleston said, “The real issues are, who gets MAT? Which medication is appropriate for which person? How long is the appropriate course of MAT?  And what is the medical rationale for making those and other decisions? That is what our publication seeks to answer for drug court professionals.”

Huddleston’s response to the Huffington Post article included a strong critique of “Big Pharma.” Alkermes, which makes Vivitrol, is very involved with behind-the-scenes promotion of the use of the medication in drug courts but did not respond to multiple requests from ADAW for information on the use of the medication.

Over the years, Vivitrol, originally developed for use in alcoholism treatment programs, has had a more important role in the criminal justice system to prevent opioid users from getting high (it blocks the effects of opioids). It can’t be administered until the patient has been free of opioids — including methadone or buprenorphine — for a week. The once-a-month injection is now provided for in the 2015 appropriations bill (see ADAW, Dec. 15, 2014). Stay tuned; ADAW will report on the MAT manual for drug courts as soon as it is available.

For the SAMHSA grant announcement, including links to the RFAs, go to http://www.samhsa.gov/grants/grant-announcements/ti-15-002.

11/24/2014 12:00 AM

Adolescents with opioid use disorders, in most places, do not get buprenorphine — they get detoxification, and then drug-free treatment. But experts tell ADAW that just as with adults, and perhaps even more so, maintenance treatment with an agonist such as buprenorphine is less likely to lead to relapse. The problem is that in many parts of the country, there are no pediatricians who are familiar with buprenorphine, much less licensed to dispense it. And while buprenorphine is commonly used as a detoxification adjunct, it should be used for maintenance, to help the adolescent get stable, according to John R. Knight, M.D., director of the Center for Adolescent Substance Abuse Research at Children’s Hospital Boston.

Adolescents with opioid use disorders, in most places, do not get buprenorphine — they get detoxification, and then drug-free treatment. But experts tell ADAW that just as with adults, and perhaps even more so, maintenance treatment with an agonist such as buprenorphine is less likely to lead to relapse. The problem is that in many parts of the country, there are no pediatricians who are familiar with buprenorphine, much less licensed to dispense it. And while buprenorphine is commonly used as a detoxification adjunct, it should be used for maintenance, to help the adolescent get stable, according to John R. Knight, M.D., director of the Center for Adolescent Substance Abuse Research at Boston Children’s Hospital.

“I work with someone who is a bereaved mom, whose daughter detoxed on buprenorphine, went to a halfway house and had a fatal overdose her first night there,” Knight told ADAW. Indeed, newspaper article after newspaper article details the tragedies of young people who cycle in and out of rehabs, their parents taking out second mortgages to pay for them, only to relapse and, in many cases, to die from an overdose. Oddly missing from these stories is any indication that the families had ever been offered, much less tried, buprenorphine.

“For adults, maintenance is the standard of care, and it should be for adolescents,” Knight said. “People need to get on maintenance, and not be tapered down.” Knight, one of the first pediatricians to have a buprenorphine license, said that adolescents can be maintained on very low doses of buprenorphine. A taper isn’t even considered at Children’s until the adolescent has been stable — defined by having no positive drug tests — for at least a year, said Knight. There are about 40 adolescents in the buprenorphine program, which is outpatient, at a time. Their parents attend groups, as do the teens, and there is regular drug testing.

Public health

“We need more research on what long-term effect there may be on the adolescent’s still-developing brain,” said Knight, noting that critical growth in both structure and function occur until the mid-20s. “But there’s one thing for sure,” he said. “Whatever buprenorphine’s effects are on the developing brain, they’re far less than the effects of continuing use of heroin.”

As the rates of dependence on prescription opioids and heroin among youth remain high and alarming, expanding effective treatment models for opioid-dependent youth is a public health priority, said Lisa A. Marsch, Ph.D., director of the Center for Technology and Behavioral Health at Dartmouth Psychiatric Research Center, author of one of the only two clinical trials of buprenorphine on adolescents. “A growing research base and clinical experience underscores the important role that buprenorphine can play as part of treatment for opioid dependence among adolescents and young adults.” Marsch’s research, funded by the National Institute on Drug Abuse (NIDA), “has shown that this medication is safe and effective to use with youth as part of a multicomponent treatment model,” she told ADAW. “Although the optimal length of medication administration for youth is not yet known, our work is increasingly showing better outcomes with a period of maintenance on the medication as opposed to brief detoxifications, after which time relapse rates to opioid use are high.”

