pain Archives - Filter

Legal Marijuana Access Linked to Fewer Suicides Among Older Adults

Aaron Houston — Fri, 12 Dec 2025 15:34:51 +0000

States that opened adult-use marijuana dispensaries saw suicide rates decline among older adults, according to a new scientific analysis of more than two decades of nationwide data. Correlating state legalization to the decline, the researchers note a “modest yet statistically significant reduction” in states with legal access to cannabis.

The research, conducted by a team of public health economists, examined monthly suicide counts from US states between 2000 and 2022. Their aim was to better understand whether easier access to marijuana, specifically through licensed retail stores, might have any measurable effect on mental health outcomes. Their working paper, published by the National Bureau of Economic Research, shows that may be the case.

The study found that in states where recreational cannabis dispensaries began operating, suicide rates among adults ages 45 and older declined. The effect was strongest among men, who historically have had significantly higher suicide rates and are more likely to use cannabis to manage chronic pain, a health challenge that increases the risk of suicide.

They found no similar pattern among younger adults, or in states that had legalized but not yet opened retail stores. That, they say, suggests actual access may be more influential.

“Given that older adults are more prone to chronic pain and various physical and mental health issues, it is not surprising that this demographic is increasingly turning to marijuana for its medicinal properties,” the paper noted.

The researchers found no similar pattern among younger adults, or in states that legalized adult-use cannabis but had not yet opened retail stores. That distinction, they say, suggests that actual access to marijuana, rather than legalization via state law changes alone, may be the more influential factor.

The researchers did not find evidence that cannabis availability increased suicides, a concern raised by opponents of legalization who have claimed that it leads to rising rates of cannabis use and worsening mental health trends among young people.

The authors also addressed the risk factors for suicide and the therapeutic benefits of cannabis in addressing those underlying factors. “The focus on pain as an underlying cause of suicide is under recognized in the literature and adds an important dimension to the policy discussion,” they wrote.

The study arrives at a time when suicide rates in the US remain near historic highs, especially among middle-aged and older adults. Though the decline associated with dispensary openings was modest, the authors argue that even small improvements deserve attention.

“Although further research is needed, these results point to one potential benefit of legalized recreational marijuana.”

The paper, which was not peer-reviewed, was authored by Dr. Sara Markowitz of Emory University and Katie E. Leinenbach of Demand Side Analytics.

“Although further research is needed to explore the underlying mechanisms driving these effects, these results point to one potential benefit of legalized recreational marijuana,” they wrote.

“These findings contribute to the growing body of literature on the public health impacts of marijuana legalization, offering evidence that recreational dispensary openings may play a role in reducing suicides among older adults, particularly in vulnerable subgroups,” the paper concludes.

To account for variables aside from state marijuana legalization, the authors also explored—and dismissed—other potential causes. Their models factored in “the real beer tax, real cigarette tax and three opioid-centric policies: initial prescription limits, pill mill laws and prescription drug monitoring programs,” they wrote.

The study comes as more robust research is being conducted related to cannabis legalization and older adults.

Earlier in 2025, scientists found that marijuana users have “superior performance across multiple cognitive domains,” according to a new large-scale study funded by the federal government, with the effects of cannabis on cognition “presented concurrently across a range of brain systems,” based on data from 37,929 participants in the United Kingdom aged between 44 and 81. The team found that cannabis consumers consistently outperformed non-users on a range of cognitive tests—suggesting that marijuana use may be linked to brain network patterns typically observed in younger individuals.

This new study also comes on the heels of a study of more than 5,000 men whom researchers evaluated over the course of 44 years, finding “no significant harmful effects of cannabis use on age-related cognitive decline.” In fact, the report said, “Men with a history of cannabis use had less cognitive decline from early adulthood to midlife compared to men without a history of cannabis use.”

Photograph by Elsa Olofsson via Flickr/Creative Commons 2.0

This story was originally published by Marijuana Moment, which tracks the politics and policy of cannabis and drugs. Follow Marijuana Moment on X and Facebook, and sign up for its newsletter.

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“They Just Dropped Me”—When Drug-Related Stigma Replaces Pain Care

Athena Huckaby — Mon, 14 Jul 2025 17:48:18 +0000

When Phillip lost motor control on one side of his body, I had only just met him. It was April 2017, and neither of us imagined the years of medical gaslighting, dismissal and delayed care that lay ahead. We also couldn’t have known how long it would take for someone to finally help him.

This is a story about chronic pain. But it’s also a story about stigma: how assumptions about people who use drugs, or previously did, are baked into our health care system—especially when it comes to pain management. Stigma, in this case, replaced compassion, logic and even the most basic standards of care, leaving a man to suffer needlessly for years. It’s a story that needs to be told because Phillip is not alone; his experience echoes countless others.

Phillip Fiuty, who is now my husband, had been in a major car accident in 1982, when he was 18. He seemed to be the least badly hurt person in the car, and helped the other victims at the scene of the crash. It didn’t occur to him until a couple of days later that he had been injured. He declined to go to the hospital at the time of the accident, and his Christian Scientist family discouraged medical care after the fact.

As a young adult, Phillip used heroin and methamphetamine; each time he tried to quit, he would notice a persistent pain in his neck. In 2007, he quit heroin and meth and decided he needed to face his medical problems head on. He began dealing with his chronic pain within the medical system.

By early 2017, Phillip’s migraines and neck pain had grown unmanageable. Seeking answers, he visited specialists and was treated for the pain and the migraines. But no one was looking at his spine. Then, that spring, he suddenly lost motor function on his right side.

Driving to work one morning, he was passing through an intersection when his right hand suddenly fell from the steering wheel into his lap and his foot slipped from the gas pedal. His dominant side had abruptly stopped responding, without warning or sensation. He was able to awkwardly finish the drive using only his left hand and foot, but by the time he arrived, he could barely lift his arm or move his fingers.

He managed to get himself to the ER and an emergency MRI finally revealed the truth: two cervical discs were missing and the nerves in his neck were compressed. It’s likely that he did injure his neck in the 1982 car crash and the discs deteriorated over time. In retrospect, it’s astonishing that this issue went undetected for so long.

A double discectomy and cervical fusion were performed, and for the first time, Phillip began to feel some improvement. He was so grateful to the surgeon.

One follow-up X-ray was conducted, but that was it. No physical therapy was ordered. These oversights would come back to haunt us.

However, this progress was overshadowed by gaps in follow-up care. He was not directed to limit neck movement during the healing process, nor to use a neck brace. One follow-up X-ray at six weeks was conducted, but that was it. No physical therapy was ordered. These oversights would come back to haunt us.

By 2021, Phillip’s symptoms began to return. Migraines, numbness, swelling, tingling in his hands and sciatica-like pain that radiated up and down his arms. Sometimes his hands would lock up like claws.

He again sought care and was treated for the migraines and pain with medications like gabapentin, rizatriptan and even the injectable migraine medication Aimovig, but still no one was looking at his cervical spine.

He also learned that male migraine sufferers often have co-occurring ADHD, and was evaluated for that condition by a psychologist. He received an ADHD diagnosis and began treatment for it. Believing his neck might be the main issue, he wanted to consult with the surgeon who had performed the 2017 surgery. But Phillip’s insurance coverage had changed, and that surgeon was no longer in his network.

In 2022 Phillip was directed to seek care through Presbyterian Healthcare Services’ Pain and Spine program in New Mexico, where we live. He began the process of care with them. At his first appointment, a urine drug screen came back positive for methamphetamine. The result shocked Phillip, who hadn’t touched meth in 15 years.

Phillip was taking prescribed Adderall for his ADHD at the time. Many providers still don’t understand that this medication, which contains amphetamine salts, can sometimes cause false positives for methamphetamine in drug screens.

He was told he had been dismissed from care, due to the positive drug screen. “It’s just our policy.”

Alarmed, Phillip immediately sprang into action. He left voicemails, messaged the pain clinic’s office through its portal, and had a second drug screen conducted through his primary care physician, which came back negative for methamphetamine.

He received no communication from Presbyterian Pain and Spine in the interim. His follow-up appointment was scheduled three months out, so he waited. Finally, he called the office again prior to his follow-up appointment.

At that time, he was told he had been dismissed from care, due to the positive drug screen. “It’s just our policy.”

Phillip was not offered referrals to care for either another spinal surgeon or for treatment for his supposedly current methamphetamine use.

“They just dropped me,” he said. He recalled asking the nurse if the positive test result could have been linked to his prescribed medications. Her response? “I don’t know.”

Presbyterian Healthcare Services did not respond to Filter’s request for comment on the substance of this article.

SAMHSA guidelines make clear that clinical decisions should not be made based on a drug test alone. Yet across the United States, patients with a history of substance use are routinely dismissed or undertreated for pain because of stigma, not science.

Fortunately, open enrollment came through my employer, where I had domestic partner benefits. Phillip joined my plan and gained access to other providers. Imaging showed that at least one of the original cervical fusions had failed. Still, this local provider told him he wasn’t “a good surgical candidate” because no one wanted to “redo another surgeon’s work.” He was referred back to pain management instead.

There, he endured multiple failed interventions. One involved a botched attempt to place an IV, despite him explaining, from years of lived experience, that ultrasound guidance would be required. He was poked more than 10 times before the procedure was scrapped.

I was in the room with him that day, and was in tears myself. I realized I needed to step in, not only as his partner, but as a public health professional.

Phillip found that buprenorphine controlled his pain about 50 percent better than the other medications, with 50 percent less side effects.

Phillip was still in pain every day and was now taking the highest dose of oxycodone available without prior authorization, as well as gabapentin, duloxetine, Adderall and other supportive medications. It was affecting his mood and cognition, and our relationship.

One of my public health roles at that time was educating providers on chronic non-cancer pain management. I gave Phillip a sheet on dosing guidelines and a comparative overview of buprenorphine formulations for pain. He brought it to his provider, who agreed to try it.