Teens at Hazelden

Hazelden was one of the first treatment programs to break away from the drug-free dogma and offer buprenorphine, mainly because patients who were discharged from drug-free treatment were overdosing when they got home (see ADAW, Nov. 12, 2012).

Now, under the direction of Joseph Lee, M.D., youth continuum medical director at the Hazelden Betty Ford Foundation, adolescents are getting buprenorphine as part of comprehensive treatment.

“A lot of families are forced to choose between buprenorphine-naloxone office treatment with very little else in the way of psychotherapy and community support, or they go to the other extreme and use a psychotherapy community approach without any medication,” Lee told ADAW. “Those of us on the front lines don’t have the luxury of using rigid ideologies, so we decided to change our protocol.”

When Hazelden started using buprenorphine, recalled Lee, “people said, ‘Finally Hazelden is coming on board’ — we wanted to offer the best of both worlds.”

To be on buprenorphine, adolescents have to be at least 16, and their opioid addiction “has to be a real deal,” based on either severity or duration, said Lee. The family is educated about different options; Hazelden also has a Vivitrol track. “Sometimes, for clinical reasons, we may ask that they consider one track over another,” said Lee. “If they go the buprenorphine route, we ask that they stay in our system.”

Some parents initially are resistant to buprenorphine, but “when they understand the stakes,” they accept that it is science-based and safe, he said. Ironically, some of the adolescents themselves have a stigma about buprenorphine, said Lee. “I make a point to let them know that my job is to keep these teens alive — I don’t sugarcoat the realities,” said Lee.

Maintenance “means different things to different people,” said Lee. “My philosophy is that as long as they need to take it, they take it.” Many teens don’t want to stay on it, he said. “You can imagine if you’re 17 years old, looking down the barrel of how long am I going to take this — they have the feeling of invincibility,” he said. “So we just let them know that for now, they need it.”

Maintenance at Children’s

In many parts of the country, pediatricians and other primary care doctors may assume that detoxification in the local hospital followed by drug-free rehab is the best treatment for teens. But once the teen has been through detoxification, that basically rules out any treatment with buprenorphine, because it has to be given while the patient is in withdrawal, said Knight. At Children’s, all buprenorphine inductions are done on Mondays, so patients are instructed “to stop using no later than Sunday morning,” said Knight.

Unfortunately, the way Children’s uses buprenorphine — as a maintenance, not a detoxification, medication — makes it an “outlier” among adolescent providers, said Knight.

Ultimately, however, most adolescents are highly motivated to get off of buprenorphine, he said, echoing Lee’s experience. “We do a very slow taper, and if cravings return, we stop the taper,” said Knight. For some patients, the taper stops at a very low dose — as low as 2 milligrams a day. “Until they get older and can learn through cognitive behavioral therapy how to handle cravings, buprenorphine is a valuable asset in the tool kit,” he said.

Knight noted that the clinical trial conducted by George Woody, M.D. and colleagues, which was a “remarkable service” to the field, lasted only six months, after which the participants were tapered. He cautioned that only six months of buprenorphine with a taper would most likely be followed by “a lot of relapses, some of which will manifest as fatal overdoses.” In fact, the NIDA POATs trial with adults found relapse rates of greater than 90 percent (see ADAW, Nov. 14, 2011).

More research needed

There is a reluctance on the part of family members to start an adolescent on a controlled substance, said Bob Lubran, director of the Division of Pharmacologic Therapies in the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), which administers the licensing program for physicians who prescribe and dispense buprenorphine. In addition, there’s a shortage of physicians who can prescribe buprenorphine, Lubran said, noting that there’s a shortage in general of physicians who are interested in treating addiction. “We don’t have the numbers on how many pediatricians” can prescribe it, he said, “but we know there are relatively few.”

“There’s an urgent need for further trials comparing maintenance treatment with psychosocial treatment,” said Lubran. “These studies should have a long follow-up period — and that’s a matter for NIDA.”