The change was immediate.

Phillip found that the buprenorphine controlled his pain about 50 percent better than the other medications, with 50 percent less side effects. He had less sedation, clearer thoughts and better emotional stability.

Buprenorphine has long been unfairly siloed as a drug “only” for opioid use disorder. But the transdermal patch (Butrans) and buccal film (Belbuca) are FDA-approved for chronic pain. Compared to full-agonist opioids, buprenorphine offers reduced risk of respiratory depression, lower potential for dependence, and unique antidepressant properties due to kappa antagonism and serotonin reuptake inhibition.

It’s not just safer, it’s often better. So why isn’t it offered first?

By 2024, Phillip and I had both reached our limits. I knew our relationship would not survive if he didn’t get the surgery he needed.

He had a new job, and he was able to select the most comprehensive insurance plan with out-of-network coverage. Every spinal program he contacted wanted to see MRI results from within the last six months, but no doctor locally could seem to get his insurance to authorize and cover an MRI.

I convinced Phillip to pay out-of-pocket for imaging so that he could be seen. We contacted multiple nationally ranked spine centers. A top-five program on the East Coast agreed to see him. They were mystified that he was a self-referral.

His evaluation with that program, which looked at his whole spine, confirmed that neither cervical fusion from 2017 had ever fused. It also showed major issues in his lumbar spine.

Phillip underwent two surgeries in 2024: a cervical revision in August, and a lumbar fusion in December. In between those surgeries, both of which lasted more than six hours, we got married.

The difference in care was incredible. The center on the East Coast was much more adept at prior authorizations and getting things approved by insurance. They utilized team care, with the anesthesiologist, the orthopedic surgeon and even a plastic surgeon working in concert. Phillip had a home nurse, physical therapy and post-op imaging to confirm healing.

Today, he’s still in physical therapy twice a week, tapering his medications, doing more yard work and continuing to heal.

Stigma almost cost my husband his ability to walk. It nearly cost him his life. And it’s happening to other patients every day.

I think often about how differently this could have turned out. What if he didn’t have a partner with my background? What if we couldn’t afford the better insurance plan, out-of-pocket imaging or cross-country travel? What if he had given up?

And how many other people today are continuing to suffer as he has done—and continuing to face discrimination for past or present drug use—with no end in sight?

I am confident that if Phillip had not gotten the surgeries he needed, he would have eventually returned to using unregulated drugs, or even completed suicide. Stigma almost cost my husband his ability to walk. It nearly cost him his life. And it’s happening to other patients every day.

Pain care in this country is broken. But it’s fixable. It starts by believing patients. By offering buprenorphine early, not as a last resort. By questioning test results and not using drug screens as grounds for exclusion. By rejecting the idea that people with substance use histories are too complicated to help.

Every patient deserves to be heard, treated with dignity and offered real options. Phillip’s story didn’t have to be this hard. No one else’s should be either.

Top photograph of Phillip Fiuty after cervical spinal surgery in August 2024; inset photograph of the author’s wedding day later in 2024. Both photographs courtesy of Athena Huckaby.

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Given Few Options for Chronic Pain, Prisoners Are Making Safer Moonshine

Tony Vick — Tue, 12 Nov 2024 15:53:46 +0000

Moonshine, hooch, julep, toilet wine, clear—whatever they call it, over the past 30 years Tennessee’s prison bootleggers have improved their product immensely.

In the ’90s when I began my sentence, I mostly saw the kind of hooch that’s more like wine than clear liquor. A very weak wine, which everyone knew tasted like shit. It was usually made by mixing fruit scraps with a little liquid and sugar inside a garbage bag and leaving it to ferment. The “wine” is no longer a feature here, at least in my experience. If you start with the fermentation process and keep going, you can instead cook off the alcohol to make actual moonshine. That’s all anyone here drinks now.

Owen* and Charlie*, like myself, are incarcerated at South Central Correctional Facility, a private prison operated by Core Civic. Both are moonshiners.

Owen learned the trade from his grandfather. As a boy he would fill mason jars with fresh moonshine from his grandfather’s liquor stills in the woods in Southeast Tennessee, load them into the old Chevy truck and make deliveries around the outskirts of town.

“Grandpop taught me early on … if the po-po caught me, I was to say nothing,” Owen told Filter. “But I never got caught.”

Charlie is from a rural, mountainous part of the state where it was rare to see a doctor, or even go into town.

“If your leg hurt, or you had some rheumatism in your back, you took a dose of moonshine,” he told Filter.

There seems to be a growing demand for prison moonshine these days. Both Owen and Charlie said that more customers are seeking it out for a specific purpose: pain management.

Chronic pain is increasing, as access to medical care is being pared away.

One compelling reason is that opioid analgesics are rarely prescribed in prison. In limited cases, for example if someone has terminal cancer, they may be allowed small doses of morphine that they have to report to a nurse three times a day to take under supervision. But for almost everyone here living with chronic pain, the most they’ll be prescribed is acetaminophen.

Ced* never drank much alcohol before he came to prison. But he has two herniated disks, and one night the pain was so crippling he couldn’t get up off the floor. Medical staff advised him to exercise and stretch more.

“I can’t sleep at night, I have such bad back pain,” Ced told Filter. “But then I’ll get a bottle of liquor, mix it in a soda can and get the best sleep without pain.”

The cost of alcohol—here at least—is about on par with marijuana, and while many people would prefer the latter it’s often much more of a hassle. Marijuana will show up on random drug tests. It also requires a flame of some sort to light it. And like many other parts of prison life, access is controlled by gangs. Alcohol doesn’t require dealing with any of these; unlike the sale of other contraband substances, this is a side hustle that people with no gang affiliation are permitted to pick up.

In addition to the reduced risk of ending up in solitary, the product itself is safer.

Alcohol is less of a risk than it used to be. Back when the fermented liquor was more common, the smell of rotting food scraps was often a giveaway. Folks who were caught with alcohol would be taken to solitary confinement for a while. Today, it’s more likely they’ll just be told to pour it out. The understaffing crisis means that, even when they catch people manufacturing, corrections officers are not looking to give themselves the extra paperwork for a substance they don’t perceive as life-threatening. Charlie said that for years, one officer who knew he was a moonshiner would stop by every afternoon for a shot.

The more fear is stoked around fentanyl and methamphetamine, the more willing officers are to look the other way when they find contraband substances that are legal, and thus less stigmatized, in the free world. To a certain extent this includes marijuana, but mainly alcohol and tobacco.

When I began my sentence, tobacco wasn’t even considered contraband yet. Over the years prison cigarettes have become more dangerous, and smoking-related harms have quietly increased. Moonshine, on the other hand, has become safer.

Tennessee prisons no longer serve fruits or vegetables, so the fermentation process now usually involves corn product, rice or grits. Sugar is usually sourced from the dry cocoa mix sold at commissary; the chocolate can be shaken out, and the sugar remains. Tang or caramels will do the job, too.

Once the mix is in the garbage bags with a little soda pop, or water if that’s all that’s available, a tube from a toothbrush holder will be taped into the opening to allow the bag to burp—and not explode—as the alcohol develops. Shaved soap or baby powder inside a soap box makes a handy deodorizer to help avoid detection. After a few days when the bag stops expanding, the mash is ready to cook off—but not the way it used to be done.

Years ago, the small hot plates used to heat the mash, or “stingers,” were cut from brass covers pulled off drainage pipes. But the brass would often poison the liquor, and folks would end up in the hospital. These days, everyone seems to have found ways to upgrade their stingers to stainless steel, which does not have the same problem. As a result, more people are willing to give the product a try.

The prison moonshine market includes many people who aren’t involved with the rest of the contraband market. The biggest factor in why alcohol is becoming more popular for managing chronic pain is just that there is more chronic pain. The prison population, here and across the country, is getting older.

Charlie’s customers pay him in commissary items. Owen’s send the money to his family on the outside.

Owen and Charlie each said that in a given batch, about four out of five 16-ounce bottles make it to market. The fifth is usually discovered and poured out, or contaminated during the production process. Each batch requires an investment of around $75, and yields around $240—which means a lot, in a facility where there aren’t nearly enough jobs to go around.

“Ain’t got any outside help,” Charlie said. “So this feeds me and keeps my ass washed with soap.”

Charlie’s customers pay him in commissary items. Owen’s send the money to his family on the outside.

“I make enough to pay my momma’s trailer payment or car payment each month,” Owen said. “They depend on me to help them; they are too old to work anymore.”

*Names have been changed for sources’ protection

Photograph of alcohol production inside a Georgia state prison, Anonymous

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National Cancer Institute Surveys Pain Patients’ Cannabis, Polysubstance Use

Ben Adlin — Mon, 23 Sep 2024 14:48:23 +0000

A federal government agency has published a wide-ranging series of scientific reports on marijuana and cancer as part of an effort to better understand “core questions” around patients’ relationship with cannabis—including sourcing, cost, behavioral patterns, patient–provider communications and reasons for use.

One study looks specifically at patients who use medical marijuana as an alternative to opioids to treat their cancer-related pain.

Published in a special issue of the Journal of the National Cancer Institute Monographs, the package of 14 articles details the results of broad, federally funded surveys of cancer patients from a dozen agency-designated cancer centers across the country—including in areas where marijuana is legal for adult use, permitted only for medical purposes or still outlawed.

An introduction by National Cancer Institute (NCI) officials describes the project as an “initial effort to address major knowledge gaps such as understanding how cancer patients access and use cannabis, assessing the perceived risks and benefits with its use, and examining whether cancer patients discuss cannabis use with their healthcare providers during treatment.”

The individual reports cover an array of issues covered in the patient surveys, the officials explained, highlighting “key topics related to cannabis use such as sourcing of cannabis, associated cost, behavioral factors associated with cannabis use (such as smoking, drinking or using other substances), patient-provider communication on cannabis use during treatment, ethnic variations in patterns, sources and reasons for cannabis use as well as methodologic concerns related to survey data analysis.”

A main finding of one study led by NCI researchers, for example, is that patients’ “reported use of cannabis since diagnosis varied only slightly by legal status.” Of those surveyed between September 2021 and August 2032, 34.3 percent of patients who resided in states where marijuana was legal for adults over 21 reported using the substance, compared to 31.5 percent in medical-only states and 24.7 percent in states where cannabis was illegal.

In all, just under one-third (32.9 percent) of patients reported using cannabis, with respondents reporting that they used marijuana primarily to treat cancer—and treatment-related symptoms such as difficulty sleeping, pain and mood changes. The most common perceived benefits “were for pain, sleep, stress and anxiety, and treatment side effects,” the report stated.

Only one in eight health-care professionals surveyed “felt knowledgeable about the topic of cannabis.”

Authors wrote that the “large geographically diverse survey demonstrates that patients are using cannabis regardless of its legality in their state of residence.”

“In general,” they observed, “cancer patients perceived that the benefits of using cannabis outweighed the risks.”

Another analysis, conducted with data from 2021 to 2022, found that about one in six patients (17 percent) were “actively using cannabis at the time of survey completion,” while about 26 percent reported having used the substance since their cancer diagnosis.

While authors of that report noted that perspectives “about cannabis use and education varied widely among health-care professionals” surveyed, 72 percent said cannabis was safe and 57 percent said marijuana was beneficial for patients.

About four in 10 (39 percent) health-care professionals “felt comfortable providing guidance to patients about cannabis use,” the paper found, but only one in eight (13 percent) “felt knowledgeable about the topic of cannabis.”

Among patients in that study, the most common modes of consumption were gummies (33 percent) and smoking (30 percent), while the most common reasons for use were related to insomnia (46 percent), pain (41 percent) and mood (39 percent).”

Black patients were less likely to manage pain with opioids compared to white patients, “and more likely to report that cannabis was more effective.”

Another study looked at marijuana use among patients with cancer in different stages, finding that “survivors diagnosed with cancer at advanced stages were more likely to consider using cannabis than those diagnosed at non-advanced stages.”

Specifically, the odds of a patient considering cannabis use were 63 percent higher “among cancer survivors diagnosed at stages III/IV than among those diagnosed at stages I/II,” that research found.

Researchers who looked at patient costs associated with marijuana use during cancer found that the median out-of-pocket cost for cannabis was $80 per month. Men and people 45 and older, meanwhile, tended to spend more than $100 a month or more on marijuana.

“Of the 166 patients who stopped using cannabis early or used less than preferred, 28 percent attributed it to cost and 26 percent to lack of insurance coverage,” that report found.

Authors concluded using marijuana during cancer treatment “may contribute to significant out-of-pocket costs, with men and younger patients more likely to pay higher costs.”

Another study in the special issue, looking at cannabis and prescription opioids among cancer patients, observed the use of marijuana “for cancer symptom management and as an opioid alternative,” noting some demographic differences.

Compared with white patients, “Black patients were less likely to use opioids for pain … and more likely to report that cannabis was more effective than opioids.”

“Clinical guidelines surrounding cannabis use for patients with cancer have not caught up with what patients are actually doing.”

More broadly, 43.4 percent of participants reported using marijuana instead of opioids to manage pain. Of those, 398 (79.6 percent white, 70.4 percent Black, 80 percent Hispanic or other race) said the reason was because “cannabis is safer”; while 366 (74.3 percent white, 53.7 percent Black, 76.4 percent Hispanic or other race) (72.3%) said the reason was because “cannabis is less addictive”; and 360 (71.8 percent white, 63 percent Black, 74.5 percent Hispanic or other race) said the reason was because “cannabis has fewer side effects.”

“Clinical guidelines surrounding cannabis use for patients with cancer have not caught up with what patients are actually doing,” lead author Rebecca Ashare, a University of Buffalo psychology professor, stated in a September 4 press release.

The press release described how in some health care systems, patients with opioid prescriptions are screened for other drugs, and patients who test positive for cannabis can have their opioid prescriptions revoked.

“At the time of this study, my thoughts about next steps would have been about educating patients on what to do, but that ship has sailed and patients are already using cannabis,” Ashare continued.

“Now I believe we need to be educating providers about how to talk to patients about cannabis, opioids, co-use and substitution.”

Earlier in 2024, separate research on the possible therapeutic value of lesser-known compounds in cannabis says that a number of minor cannabinoids may have anticancer effects on blood cancer that warrant further study.

That research, published in the journal BioFactors, looked at minor cannabinoids and multiple myeloma (MM), testing responses in cell models to the cannabinoids CBG, CBC, CBN and CBDV as well as studying CBN in a mouse model.

“Together, our results suggest that CBG, CBC, CBN and CBDV can be promising anticancer agents for MM,” authors wrote, “due to their cytotoxic effect on MM cell lines and, for CBN, in in vivo xenograft mouse model of MM.”

In some cases, different types of cancer cells affecting the same part of the body appear to respond differently to various cannabis extracts.

While cannabis is widely used to treat certain symptoms of cancer and some side-effects of cancer treatment, there’s long been interest in the possible effects of cannabinoids on cancer itself. As the new study notes, most research on that front has looked at cannabinoids like THC and CBD.

And, as a 2019 literature review found, the majority of the studies have also been based on in vitro experiments, meaning they did not involve human subjects but rather isolated cancer cells from humans, while some of the research used mice. Consistent with the latest findings, that study found cannabis showed potential in slowing the growth of cancer cells and even killing cancer cells in certain cases.

A separate study found that in some cases, different types of cancer cells affecting the same part of the body appeared to respond differently to various cannabis extracts.

A scientific review of CBD earlier in 2024 also touched on “the diverse anticancer properties of cannabinoids” that the authors said present “promising opportunities for future therapeutic interventions in cancer treatment.”

Research published in late 2023 found that marijuana use was associated with improved cognition and reduced pain among cancer patients and people receiving chemotherapy

While cannabis produces intoxicating effects, and that initial “high” can temporarily impair cognition, patients who used marijuana products from state-licensed dispensaries over two weeks actually started reporting clearer thinking, the study from the University of Colorado found.

Also in late 2023, the National Institutes of Health awarded researchers $3.2 million to study the effects of using cannabis while receiving immunotherapy for cancer treatment, as well as whether access to marijuana helps reduce health disparities.

Federal courts are also considering two separate lawsuits on legal access to therapeutic psilocybin among cancer patients in end-of-life care.

Image (cropped) via Oregon State

This story was originally published by Marijuana Moment, which tracks the politics and policy of cannabis and drugs. Follow Marijuana Moment on Twitter and Facebook, and sign up for its newsletter.

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BC Lawsuit Highlights Harms of Opioid Prescribing Crackdown

Dustin Godfrey — Fri, 19 Jul 2024 14:49:56 +0000

A lawsuit in British Columbia details how a regulatory body is allegedly “harassing” doctors into taking pain patients off their medications.

The lawsuit stands out against the growing stack of legal claims in Canada and the United States seeking to hold opioid manufacturers, like Purdue Pharma, Sanofi Canada and Pfizer Canada, liable for misleading the public about the potential for addiction to their pain medications.

Those claims pin the blame for what they call the “opioid crisis” on the manufacturers of the drugs, saying their deception led to overprescribing. But the lawsuit filed in February 2023 by Rodney Madryga against the BC College of Physicians and Surgeons is targeting an overreaction to that issue.

And it’s a lawsuit that some advocates say gets at a problem more pressing than overprescribing: how top-down deprescribing harms pain patients and worsens the opioid-involved overdose crisis.

BC resident Rodney Madryga was severely injured in 1997, when the heavy truck he was driving for work “broke through a road and slammed downwards,” according to court documents. Ever since, he has experienced severe chronic pain from a dislocated tailbone, and “quite likely” soft tissue or ligament damage.

A surgery in 1999 only made the pain worse, and doctors determined no further surgery should be pursued. Instead, they settled on pain management “consisting primarily of various opiates,” according to the lawsuit, which said Madryga didn’t respond to other treatments, like non-opioid analgesics.

According to Dr. Mitchell, Madryga’s dosage is “necessary to manage his pain,” and his patient would “experience a very high level of suffering” if he were tapered off.

There is no evidence of Madryga using his medications other than as prescribed, the lawsuit states.

“In my view, there is no significant risk that Mr. Madryga is diverting his medication for sale on the black market,” reads an affidavit from Dr. Ian Mitchell, the physician treating Madryga. “Mr. Madryga’s dosage has remained stable since I became his physician; there have been no early refills, no lost prescriptions or any other warning sign of problematic opiate use. In no sense can Mr. Madryga’s prescription be said to be recreational.”

On the contrary, according to Mitchell, Madryga’s dosage is “necessary to manage his pain,” and his patient would “experience a very high level of suffering that would be unbearable to him and … would be psychologically and physically debilitated by pain” if he were tapered off of his medication.

Despite this, the BC College of Physicians and Surgeons began interfering with Madryga’s treatment in August 2015, “under the guise of a continuing education program,” the lawsuit says—referring to the college’s Prescription Review Program (PRP)—and this effort has continued “unabated since then.”

It started with Madryga’s previous doctor, who, according to the lawsuit, was repeatedly told by the college to reduce Madryga’s dose by 10 percent every two weeks.

The doctor was reportedly “manifestly distressed” by the results of doing so, and pushed back against further pressure to continue reducing the dose, according to the lawsuit. It added that he was “shaken” by the process and asked Madryga to seek out another doctor.

That led Madryga to Mitchell, who faced similar pressure from the college, the lawsuit claims.

The lawsuit claims the college’s de facto position is that no patients should receive a high dose of opioids—and that it leaves “no room” for doctors to disagree with that view.