It’s unclear whether NIDA is planning to do anything more with buprenorphine and adolescents. NIDA was one of the first places we contacted, but they were unable to provide anyone to be interviewed, instead referring us to David Fiellin, M.D., at Yale, who conducted the initial trials on buprenorphine for adults. He referred us to Knight. NIDA funded the only two studies on buprenorphine among adolescents, but they are both old: one by Woody in 2008 (see ADAW, Nov. 10, 2008), and the other by Marsch in 2005 (see ADAW, Oct. 10, 2005). Both showed buprenorphine was effective. Woody told us it was very difficult to recruit subjects, as those under 18 had to get parental consent; most didn’t want to tell their parents.

Still, more studies are essential, said Lubran. “I think there’s the reluctance of a clinician to start a young adolescent on a maintenance therapy, because you’re exposing somebody to a drug for which there are no long-term studies for adolescents,” he told ADAW. “I heard this years ago with methadone — there’s a tendency to be concerned about the consequences of long-term therapy for an adolescent,” he said. “I would venture that the same is true of buprenorphine.” However, he stressed that untreated opioid addiction leads to a high risk for overdose, hepatitis and HIV.

Lubran’s agency has been aggressively promoting buprenorphine, to the extent of lifting the 100-patient cap. But when it comes to adolescents, “the current state of the art is detox to drug-free,” he said. “We would argue for more research to help guide clinical practice.”

Knight knows that a study will have to be done on adolescents showing the effects of buprenorphine. “My sense is we’re not going to find much, once that study gets done,” he said. In the meantime, “buprenorphine can save young lives,” he said.

Other resources include http://pcssmat.org/wp-content/uploads/2014/03/PCSS-MATGuidanceTreatmentofOpioidDependantAdolescent-buprenorphine.SubramaniamLevy1.pdf.

Bottom Line…

Buprenorphine maintenance treatment has not been studied in adolescents, but whatever the risks, they are not as great as those from untreated opioid addiction, experts say.

From the Field
10/27/2014 12:00 AM

Last week, the Harm Reduction Coalition held its conference in Baltimore. Marijuana legalization is not one of its issues, which are mainly access to clean needles and syringes, overdose prevention with naloxone, HIV and hepatitis C, and the rights of drug users. Keynote speaker Michael Botticelli, acting director of the Office of National Drug Control Policy (ONDCP), supports naloxone and medication-assisted treatment. He is a clear harm reduction advocate, but not an advocate of marijuana legalization.

But harm reduction sometimes gets confused with marijuana legalization. I had the privilege of speaking to the “Politics” class at American University in nearby Washington, D.C. on October 20, a few days before the conference was to begin. I was invited to discuss the movement toward drug legalization. I also covered some “harm reduction” assertions as well.

Unfortunately, because the legalization movement is sweeping across America, my counterpoints were very well-received — I say “unfortunately” because we are being overcome by the tidal wave of the movement. Here is some of what I said to Assistant Professor Rick Semiatin’s “Washington Semester” class of juniors and seniors from 200 colleges and universities across the United States.

I’m a “liberal” on most things, but on the drug issue, I know the harm that is done by car crashes, DUIs, date rape and the impact of flooding already overcrowded emergency rooms — and that includes from marijuana, which most “legalizers” claim they want to separate from “harder” drugs. I was the one who wrote then-Congressman Ed Koch’s testimony on his bill in the 1970s to legalize marijuana, and sat with him at the table as he told Congress that drugs are personal and harmless, and that we should stop crowding our prisons. But both Ed and I learned and changed our positions, he as mayor of New York City and me as I learned more and more as spokesman for the House Narcotics Committee and then the White House ONDCP.

I told the students that the election is being overwhelmed by the issue because my own party, the Democrats, don’t want to touch it. They are afraid their candidates will lose a big chunk of the youth and liberal base who support legalization/decriminalization in the legislatures and state referenda. Like laetrile in the 1970s (which was legalized in more than 20 states and was supposed to cure cancer but turned out to be useless apricot pits that simply deferred real and needed treatment), “medical” marijuana is backed up only anecdotally and never is compared to an “n” of other treatment modalities that would be prescribed by doctors. There is truth to former drug czar Barry McCaffrey’s joke that a shot of gin also takes away your pain. Having said that, no one wants to deny a truly sick or dying patient who wants to get high the opportunity to feel better, even if it’s a placebo effect. It’s not the truly “medical” cases anyone wants to stop; it’s what law enforcement tells us are the 90-percent-plus (and as many as 99 percent) nonsick people who also come in to the clinics feigning illness with a makeshift letter just to get drugs.