College standards for prescribing high-dose opioids—defined as a daily dose of over 90 mg of morphine-equivalent—say this can only be permitted “if there is substantive evidence of exceptional need and benefit to the patients,” the lawsuit notes.

“But this exception is nominal and illusory and expressed in bad faith,” it asserts. “In practice, the college does not recognize any exceptions.”

Lawyer Jason Gratl, representing Madryga, described the PRP in a March 2023 interview as “extremely intrusive and unlawful.”

The lawsuit claims the college’s de facto position is that no patients should receive a high dose of opioids—and that it leaves “no room” for doctors to disagree with that view. The lawsuit also questions the science behind the 90 mg limit.

In court filings, Gratl argues the college’s use of the PRP violated Madryga’s rights by interfering in the treatment of his chronic pain and forcing his doctor to taper him off of medications—despite college representatives never having met with Madryga.

The college describes the PRP as purely educational. But Gratl’s court filings call this description “semantically tortured.”

“The ‘learning’ of the physician is manifested not by passing an oral or written test …” the filings read, “but only by changing individual patients’ prescriptions or dropping the patient.”

The program includes self-audits, audits by the college, mandatory training and interviews “that scrutinize the medical files of individual patients,” the filings say, which amounts “in the aggregate to harassment of the physician.”

“The program culminates in disciplinary referrals to the inquiry committee for physicians who refuse this ‘education’ by failing to change their patients’ prescriptions,” Gratl’s filings add.

Through the program, the college allegedly “accesses patient pharmacare records to identify persons with high-dose opiate prescriptions” using BC’s PharmaNet database, “then purports to ‘educate’ the target patients’ physicians by directing their treating physicians to reduce the prescription dosage.”

“The database wasn’t set up to allow the college to spy on patients, to figure out who’s receiving too many opiates.”

Gratl told Filter that this use of PharmaNet is an “abuse and misuse” of the database.

“The database wasn’t set up to allow the college to spy on patients, to figure out who’s receiving too many opiates,” he said. “The college doesn’t have a mandate for oversight of patient care of that type.”

In its own legal filings, the BC College of Physicians and Surgeons says that it “does not proactively access or ‘mine’ pharmacare records on an individualized patient basis,” but rather “reviews physicians’ prescribing practices, without regard to individual patients, and opens a PRP file only if there are several instances of prescribing outside clinical practice guidelines.”

Laying out its own account of how the PRP works, the college insists it doesn’t “harass” doctors.

Rather, it says, the college’s PRP consultants provide “educational feedback tailored to the [doctor’s] unique practice,” and “if the registrant continues to have challenges with safe prescribing, the PRP may make a recommendation to attend a specific course.”

The college says its consultants will interview doctors “to discuss barriers to, and opportunities for, safe prescribing,” and that the consultants may request that a panel review the file “for expert advice.”

That panel then “has the ability to refer cases to the college’s inquiry committee when appropriate.” The inquiry committee has the power to investigate potential infractions of laws or standards, and may refer files to the disciplinary committee.

Court filings for Madryga say that the college’s response does “not deny the allegations … but can be understood as euphemistic restatements of the plaintiff’s statement of facts that are more sympathetic to the college.”

“It’s an emergency, quite frankly, because those people are going to top up from the street supply, which is lethal.”

The PRP fits into a broader pattern of deprescribing opioids, according to Garth Mullins, an organizer with the BC Association of People on Opioid Maintenance (BCAPOM) and a prominent harm reduction activist.

He said deprescribing—not overprescribing—is a key driver of North America’s crisis of drug-related deaths. “It’s an emergency, quite frankly, because those people are going to top up from the street supply, which is lethal.”

“I’m not really one of those people who’s cheerleading the ‘bad doctors, bad companies’ motive,” Mullins told Filter, although “I don’t think Big Pharma is a good idea; I think pharmaceuticals are so important they should be nationalized.”

“I’m sure there was some overprescribing from Purdue and all that,” he continued, “but there was a lot of people that just weren’t getting their pain medication, and the real tragedy came when people were getting cut off those scripts across North America.”

History is now repeating itself, Mullins said, with a renewed prescription-opioid panic over safe supply.

BCAPOM hears from those people “every week,” he added, recalling that this was especially pronounced during the OxyContin panic of the mid-2010s. “We saw loads of people posting up to our meeting, saying they just got cut off their medications.”

History is now repeating itself, Mullins said, with a renewed prescription-opioid panic over safe supply in BC.

“Now that we’re in the middle of the big Dilaudid backlash, safe supply panic from the right, 10 years later, we’re seeing [it] again, sometimes even the same people who are saying they’re getting cut off,” he said.

The court recently heard arguments on an application by the plaintiff to access documents which the college has refused to hand over, claiming it is legally obliged to withhold them. The plaintiff argued the records “deal with how the program was administered on the plaintiff,” and that the law isn’t intended to shield the college from legal action, but to shield doctors—and no doctor is under threat of lawsuit in this case.

The case is scheduled to go to trial in June 2025.

Mullins said he’s sympathetic to people who want to sue the college and the provincial government over deprescribing.

“When they overreact by cutting people off and creating all this death, or invading people’s privacy and making it impossible for pain patients to even access opioids,” he said, “then, yeah, I think it’s smart to try and correct that.”

Photograph by Lucas Guimarães Bueno via Pexels/Public Domain

The post BC Lawsuit Highlights Harms of Opioid Prescribing Crackdown appeared first on Filter.

My Old Doctor Gave Me Methadone. Being Forced Into a Clinic Ruined It.

Ryan Montague — Tue, 09 Jul 2024 14:27:54 +0000

I lost my leg in a car accident when I was 15. A little while after, I started having pain from nerve damage. I was prescribed oxycodone. Very quickly, and unlike the large majority of people prescribed opioids, I became addicted, using oxy to treat my mental as well as physical pain.

I was going through my prescriptions too fast. Then I was introduced to heroin, and fell in love.

Fast forward some years, to 2012. I had pushed my family and friends away to the brink of no return, and I went to detox. I was scared of the pain, of both kinds, that I would experience without the comfort of a needle and drugs.

But they gave me methadone for withdrawal, and right away, I wasn’t in nearly as much pain. Actually, I was more pain-free then I had been since losing my leg.

After eight days, I left detox and returned home. I was scared again. This time, it was for the embarrassment and shame I would feel for what I’d put my family through; I was also afraid of what kind of life lay ahead.

I went to my doctor, and we had a conversation because I was back in a great deal of pain and wanting to use.

I told the doctor about methadone and how well it worked for me, and he said he was comfortable prescribing it as pain management and a deterrence to using heroin.

I began what at last felt like a normal life. Eight years passed. Then, one day in 2020, I found out my doctor was retiring.

It was the pain management aspect that allowed him to prescribe it to me directly; methadone rules in the United States forbid this if it’s being prescribed for opioid use disorder.

I began what at last felt like a normal life, taking my methadone and not using illicit drugs. Eight years passed.

Then, one day in 2020, I found out my doctor was retiring.

He told me that nothing would change with my medication. But restrictions and crackdowns during the overdose crisis have left doctors scared to prescribe opioids. I would soon learn just how scared.

The first time I saw my new doctor, he told me straight out that he wasn’t comfortable prescribing me methadone. He suggested that I go to a methadone clinic instead.

I had heard of these of course, but had never been to one. So I did some research, and found one 15 miles away. I called and did an intake interview.

I was told I could dose. And that I was going to start at 30 mg. Yeah, 30mg! One quarter of the dose I’d been on long-term.

I gave them a brief version of my medical history and told them that I was on 120 mg of methadone, and had been for over eight years. I was assured I would be well taken care of.

I attended my first appointment. Having run out of methadone by that point, I was sicker than I had been in a long time—and wanting to go back to old habits. I pushed those thoughts aside, sucked it up and waited my turn.

After an exam, I was told I could dose. And that I was going to start at 30 mg. Yeah, 30mg! One quarter of the dose I’d been on long-term.

At the dosing window, I was told that after two to three days, they would do a dose review and see where I was at.

The clinic was closed on Sundays, they said, so all patients got one take-home per week. We had to attend in person on the other six days.

I dose, go home and I am still sick. I’m in severe pain, literally wanting to die.

I went back to the clinic the next day, which was a Saturday, and asked about my dose review. I told them I was very sick and wanted to use. But they said it had to be a minimum of 48 hours before the dose review. So I suffered through it.

By Monday, I was up at 3 am, counting the milliseconds until 5:30 when the clinic opened. I took hot showers every 30 minutes, to try to get some relief. Finally, I drove to the clinic.

My review took place, and they told me they would up my dose—by 10 mg. I got just a little relief.

This sequence repeated itself for some time, through multiple further dose reviews, until finally I got to a dose I was ok with.

The clinic hours put my ability to keep my job on a knife-edge. I have to start work 30 minutes after the clinic opens. It’s a 20-mile drive.

Meanwhile, I had to drive to the clinic six days a week, for three months, during the height of COVID, until they had urine-tested me enough to have three “clean” results. Then I was permitted to get two take-homes. This cycle goes on and on.

I got a job offer more recently. But the clinic hours put my ability to keep that job on a knife-edge. I have to start work 30 minutes after the clinic opens. It’s a 20-mile drive from the clinic to work. So as long as I’m waiting at the clinic beforehand and there’s no delay, I can make it, with no room for error.

The clinic’s missed dose policy, which removes your take-home “privileges,” can really set you back. If I lived further away or didn’t have a car, I’d be in a much worse situation.

It’s bad enough as it is. At the clinic, counseling is mandatory. One of the first things I was told in rehab years ago is that you can’t force counseling on anyone: You have to want it, otherwise it doesn’t work.

At the clinic, every patient is a number. You type a number in a computer to check in, and when you’re at the window they ask your clinic number, date of birth and dosage. I’m not sure if they even know my name; they never use it. But facing the threat of being dope sick, you stand up and salute them: “Yes sir,” or “Yes ma’am.”

I keep returning to this thought: Not so long ago, I was going to my doctor once a month for a prescription and picking it up at a pharmacy. It worked just fine.

Have I seen evidence of SAMHSA’s “relaxed” methadone rules in my clinic? Not so much.

It took me four years to get to 13 take-homes per month, and I am told how lucky I am. I guess luck is a perception thing; these days, I don’t feel lucky. I’m just hoping maybe one day I won’t have to panic about the time when I go to work.

When I evaluate my life, and how it’s now dominated by driving back and forth to the clinic and the way they treat me there, I keep returning to this thought: Not so long ago, I was going to my doctor once a month for a prescription and picking it up at a pharmacy. It worked just fine.

One day, I’m hoping that we can get some change and be treated with more dignity.

Photograph by Helen Redmond

The post My Old Doctor Gave Me Methadone. Being Forced Into a Clinic Ruined It. appeared first on Filter.

A Close Look at Denial of Pain Meds to People Who Use Drugs

Doug Johnson — Thu, 18 Apr 2024 14:04:19 +0000

For people who use drugs, accessing prescription pain medication when needed can be a severe challenge. A new paper digs into this issue by investigating factors that may cause a doctor to prescribe or not prescribe to people who use drugs (PWUD)—and what people do if they’re turned away.

“I think the way the health care system is developed is not necessarily with a harm reduction approach,” Evelyne Piret, one of the paper’s authors, told Filter.

The paper was published on March 28 in the Harm Reduction Journal. It studies outcomes for 1,168 Vancouver-based participants who had asked to be prescribed pain medication—of any kind, such as opioids, gabapentin, muscle relaxants, over-the-counter medicine like tylenol, cannabinoids or unspecified drugs—between 2012 and 2022. The pain that people hoped to treat was related to situations including surgery, injuries and various types of chronic pain, among others.

This data came from three ongoing studies with PWUD in the city: The Vancouver Injection Drug Users Study, the AIDS Care Cohort to Evaluate Exposure to Survival Services, and the At-Risk Youth Study. All participants in these projects were using banned drugs at the time they joined.

People’s self-management of pain prior to seeking formal treatment for pain was a factor associated with denial.

Conducting a statistical analysis of health care visits across 4,179 six-month observation periods, the team found 907 reports (21.7 percent) of a person being denied a prescription for pain medication.

Their analysis showed that factors positively associated with denial included: having experienced a non-fatal overdose; accessing opioid agonist therapy; and daily use of opioids from unregulated markets. Being younger was also positively associated.

In something of a Catch-22, people’s self-management of pain prior to seeking formal treatment for pain was another of the factors associated with denial.

Participants who reported self-managing pain variously did so with unregulated drugs; with prescription drugs which hadn’t been prescribed to them; with cannabis or other regulated drugs; with over-the-counter medicines; or, less frequently, with exercise or heat therapy.

This all illustrates some of the likely elements—whether decisions are based on prejudice, or on medical professionals’ perceptions of risks—behind denial of pain medications to PWUD, according to Piret, who is a graduate student at the University of British Columbia’s School of Population and Public Health, and works at the British Columbia Centre on Substance Use.

Being denied pain medication can leave people to suffer mental and emotional pain, as well as physical pain, she pointed out.

These outcomes could also worsen an already-difficult relationship between PWUD and the health care system by adding to stigmatization of drug use and potentially fostering adversarial interactions. This, in turn, could hinder opportunities for health care professionals to provide care for PWUD beyond pain management, Piret said.

The study also examined what PWUD did after being denied pain medications. Among the 895 reported actions taken post-denial, 53.5 percent saw a person turn to unregulated drug markets instead, and 6.1 percent involved a person going to a different doctor.

Piret noted that the paper cannot be taken as proof that being denied pain medications directly causes people to self-medicate with non-prescribed drugs. The connection has been widely drawn elsewhere, however.

“We’ve known this for a long time.”

The paper’s overall findings come as no surprise to John Braithwaite, a board member and supervisor for the Vancouver Area Network of Drug Users. “We’ve known this for a long time,” he told Filter. He’s experienced being denied pain medication himself, he said, and many people constantly go through this.

Braithwaite also described how the body language and attitude of a medical professional can suddenly shift, once they become aware that a patient is on a methadone program, for instance.

“Everything kind of changes. They’re reluctant to give you any kind of real painkiller,” he said. “Well, it’s frustrating … just to see someone change so drastically just because you’re on a doctor-prescribed medicine.”

Braithwaite said that this has become more common since 2016, when the College of Physicians and Surgeons of British Columbia (CPSBC) released a legally enforceable set of guidelines to reduce prescribing of opioids and certain other drugs.

“The College expects physicians to use their own professional [judgment] to make treatment decisions in the best interest of their patient,” the CPSBC emailed in response to Filter’s request for comment. “The College practice standard Safe Prescribing of Opioids and Sedatives does not prohibit prescribing; it provides principles to make prescribing opioids and sedatives, which carry risk, safer.”

“I would really love to see guidelines specific to the management of pain among people who use drugs.”

Piret said that the new research didn’t seek to evaluate these prescribing guidelines—and the study notes that the guidelines did not seem to change denial rates. But she added that they do provide important context to what’s happening.

The paper stated that these guidelines, and others released in 2017 by the Canadian government, “may be mismatched with the realities of PWUD.”

“I would really love to see guidelines specific to the management of pain among people who use drugs,” Piret said. These, she envisages, would cover “all of the special considerations around drug use and drug interactions and access to care.”

Photograph by Karolina Grabowska

The post A Close Look at Denial of Pain Meds to People Who Use Drugs appeared first on Filter.

They Call Me a Drug Seeker. Here’s What Their Opioid Policies Did to Me.

Arianne Grand-Gassaway — Mon, 27 Feb 2023 14:21:07 +0000

My life changed in a matter of seconds, when in 2010 I sustained a serious spinal injury in a tree-cutting accident.

The pain was almost unbearable. For the first three months, I had to sit upright in a chair, day and night, unable to lie down or move much, aside from getting to the bathroom. I was prescribed medications, including an opioid. The pain was still severe. But even though the medicines didn’t take all the pain away, it was like having a knob that turned down the volume.

I’m more than a pain patient: I’m a mother, a grandmother, a wife, and worked in the nursing profession until long-term illness ended my career over 20 years ago. I’m also one of approximately 100 million people in the United States living with chronic pain. Too many of us have had the medications we need taken away. In my case, I was without access for a decade.

Tragically, the physical pain I face daily has been overshadowed by something far worse. Last year, my eldest daughter lost her life due to “acute drug toxicity” involving illicit fentanyl.

This is the story of how my family and I have been irreparably harmed by the drug war. So, let’s start at the beginning.

As healing progressed after my accident, I was able to lie down again. I could sleep a bit more and gradually returned to doing the things I love, like gardening, visiting with family and friends, attending community functions and traveling. For about two years, I took my prescribed opioids and maintained my quality of life.

Despite the frightening stories we’re too familiar with, most people who take opioid medicines use them as prescribed. We take them to manage our pain. We take them to live and work. Only a tiny
percentage of us ever experience either substance use disorder or overdose. While it’s true that some people started their use with prescription opioids before moving on to heroin or fentanyl, the data show that in most cases the pharmaceutical pills they took were not prescribed to them but instead were obtained through friends, family members or illicit sales.

The distortion of these realities did not happen overnight. The overdose crisis, which had already begun around the time of my accident, but has since escalated to unprecedented levels, was incorrectly labeled an “opioid epidemic.” (In fact, most deaths involve combinations of different substances.)

Moreover, in both medical and media circles we see the tendency to conflate addiction with physical dependence. The difference between the two is vital: Criteria for substance use disorder include, for example, using more than you wish to, continuing to use despite harms, or giving up important life activities because of your use. Most people who use opioids for pain experience the opposite: Their lives improve. Many medicines—like antidepressants or corticosteroids—can cause physical dependence; medication dependence in the absence of harms continues, wrongly, to be viewed as evidence of addiction.

My condition and care were stable. Despite this, my doctor, who was usually compassionate and kind, suddenly turned cold.

Armed with these misperceptions, the nation reacted to the “opioid epidemic” in predictable fashion. Leaders resorted to reactionary policies, feeding into a media fear campaign that demonized prescription opioids, leading in turn to more bad policies. We tried to arrest and further stigmatize our way out of a public health crisis—despite the devastating impact of such drug-war approaches on communities of color and others for generations.

I was just one of tens of millions of chronic pain patients to pay the price.

In 2012, my condition and care were stable. Despite this, my doctor, who was usually compassionate and kind, suddenly turned cold.

She came into the exam room one day, and without making eye-contact, stated that she was being monitored by the DEA. She began making it clear that she was now uncomfortable with continuing to prescribe me opioids. Things just got worse from there.

At one point she put me on an anticonvulsant called gabapentin, as she stated she wouldn’t prescribe an opioid alone for pain. She kept me on the gabapentin even though I was having serious adverse side effects. Around this time, she also began giving me frightening ultimatums: If I did not consent to steroid injections into my spine or invasive spinal surgery, she told me she would no longer prescribe the opioids that I relied on for my pain.

For me, taking oral medicine was preferable to the risks of surgery or epidural steroid injections, especially given my complex medical history with serious, chronic illness and rare infections. I fully understood the options available to me, and had researched them thoroughly. But my preferences counted for little as the DEA-led response to the “opioid epidemic” escalated. If you were someone like me, you would now need to sign what was called a pain contract.

For those not familiar, these contracts stipulate random drug testing for the duration of your pain care, to somehow prove you’re not “drug seeking” or selling your medicine. These contracts often stipulate random pill counts, where patients must show up the same day to verify that they haven’t taken any more or less of their medicine than prescribed. Bad or good pain days are not acceptable reasons for any deviation.