Harms of marijuana

The evidence on harm in the legalizing states is rolling in. You have to scrounge for the reports, but they say, “youth marijuana use increased by nearly 11 percent since medical marijuana became legal in 2009,” “traffic fatalities involving drivers testing positive for marijuana have increased by 100 percent between 2007 and 2012” and “toxicology reports with positive marijuana results for driving under the influence have increased 16 percent from 2011 to 2013.” In addition, Colorado Public Radio reported, “Denver Emergency Room Doctor Seeing More Patients for Marijuana Edibles.” The United Nations reported, “Marijuana-related Health Problems on Rise in US,” with a 12 percent rise last year in marijuana usage by teens.

But for the most part, the legalization referenda are speeding ahead. The most-cited ones, in Oregon and D.C., show legalization 11 and 20 points up, respectively, with just days before the election, and the legalization advocates say they are counting on “young voter turnout.” Since Democrats count on that demographic as well, you can understand the silence.

Even though Maryland Governor Martin O’Malley told me personally two weeks ago that “I’m concerned about legalization” because of car crashes, emergency room upticks, the horrible message to kids (how legalization disarms parents from the moral high ground on the message), and the like, politicians in the state are silent on the issue.

Of course, the legalizers say the drug war is a “failure.” But the students I addressed did open their eyes when I said that because of the efforts of parents, teachers, coaches and religious and business leaders, and a strong foreign policy (Plan Colombia) and domestic enforcement efforts, drug use has declined almost 50 percent in the last three decades, and cocaine use — the disproportionate driver of crime — is down 70 percent. If any other social problem, such as literacy, hunger or poverty, or health problem, such as cancer, diabetes and heart attacks, improved 50–70 percent, would we call it a failure?

To these quite smart college juniors and seniors, I pointed out that medically assisted treatment — including methadone, buprenorphine and Vivitrol — is in fact harm reduction. It’s valid because people can function, work and pay taxes. But if we’re talking about heroin, cocaine and methamphetamine to addicts, that’s pure nonsense that destroys their lives. If we are talking about marijuana, I still oppose it because it jams hospital emergency rooms with car crashes and treatment centers with patients. Legalization or decriminalization would simply increase availability and use. When I debate the Ethan Nadelmanns of the world on radio or Bill Maher or Crossfire, they invariably say, “That’s true but…” I cut in and say, “You can’t say ‘but’ to more availability and use — that’s the point. Aside from that, Mrs. Lincoln, how was the play?”

I do concede we need to stop prison overcrowding but point out that’s why Attorney General Janet Reno and ONDCP Director McCaffrey supported creating drug courts, for treatment instead of prison for nonviolent drug offenders. There were eight drug courts when we started in 1996. Drug courts rose to 1,000 under Clinton-Reno-McCaffrey, and now are near 3,000.

Science, not politics, should guide U.S. drug policy.

From the Field
8/25/2014 12:00 AM

One of the greatest NFL players of all time, if not the greatest, is Lawrence Taylor. Known as LT, his struggles with cocaine are as well known as his quarterback sacks.

Thurman Thomas was one of the most versatile players of his era, a strong, tough, speedy back who was elected to the Hall of Fame. His battles with alcohol are well documented.

Max McGee scored the first touchdown in Super Bowl history. However, he is better known for playing that famous game with a hangover.

Substance abuse, in any form, is nothing new to the NFL — not even the abuse of painkillers, as one of the best quarterbacks in history, Brett Favre, has publicly struggled with addiction to Vicodin. Jason Peter, a lesser-known player but a highly touted defensive prospect when at school in Nebraska, became addicted to painkillers while in the NFL, which in turn led to a heroin addiction.