My doctor explicitly threatened that if I did not sign the pain contract, my medicines would be stopped immediately.

Most contracts state that only one doctor can prescribe pain medicine to you, even after surgery. You are made acutely aware that you’re under direct threat of care being discontinued for anything other than total compliance.

In 2013, under extreme duress, I signed the contract presented to me. My doctor explicitly threatened that if I did not sign it, my medicines would be stopped immediately. It felt like I was doing something wrong for wanting relief from my pain.

But pain contracts and threats weren’t enough to satisfy the anti-opioid outcry. Next came the prescription drug monitoring programs (PDMPs).

These databases to track prescribing now exist in every state. They’re said to have been implemented with the goals of preventing “doctor shopping” and shutting down “pill mills.” For the chronic pain patient however, they amount to prohibitive surveillance systems—a law enforcement dragnet that guarantees being treated with suspicion by medical professionals. We now encounter targeted discrimination and barriers to care in emergency rooms, for example—visits that for those of us with chronic health issues are all too necessary.

PDMPs have had a chilling effect on prescribing practices while doing nothing to prevent overdose deaths. What is a person seeking pharmaceutical opioids, but blocked by a PDMP, likely to do?

The answer may lie in statistics that show over 106,000 overdose deaths between 2021 and 2022. According to the CDCs own figures, deaths involving opioids have increased by 125 percent since 2013—the year I was made to sign a pain contract.

Despite the obvious fact that current approaches to the overdose crisis are harming millions, drug policies are still being hailed as a success. How often do we hear about the “success” of combatting the “opioid epidemic” because there are now fewer prescriptions dispensed?

After prescribing practices changed, my new normal became a cycle of medical trauma. I even found myself practicing what to say to avoid saying something “wrong.” Routine appointments and calling for monthly refills became anxiety-inducing ordeals. Will this be the day my doctor refuses to write me the prescription I depend on to function?

There were sideways glances, covert whispers by medical staff, discussions by pharmacists who called to verify every valid prescription I presented. There was an ever-increasing undercurrent of blatant hostility and contempt. I hate to admit that I initially avoided advocating for myself too strongly, for fear I would be pharmaceutically punished. Those fears weren’t unfounded.

I lost access to pain care altogether.

A few months after I signed the pain contract, my situation became untenable. When I continued to refuse surgery, my doctor accused me of not wanting to help myself. She also accused me of being “dependent” on my medicines, in that all-too-familiar conflation. I told her that having to be drug screened and scrutinized to somehow prove myself worthy to receive care made me feel criminalized. I was done with it.

Her reply was that if I wasn’t going to consent to spinal injections or surgery, or if I kept disagreeing openly with the practice’s policies, I would need to find a new doctor.

I walked out.

This decision left me without real options for finding a new prescriber, thanks to the policies I’d objected to being system-wide, and my limited health insurance. I lost access to pain care altogether.

My health and quality of life declined dramatically. I suffered from significantly increased daily pain. Left without needed medication, I now battle multiple, likely permanent, pain-induced health complications. The stress of a decade without pain care also caused my chronic illness, myalgic encephalomyelitis, to go from remitting/relapsing to a progressive phase.

Once functional and living my life with the help of opioid medication, I am now primarily housebound. Sometimes I can’t leave my bed for weeks. Isolated like this, I’ve lost both my health and irretrievable moments with loved ones. This decline has been a direct result of what I consider medical abuse.

But there was one thing I could do when I lost access: Embark on my journey into pain patient advocacy. I began making calls and writing articles about my experience. I started submitting formal complaints and speaking out online, where I found a group of people like me operating an advocacy campaign called Share Our Pain. I started opening up to friends and family, and tried to initiate conversations with elected officials.

It was in 2021 that I was officially labeled a “drug seeker” by certified mail.

I received very negative responses to most of my efforts. I faced derision, even from some chronic pain patients, and the personal attacks began. Some people told me that I must have done something wrong to be presented with a pain contract. I even faced accusations that I must be an “addict,” since I was vehemently against drug-testing policies. The attacks have been difficult to endure.

And the system still hadn’t finished with me. It was in 2021 that I was officially labeled a “drug seeker” by certified mail, and banned from care at a medical clinic in our town.

I had dared ask to continue taking a benzodiazepine that had been prescribed to me in the ER for severe vertigo, a new and debilitating symptom that began after a shingles infection.

The doctor concerned had repeatedly said that his hesitancy to prescribe was due to his “being watched”—not because he felt it wasn’t medically indicated. In the past, he said, he’d have prescribed the medicine gladly, with refills. But administrative and DEA oversight made him fear being targeted.

Many in the pain community have heard this refrain from doctors over and over: “It’s your medicine or my license.” We know what most choose.

At the time I was also undergoing tests to determine if I had breast cancer. I was left with challenging task of finding alternative care from my small, rural town. Eventually I found another doctor, and the lesion they thought might be cancer was ruled benign. The whole thing, for me, was yet another cycle of medical trauma.

It’s imperative to understand that the “drug seeker” label and alerts in the PDMP can stay with a patient forever, following them around in what’s known as a NARXcare score. Should we require emergency care or surgery, it can affect our access to needed medicines, causing those already vulnerable, sick or injured to face unnecessary pain and suffering.

All of this, for millions of us, because of the government’s crackdown on opioids amid the overdose crisis. That crisis is very real—created and greatly exacerbated by a host of disastrous policies.

As I said at the beginning, my family knows this first-hand.

In February 2022, I lost my beloved daughter, Desiree, to this government-made disaster. She had two children of her own, kids who will now grow up without their mom.

One of the many devastating things about this is that about two years before her death, my daughter had approached me and asked for my help. She wanted me to take care of my granddaughter for an extended time, so she could focus on recovery from her issues with alcohol and other drugs. She was also working on custody issues, and trying to get out of a toxic relationship.

I couldn’t help her. Without medication, my health, by that time, had deteriorated too much. I couldn’t even take care of myself, let alone a school-aged child. I was unable to even drive at that point.

I think my having to say no that day broke Desiree’s heart. I know it broke mine.

My daughter died due to her inability to get safe, effective, controlled medicines at a therapeutic dose from her prescriber.

Despite my inability to help, my daughter figured things out. She got into an inpatient detox/rehab, and was doing really well. We talked often, and she sounded more positive and hopeful than ever. In late 2021, she left the relationship she was in and moved into a women’s shelter. She had a new job and was trying to take care of her physical and mental health. But she was struggling day to day, due to severe PTSD and a debilitating panic disorder—issues she used to self-medicate with alcohol and prescription drugs, obtained primarily through friends.

The tragic irony? I had been so worried my daughter would lose her life due to alcohol. But in the end, she died due to her inability to get safe, effective, controlled medicines—in her case, benzodiazepines—at a therapeutic dose from her prescriber.

When she was unable to get the medicines she desperately needed, she resorted to the street supply. She obtained pills that she thought were Xanax from someone she knew. But they weren’t Xanax. They were counterfeit pills containing both alprazolam and fentanyl.

My daughter died alone. She was only 35. She died in a women’s shelter, a place she often referred to as her sanctuary. My loving, fierce, beautiful child was found unresponsive on the floor of her tiny room after she didn’t sign in at curfew. She had collapsed, unable to make it the few steps to the hall, right outside her door, where she could have gotten help.

For those who have some romanticized notion of a death due to drug toxicity being just peacefully going to sleep, that’s not what happens in real life. I will spare you the horrific details.

My family has been ripped apart. My heart is permanently shattered. Words cannot adequately convey the scope and devastation of what’s transpired since that sunny day we went tree cutting in 2010.

It means ending the drug war, which criminalizes, incarcerates and kills where we should care, support and heal.

We must reverse the disastrous practices and attitudes that have done this to not only my family, but countless others. If we actually want to save lives, we must transform drug policy in the United States. I hope I have shown you why.

If we are truly intent on saving lives, it means ending the drug war, which criminalizes, incarcerates and kills where we should care, support and heal. It means spreading harm reduction provisions and practices—both in medicince and in regard to nonmedical drug use—prioritizing keeping people alive and healthy.

It means establishing bodily and prescribing autonomy in the practice of medicine, to allow people to make choices through informed consent, without stigma—starting by getting law enforcement out of the PDMPs, and out of the practice of medicine altogether. It also means establishing access, for everyone, to the individualized treatments we need to survive and thrive—the foundation of patient centered-care.

All of this, and the rational, compassionate discourse about drugs that we desperately need, will require political courage from our leaders. Unfortunately, I don’t see much of that happening from where I’m standing.

Photograph by Kathea Pinto via Flickr/Creative Commons 2.0

The post They Call Me a Drug Seeker. Here’s What Their Opioid Policies Did to Me. appeared first on Filter.

The State of Research on Cannabis as an Opioid “Exit Drug”

Carlyn Zwarenstein — Thu, 29 Sep 2022 11:20:39 +0000

It’s legal for adult use in 19 states, two territories and DC, and for medical use in 37 states, four territories and DC. It’s on the Nasdaq, and produced in a capitalist profusion of brands and formats. Despite not being legal everywhere yet, cannabis and its derivatives are increasingly considered part of “wellness” culture.

This is reflected by increasing research focus on benefits rather than harms. Meanwhile, 108,000 Americans died from overdoses involving other drugs, primarily illicit opioids, last year. Given the prominent (though far from exclusive) role of opioids in the current drug poisoning crisis, there is naturally great interest from policymakers, researchers and investors in the possibilities of cannabis in addressing both perceived and real harms around opioid use.

I’ll say right away that I have a personal stake in this. I’ve tried both a prescribed synthetic cannabinoid and a variety of regular cannabis preparations through Canada’s medical cannabis program, in hopes of finding a readily accessible alternative to effective but stigmatized opioid medication for the management of my pain from ankylosing spondylitis, a degenerative spine disease.

Ultimately, however, a low dose of an atypical opioid has proven to be the most tolerable treatment to restore my function and quality of life over more than a decade. I have not experienced opioid use disorder (OUD).

But what does the research say? It was long near-impossible to study cannabis in the United States (and challenging elsewhere). Yet over the past couple of decades, research on the drug has grown. As a result, data pointing to the potential of cannabis or its constituents to reduce opioid-related harms have increased, and—given the way in which such harms increasingly frame research questions—continue to accumulate.

Prior to 2010, access to legal cannabis did seem to prevent overdose, but as opioid use shifted from prescription drugs to heroin and then fentanyl, this became less relevant.

In sorting through this literature, it’s important to tease out conflicts of interest and wishful or ideological thinking that color the framing of studies and the conclusions that may be drawn. Nevertheless, there are many good things to say about the increasing availability of cannabis in a society where both pain and anxiety are rife.

Indeed, there has been hope that cannabis legalization and decriminalization may already be having an organic effect. A 2014 review of death certificates and medical cannabis laws in all 50 states between 1999 and 2010 found significantly lower rates of opioid-involved deaths in states with medical cannabis laws.

When this study came out, its exciting findings—at a time when, as now, overdose deaths were skyrocketing—received significant media attention, and it has been cited by hundreds of other research papers since.

Later studies, however, have seriously muddied the rosy picture in which cannabis straightforwardly replaces opioids and all harms are reduced. One review, for example, showed that by extending the study period of the 2014 paper, the negative association between medical cannabis laws and opioid-involved overdose mortality lost statistical significance.

That is, prior to 2010, access to legal cannabis did seem to prevent overdose (and admissions for opioid painkiller addiction treatment), but as opioid use patterns shifted away from prescription drugs to heroin and then illicit fentanyl, this became a less relevant protective factor.

Most recently, a 2022 case control study and individual-level data review simply found no such protective association between fatal opioid-involved overdoses and state medical cannabis laws. There is a profusion of more local data, though, and it’s rarely studying exactly the same thing in the same way over the same time period—and often seems contradictory.

A 2017 study, for example, concluded that adult-use cannabis legalization resulted in a small monthly reduction in opioid-involved overdose deaths in Colorado, but a 2020 study of this relationship over a longer time period found inadequate evidence to say that adult access to cannabis reduces opioid-involved deaths.

There’s potential in the increasing availability of cannabis for reducing opioid-related harms—if we can figure out the right policies.

When it comes to medical cannabis use, the ways in which it may influence opioid use and overdose clearly depend on many ever-shifting factors. And yet, more experimental and mechanistic research, as well as anecdotal reports, suggests continuing potential in the increasing availability of cannabis for reducing opioid-related harms—if we can figure out the right policies and practices to take advantage of it.

“People almost exclusively talk about the quality of life being better on cannabis than opiates,” Peter Grinspoon told Filter. He’s an addiction medicine doctor well-known for both his medical cannabis advocacy and his openness about his own past experience of prescription opioid addiction (he’s written a book about the latter; a second book, looking at data on cannabis in historical perspective to address common misconceptions, will be published next spring).

Dr. Grinspoon outlines four ways in which he says cannabis can help: to start new chronic pain patients on cannabis rather than either opioids or non-steroidal anti-inflammatory drugs, which can have severe side effects especially with long-term use; to (voluntarily, he specifies) transition chronic pain patients from opioids to cannabis; to use cannabis in conjunction with opioids to treat pain disorders; and to treat opioid withdrawal.

Each of these is indeed a possibility—although the first two, in particular, are controversial among harm reduction advocates and pain patients—and it’s worth examining the data supporting each of these uses of the much-redeemed drug.

Before Trying Other Drugs for Pain

While few people die of overdose from opioids prescribed to them for pain, there is a theoretical risk of accidental overdose as well as a real risk of suicide by overdose in this population, to which I belong. Then, although illicitly obtained prescription opioids could be seen as protective if they replace a dose of heroin or illicit fentanyl of unknown potency, many people who use non-prescribed opioids actually do so to treat physical pain, and are at higher risk of harms, including overdose, than “official” patients.

The risk is that in the enthusiasm for cannabis or the rush to avoid opioids, a patient is denied fair treatment.

Long-term effects of opioids—such as reduced androgens like testosterone and consequent risk of bone thinning, as well as tolerance and physical dependence (which can also arise with chronic, heavy cannabis use but is less problematic)—might also be avoided by never starting them in the first place.

It’s because of this that opioids are very rarely considered a first-line treatment for chronic pain; typically, a patient will first have been asked to try non-pharmaceutical and at least one and probably more non-opioid pain medications. Such pain treatments, often taken for long periods, include non-steroidal anti-inflammatory drugs (NSAIDs), which may come with serious long- and short-term side effects.

Cannabis works on a different body system from opioids, but with many overlapping effects; most notably, analgesia (killing pain) and anxiolysis (killing anxiety). While opioids bind to the mu-opioid and other opioid receptors, triggering a cascade of biochemical effects on the brain, gut, and other parts of the body, cannabis triggers the endocannabinoid system, which, just like the endogenous opioid system, produces self-made chemicals similar to the active molecules of cannabis.

Cannabis has a notable benefit over opioids: there is no risk of respiratory depression, and overdose death is essentially impossible. If it were possible to get equivalent analgesic and anxiolytic effects from cannabis, it would therefore be generally far safer for people using opioids, especially illicit opioids, to treat mild-to-moderate (not severe) pain, unless they have potential contra-indications, such as (for example) high risk of heart attack or schizophrenia. If a well-tolerated dose of cannabis isn’t effective, the patient might then and only then consider NSAIDs or opioids.

The risk of advocating this, of course, is that in the enthusiasm for cannabis or the rush to avoid opioids at all costs, a patient is denied a fair trial of opioid pain treatment even when it best balances the risks, benefits and individual values of that person. Caution is warranted.

Transitioning Pain Patients From Opioids to Cannabis

Tyler Prock, a 37-year old Texan, told Filter that he moved to Colorado in 2012 to gain access to medical cannabis after he was prescribed two opioids (tramadol and hydrocodone) and another painkiller to deal with pain from scoliosis. Although he was only on opioids for two weeks, his personal psychological experience with them was negative, yet his doctors expected he would continue with them indefinitely.

After what Prock described as terrible opioid withdrawal (“It was worse than any hangover I’d ever experienced with alcohol”), and six months of experimentation with cannabis products to find the best type, dose and route of administration for them, he has not looked back. He mentioned that his wife’s autoimmune disorders, for which she had tried a variety of medications, also seem to be under control thanks to five daily dabs of cannabis.

“I was just lucky that I had a friend introduce me to cannabis before [opioid use disorder] would be an option,” Prock said.

(A 2018 meta review found incidence of opioid use disorder among long-term pain patients of just 4.7 per cent including all studies; about 3.1 per cent if only “good” quality studies are included; and approximately 0.2 per cent among patients with no prior history of substance use disorder.)

Besides obvious variations in individual preferences and tolerances, different types and intensities of pain respond better to cannabis than others. Esther Choo and colleagues (2018) note that evidence on the use of cannabis to treat pain is limited by the number and quality of studies, and by the difficulty of drawing useful conclusions for patients given the wide range of cannabis strengths, compositions and preparations available.

While evidence validates its use for certain types and intensities of pain, it has been promoted far more widely and it is prescribed for any number of indications. Of course, it’s not unusual for a drug to be prescribed for “off-label” uses; but if it is pushed without adequate evidence on patients who were stable on a given type and dose of opioid, they may be risking hard-won stability on the basis of wishful thinking.

Even if not coerced, patients fearing opioids might avoid seeking the best-evidenced treatments.

In New York State and Illinois, laws were amended in 2018 to allow patients with an opioid prescription to access cannabis instead. Although it offers welcome flexibility for patients who want to try cannabis, some commentators warn that in the process of encouraging what is increasingly seen as an innocuous, “natural” panacea as an alternative to opioids, more effective but more stigmatized alternatives are being underprescribed, including methadone and buprenorphine (well-evidenced treatments for people with OUD and for some people with chronic pain). It could also, perhaps, increase stigma for patients who choose to stick with opioids.

In cases of opioid cravings in patients who believe, rightly or not, that they cannot access opioid treatments, an unsuccessful experiment with cannabis could be fatal if they then resort to the illicit opioid market. In developed cannabis markets like Canada and legalized US states, marketing often emphasizes myriad supposed medical benefits.

Even if not coerced, patients with fears around opioids, whipped up by overdose headlines and politicized crackdowns on prescribing, might avoid seeking the best-evidenced treatments and instead self-medicate with cannabis for conditions for which it doesn’t work, risking reduced function as well as overdose.

Dr. Ziva Cooper, a researcher who studies cannabinoids at UCLA, also warns of the limitations of survey studies that self-select for people who have had positive experiences with cannabis use for pain being generalized to others, and of the need for research to better determine who might benefit, and how.

Given evidence that the opioid crisis doesn’t substantially involve opioids prescribed for pain, it seems unlikely that replacing pain treatment with cannabis will prevent overdose deaths.

As a Co-Treatment With Opioids

The notion of offering cannabis as an adjunct treatment to patients who are already prescribed opioids is well founded, however. When pain patients have access to cannabis, they often voluntarily reduce their regular opioid dose. Given that patients often require higher doses of opioids over time due to the development of tolerance, even maintaining a constant dose with the help of cannabis can be considered a victory that could reduce the likelihood of opioid side effects.

Dr. Cooper has been working with colleagues on the experimental use of sub-therapeutic doses (too low to be expected to help with pain, and too low to trigger side effects) of the opioid oxycodone in combination with smoked cannabis THC, to see if the synergistic effect can provide adequate pain treatment with fewer negative effects. This was an attempt to build with placebo-controlled human studies on still poorly-understood interactions that have been found between opioid (mu-opioid) and cannabinoid (CB1) receptors.