There is a criminal aspect to substance abuse as well. In this regard, entire teams have been investigated in the past. The New Orleans Saints — no strangers to team-wide discipline from the league — had its entire franchise under suspicion. Team officials were accused in a 2010 lawsuit of covering up the theft of the prescription narcotic Vicodin from team headquarters, an allegation that triggered an investigation by the U.S. Drug Enforcement Administration. Kyle Turley, an offensive lineman for eight years who retired after the 2007 season, said it was common for members of the Saints’ medical staff to routinely hand out the prescription painkiller Vicodin on the flights home — regardless of whether a player had a prescription for it.

“The trainers and the doctors used to go down the aisle and say, ‘Who needs what?’” Turley said. “If you had something hurting and needed a painkiller to take the edge off so you could sleep that night, they made sure you had it,” he said in a piece first published by ESPN.

Entire league under investigation

Yet now, it is not an individual being investigated, or even just one franchise. It’s the entire league. Agents from the Drug Enforcement Administration’s New York division are reaching out to former players to learn how NFL doctors and trainers get access to potent narcotics such as Percodan and Vicodin, according to the New York Daily News. The investigation was prompted after more than 1,300 former players joined in a lawsuit against the league, alleging that the league illegally used painkillers to mask injuries and that the NFL obtained and administered the drugs illegally without prescriptions. The lawsuit also claimed that the league failed to warn players about potential side effects. The reasons for this abuse, according to the players, were to expedite the return of injured players to the field and generate the highest possible profits.

The nine named plaintiffs include Chicago Bears quarterback and Super Bowl champion Jim McMahon, and his Bears teammate, Hall of Fame defensive end Richard Dent. The lawsuit alleges that the NFL has violated state and federal drug laws. The drugs numbed pain, allowing hurt players to return to the field, but they also led to aggravated injuries and created long-term health problems — both in terms of the underlying physical injuries being aggravated and in the form of addiction.

Complaints by players

Also, NFL retirees have long complained that the disability program the league operates jointly with the Players Association seems designed to reject claims by players physically debilitated by football-related injuries. Not only do these claims need to be accepted, but the insurance carriers must recognize that substance abuse and addiction must be treated as well, especially if a player’s team, or the entire league, was negligent in distributing controlled substances to those without a prescription, or even to those with a prescription if the player was not properly monitored while on the drug.

There’s a reason a medication requiring a prescription is a “controlled substance.” Without the “control” aspect, it can indeed lead to abuse and dangerous implications for the user. In many cases, even with tight controls, addiction is still a risk. If the allegations are true, not only were teams promoting substance abuse, but they were adding one more health problem to a player’s already existing injuries, without thought or consideration to the player’s welfare. Just reimagine Turley’s story for a minute, with one wrinkle: imagine team officials walking down the aisle of the plane with baggies of heroin, passing them out indiscriminately. Sounds pretty insane, doesn’t it? That’s how reckless these team officials were.

Painkiller misuse

A scientific study conducted by researchers at Washington University in St. Louis found that retired NFL players misuse opioid pain medications at a rate more than four times that of the general population. The study, co-funded by ESPN and the National Institute on Drug Abuse, provides new evidence to suggest the roots of that misuse can be traced to the misuse of painkillers during players’ NFL careers. Linda Cottler, a professor of epidemiology in Washington University’s Department of Psychiatry, who directed the research, said, “That’s a problem, I think, that only 37 percent got [prescription pain medications] exclusively from a doctor…. It tells me that there has to be more evaluation, more monitoring.”

Between the drug policy violations and the concussion issue, we are forced to recognize that football is a gladiatorial sport. Pain is inflicted, often and in large amounts. This author, for one, accepts that and, to be candid, enjoys the sport to a level of fanaticism. While the league looks for new ways to prevent concussions, via equipment and rule changes, one has to wonder if they can ever be truly done away with based on how the game is played. Concussions might be down in recent years, but they are far from being eliminated. Can rules be implemented to cut down on painkiller abuse? The answer in a perfect world is “yes,” but in reality, any player who is injured wants to get back to playing as fast as possible — not only because of their competitive nature and drive to win, but for fear if they do not, they will lose their job and their livelihood.