“There’s overlapping behavioral and physiological effects of drugs that act at these two receptors,” Cooper told Filter. “If you have an animal that is opioid dependent, so they’re receiving opioids daily, and then you take the opioid away, just like with a human being, you’ll see opioid withdrawal symptoms. If you then give that animal a drug that acts as a CB1 receptor, like THC, you will see a reduction in that withdrawal, and vice versa.”

Cooper’s team found the same in their volunteer human population—although Cooper warns that this was experimentally-induced acute pain in a non-pain patient population of existing cannabis users, a highly selected group for the highly controlled study. More human research is needed to say whether the same results might be found with other forms of cannabis, a complex pain patient population, or a population with experience of opioids and no experience of cannabis.

Is the association because it reduces pain? Because it eases opioid withdrawal? Or because it helps with stress, or insomnia?

An important 2019 study of people who use illicit drugs in Vancouver, where opioid-involved overdose rates have been extraordinarily high, compared drug users with chronic pain who used cannabis with a similar population of drug users, also with chronic pain, who did not. It found that daily cannabis users had about a 50 per cent lower likelihood of using illicit opioids on any given day than those who didn’t use cannabis, suggesting that daily (but not occasional) cannabis use has an opioid-sparing effect for chronic pain.

Other research has shown the same. Dr. Stephanie Lake, lead author of this study, notes it did not prove that cannabis can work as a direct substitute for opioids, however. “Now we need to figure out what is driving the association,” she told Filter. Is it because it reduces pain, for example, because it eases opioid withdrawal, or because it helps with other symptoms associated with pain, such as stress or insomnia?

A law similar to Illinois’ that makes it possible for people to access cannabis in addition to their methadone, buprenorphine or chronic pain opioid treatment—and that makes it illegal to kick someone out of treatment for using cannabis—could be a sensible idea that’s well supported by evidence.

To Treat Opioid Withdrawal

The most contentious assertion about cannabis in relation to opioids is that it can function as a direct replacement for a person who is physically dependent on opioids and going through withdrawal. Preventing withdrawal is vitally important for people with OUD who are very likely to resort to illicit opioids to treat unbearable symptoms; it is also important for the medical stability of pain patients physically dependent on opioids.

It’s important to be clear on the high risk of overdose if a person tries to treat withdrawal with cannabis, finds it ineffective, and resorts to a dose of illicit opioids. Or where internalized shame about the use of opioid agonists or “meds” instead of “natural” remedies like cannabis could result in a dependent person pushing themselves to rely on cannabis even if it is not adequately preventing withdrawal.

There have long been anecdotal reports from people who find cannabis helpful in easing specific withdrawal symptoms. “I can say personally that it was extremely helpful for my withdrawal symptoms,” Grinspoon said. “Cannabis works to so many different neurotransmitter systems to [just] the endocannabinoid system that it really is spectacular for opiate withdrawal symptoms.”

Indeed, rates of cannabis use are high among people initiating medications for OUD, especially during the period before dose stabilization. However, in a 2020 systematic review of 43 studies involving methadone, buprenorphine or naltrexone treatment for OUD and cannabis use, Stephanie Lake and her colleague Michelle St. Pierre discovered most studies did not in fact find a statistically significant relationship (either positive or negative) between cannabis use and treatment outcomes, except for withdrawal where evidence at least suggests it doesn’t hurt.

“In general what I found in that review was that the evidence was very mixed,” Lake said. It would “support working with someone using cannabis to find out why they’re using cannabis.”

Chris Backer, in Halifax, Canada (following High Hopes, a more established program in the Downtown Eastside of Vancouver), supplies free “care packages,” including a variety of donated cannabis products, to people who use illicit opioids. Backer’s East Coast Cannabis Substitution Program is a volunteer program not backed by any independent medical organization (Backer had an association with Direction 180, a Halifax opioid treatment program run by the Mi’kmaw Native Friendship Centre, but said that the medical director withdrew due to a perceived conflict of interest).

“We have spectacular evidence for the efficacy of buprenorphine and methadone. With cannabis we don’t have that data.”

Backer told Filter that the roughly 200 people to whom he and other volunteers hand out the kits, with the goal of facilitating a move off of opioid use, are all experiencing addiction. Backer cited some of the evidence mentioned earlier, and said that providing as much cannabis as possible enables people to reduce the number of shots (heroin or fentanyl) they do each week. He said that he has no concerns about a possible heightened risk of overdose due to abruptly reduced opioid tolerance in a highly dangerous market.

Grinspoon, however, distinguishes between easing withdrawal during treatment with buprenorphine or methadone, and actually attempting to replace these drugs, which he warns is not supported by the literature—yet.

“From the perspective of a doctor, we have spectacular evidence for the efficacy of buprenorphine and methadone, a 50 per cent decrease in overdoses and deaths,” he said. “And with cannabis we don’t have that data.”

The risk of overdose if it doesn’t work is high, he added. “I really do think cannabis should be viewed as an adjunct in this capacity.”

Research Is Still Playing Catch-Up

Gateway theory supposes that the non-medical (or perhaps even medical) use of cannabis can increase the likelihood of moving on to other drugs and ultimately to opioid use disorder. This used to be received wisdom but has now been widely debunked.

The sheer numbers of people using cannabis for both medical and non-medical reasons without concomitant increases in opioid use would seem, in itself, to put paid to the idea. Yes, studies have shown that cannabis use, and particularly heavy cannabis use, often precedes use of other drugs. But that doesn’t demonstrate causation, and is akin to saying that people who use drugs are more likely to use (other) drugs.

Evidence to date seems to support the notion that cannabis should be made more available as one option for patients as part of a hierarchy where a trial of cannabis might be recommended before opioids for certain patients and conditions. It also supports the contention that using cannabis, along with well-evidenced medication-based opioid use disorder treatment, should be considered a legitimate version of recovery from OUD rather than a reason to get kicked out of one’s treatment program.

Despite roughly 20 years of accumulating data, it seems that in some respects cannabis research has not yet caught up to the ways it is enthusiastically used, and in others, clinical practice has some catching up to do. With time, science should provide us with data to better define the ways in which cannabis may indeed act as an “exit drug” for opioids, and where its use is not borne out by evidence.

Top photograph courtesy of elsaoloffson/Pixabay. Inset photograph of Tyler and Samantha Prock courtesy of Yaka Jefferson

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.

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Win for Pain Patients as SCOTUS Cuts DEA’s Power to Persecute Prescribers

Alexander Lekhtman — Tue, 28 Jun 2022 14:30:07 +0000

On June 27, the United States Supreme Court ruled 9-0 that the government cannot rightfully prosecute prescribers for violating the Controlled Substances Act (CSA) unless it can demonstrate that the violation was committed knowingly or intentionally. Coming just days after the rollback of Roe v. Wade, the Ruan v. United States decision represents a significant curtailing of Drug Enforcement Administration (DEA) oversight—and a victory for chronic pain patients and everyone who prescribes or receives controlled substances.

The case involved two doctors, Xiulu Ruan and Shakeel Kahn, who were separately convicted—unlawfully, per the new ruling—of improper opioid prescribing and sentenced to 21 and 25 years in prison, respectively. SCOTUS has now kicked the case back to the lower courts, where the doctors will be able to challenge their convictions. Delivering the court opinion, Justice Stephen Breyer wrote that a doctor issuing a CSA prescription is not acting unlawfully if they believe “in good faith that the prescription is a valid means of pursuing a medical purpose.”

It has been “easier to convict a doctor of a federal felony and send them to prison for the rest of their lives than it is to win a medical malpractice case or action at the state board,” Jennifer Oliva, a law professor at the University of California, Hastings, told Filter. “That’s flipping the law on its head.”

“Under the way this statute was being interpreted, the government can put on some expert [and ask], ‘Do most doctors do this?’ and the expert says ‘No’ … Now you’re going to federal prison.”

Oliva, who co-authored an amicus brief in support of the doctors in the case, said that the DEA has increasingly been given authority to punish providers for whatever it deems to be improper practice, when that should be under the jurisdiction of state medical boards.

“Boards are staffed with medical doctors and bring in experts in the field,” she said. “That’s different than the federal government using a law enforcement statute that was meant to apply to illicit drug distributors … to have this blunt-force instrument where they can come in and suspend a prescriber.”

The chilling effect on prescribers has brought immeasurable suffering for US pain patients and contributed to public demonization of opioids that further fuels the drug war. With the Ruan decision, SCOTUS has clarified in the public record that a prescriber’s state of mind, and the intention behind their actions, is what matters in the context of federal criminal law—not the DEA’s reading of their actions.

Todays Ruan decision is right on law, right on the science

Also a rebuke of DEA’s harmful, wasteful blanket campaign against prescribers and pharmacists as scapegoats in the spiraling overdose crisis

Kudos to @jenndoliva @dineenkk et al leading voices of reason in amicus https://t.co/cIsZuXO5qC

— Leo Beletsky (@LeoBeletsky) June 27, 2022

This is a huge win for pain patients, those in need of MOUD & others needing access to controlled substances. Now we just need a communications campaign to disseminate the findings to doctors in the hopes that it will assuage their fears of the DEA. https://t.co/ApjHzo2NJj

— Taleed El-Sabawi, JD, PhD (@el_sabawi) June 27, 2022

“Under the way this statute was being interpreted,” Oliva continued, “the government can put on some expert [and ask], ‘Do most doctors do this?’ and the expert says ‘No’ … and then they say you’re outside the scope of what the ordinary physician is doing here. Now you’re going to federal prison.”

Threatening controlled substance prescribers with incarceration has reduced neither drug use nor overdose. Rather, restricting access to regulated opioids has only pushed people toward the adulterated unregulated supply, increasing overdose risks and deaths.

Photograph via Wyoming Department of Health

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