Much of the news about the NFL lately has been about their drug policy. Numerous players have been suspended anywhere from one game to an entire season, based on the number of times the policy was violated. In many of the cases, the violations were for marijuana use, which has caused a debate as to whether marijuana use should be the harbinger of such stiff penalties. Maybe, instead, we should be looking at the hypocrisy of the league, as some players are suspended while others become addicts and the league turns a blind eye.

From the Field
6/30/2014 12:00 AM

Marijuana is a potent drug. My personal experiences with marijuana — occasional recreational use during graduate school — were relatively benign. A few times I had experiences I found distinctly unpleasant. Usually I found that marijuana made me feel slow, heavy, dull and sedate. And because I am a person who is predisposed to the seduction of altered states, I generally enjoyed those feelings. But I found that mixing alcohol and marijuana tended to make those unpleasant experiences more likely. And because I greatly preferred the effects produced by alcohol to those produced by marijuana — and because I was uncomfortable with the illegality of marijuana — I almost always forsook smoking for drinking.

In sobriety, I have had the opportunity to see a very different side of marijuana from the privileged, private-university world I inhabited when I indulged. In the rooms of Alcoholics Anonymous, it is very common that the stories I hear involve both drugs and alcohol. While I consider myself to be fairly exclusively an alcoholic and not a drug addict, I have no illusions about the nature of my disease: I enjoy treating discomfort with mind-altering substances. Though alcohol is my preference, I have also used marijuana and benzodiazepines. That’s not uncommon at all, nor is using cocaine, heroin, methamphetamine, or any number of prescription drugs.

The effects of chronic marijuana use that I have seen are not particularly dissimilar in their manifestations from the effects of chronic alcohol use. Not in terms of how they affect a person’s body, perhaps, but in terms of how they affect a person’s life — increasing isolation from mainstream society, ruptures in relationships and families, unemployment, legal consequences, despair, suffering and misery — problems that are routinely relieved when the abuser commits to abstinence and a program of recovery.

I also see what we in AA call “The Marijuana Maintenance Program.” Many of us come to realize that we have a problem with alcohol and need to stop imbibing. But we are unwilling or unable to face the things in ourselves that are necessary to face in order to recover. And so we turn to a drug that we believe is less harmful, or more manageable. This is no different from deciding that liquor is too dangerous so we try to switch to beer. There is occasionally a brief period of respite, but our addiction will not remit until we abandon all of our artificial anesthesias and examine the underlying causes of our affliction.

As a member of Alcoholics Anonymous — I do not, of course, speak for that organization — I take no position on the legalization of marijuana for recreational use. As a scientist, I do believe that the medical value of the cannabis plant should be studied as we study any other plant and given appropriate opportunities to relieve human morbidity and suffering as is possible. Simply because some people abuse it, we should not discard it as a source of medicines. And there is significant evidence that medicines derived from marijuana, or marijuana itself, may be beneficial for a variety of conditions. A recent article in the British Medical Journal (Farrell M et al., Should doctors prescribe cannabinoids? BMJ 2014;348:g2737) neatly capsulizes the evidence and counter-evidence for marijuana as a medical intervention for a variety of conditions.

Medical marijuana is, of course, also obviously a capillary-action attempt to open the door to recreational marijuana, and it has been successful in Washington and Colorado. The joke I’ve heard over and over again from such advocates is “I need medical marijuana because I get depressed when I run out of pot.” From the pragmatic perspective of someone who is primarily interested in addicts and alcoholics having a path to recovery, and the opportunity to reclaim lost lives, I am not certain that whether marijuana, or even alcohol, is legal or not matters much to me. Humans will use and abuse mind-altering substances. Some will become dependent. Of those, a few will seek recovery.

There are enormous societal investments and consequences associated with the control and enforcement of marijuana as a banned substance, and it may be worth investigating whether legalization would have a net positive or net negative impact on things like crime, poverty and social disparities. I don’t pretend to know the answer. What I know is that marijuana abuse and dependence are real and troublesome problems, but recovery from them is entirely feasible. I have seen it countless times.

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  • Meet the Editor

    Alison Knopf
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    Alison Knopf is a professional journalist who began covering the addiction field in 1984 as founding editor of Substance Abuse Report. She has been the editor of Alcoholism & Drug Abuse Weekly since 2005.
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