06/24/18 Dr. Dustin Sulak & Dr. Staci Gruber
Century of Lies
This week: Dr. Dustin Sulak and Dr. Staci Gruber speaking about medical cannabis at the Patients Out of Time National Clinical Conference on Cannabis Therapeutics, plus Philip Alston, United Nations Special Rapporteur on extreme poverty and human rights.
CENTURY OF LIES
JUNE 24, 2018
DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.
DOUG MCVAY: Welcome to Century Of Lies. I'm your host Doug McVay.
Well, on today's show, we're going to hear from Doctor Dustin Sulak about medical cannabis, we're also going to hear from Doctor Staci Gruber about medical cannabis. But first, Philip Alston is the Special Rapporteur on Extreme Poverty for the United Nations Human Rights Council. On Friday June 22, he reported on conditions in the United States. Let's hear what he had to say.
PHILIP ALSTON: In relation to the USA, I note with regret that United States Ambassador Nikki Haley has characterized this Council as a cesspool and has chosen to withdraw from it just days before my presentation.
Speaking of cesspools, my report draws attention to those that I witnessed in Alabama as raw sewage poured into the gardens of people who could never afford to pay $30,000 for their own septic systems in an area remarkably close to the State capital. I concluded that cesspools need to be cleaned up and governments need to act. Walking away from them in despair, as in Alabama, only compounds the problems.
Ambassador Haley complained that the Council has done nothing about countries like Venezuela. In fact I and several other special rapporteurs reported earlier this year that, and I quote, "vast numbers of Venezuelans are starving, deprived of essential medicines, and trying to survive in a situation that is spiraling downward with no end in sight.". We warned of an unfolding tragedy of immense proportions.
Mr President, I turn now to my report on the United States. My starting point is the combination of extreme inequality and extreme poverty, which generally create ideal conditions for small elites to trample on the human rights of minorities.
The United States has the highest income inequality in the Western world, and this can only be made worse by the massive new tax cuts overwhelmingly benefiting the wealthy.
At the other end of the spectrum, 40 million Americans live in poverty and 18.5 million of those live in extreme poverty.
In response, the Trump administration has pursued a welfare policy that consists primarily of, one, steadily diminishing the number of Americans with health insurance. Two, stigmatizing those receiving government benefits by arguing that most of them could and should work, despite evidence to the contrary. And three, adding ever more restrictive conditions to social safety net protections such as food stamps, Medicaid, housing subsidies, and cash transfers.
For example, a farm bill approved yesterday by Republicans in the House of Representatives would impose a stricter work requirement on up to 7 million food stamp recipients. Presumably this would also affect the tens of thousands of serving military personnel whose families need to depend on food stamps, and the 1.5 million low-income veterans who receive them.
The US health care system already spends eight times as much to achieve the same life expectancy as in Chile and Costa Rica, and African-American maternal mortality rates are almost double those in Thailand.
Babies born in China today will live longer healthy lives than babies born in America.
In an exclusive Fox News story yesterday Ambassador Haley called my report misleading and politically motivated. She didn’t spell out what was misleading but other stories from the same media outlet emphasized two issues.
The first is that my report uses official data from 2016, before President Trump came to office. That's true, for the simple reason that there will be no Census Bureau data on the Trump era until September. But these data do provide the best available official baseline, and my report then factors in the effects of combining massive tax cuts for the wealthy and systematic slashing of benefits for the less well-off.
The second criticism, as noted by Sean Hannity, is that the US economy continues to roar to life under President Trump. Indeed, the US economy is currently booming, but the question is who is benefiting.
Last week’s official statistics show that hourly wages for workers in production and nonsupervisory positions, who make up 80 percent of the private workforce, actually fell in 2017.
Expanding employment has created many jobs with no security, no health care, and often with below-subsistence wages. The benefits of economic growth are going overwhelmingly to the wealthy.
The American dream of mobility is turning into the American illusion, in which the rich get ever richer, and the middle classes don’t move.
My report demonstrates that growing inequality, and widespread poverty which afflicts almost one child out of every five, has deeply negative implications for the enjoyment of civil and political rights by many millions of Americans.
I document the ways in which democracy is being undermined, the poor and homeless are being criminalized for being poor, and the criminal justice system is being privatized in ways that work well for the rich but that seriously disadvantage the poor.
Underlying all of these developments is persistent and chronic racial bias. That bias also helps to explain the abysmal situation in which the people of Puerto Rico find themselves. It's the poorest non-state in the Union, without a vote in Congress, at the mercy of an unelected and omnipotent oversight board, and suffering from record poverty levels in the aftermath of Hurricane Maria.
In her statement on my report, Ambassador Haley says that it is patently ridiculous for the United Nations to examine poverty in America, and claims that I should instead be looking at the human rights situations in two war-torn African countries, Burundi and the DRC [Democratic Republic of Congo].
Leaving aside the fact that this Council has published many report detailing the situations in those two countries, my view is that when one of the world’s wealthiest countries does very little about the fact that 40 million of its citizens live in poverty, it's entirely appropriate for the reasons to be scrutinized.
If this Council stands for anything, it's the principle of accountability, which is the preparedness of States to respond in constructive and meaningful ways to allegations that they have not honored their human rights commitment.
The US position, expressed by Ambassador Haley, seems to be that this Council should do far more to hold certain states to account, but that it should exempt the United States and its key allies from such accountability.
DOUG MCVAY: That was Philip Alston, Special Rapporteur on Extreme Poverty, reporting to the United Nations Human Rights Council on conditions in the United States. I weep for my country.
Now, let's get on with the rest of the show. First, let's hear from Doctor Staci Gruber from Harvard University.
STACI GRUBER, MD: I am Doctor Staci Gruber, I am the director of the Marijuana Investigations for Neuroscientific Discovery program at MacLean Hospital, Harvard Medical School.
DOUG MCVAY: Tell me about the MIND Project, very quickly.
STACI GRUBER, MD: The MIND Program was started just under four years ago, specifically to look at the impact of medical marijuana treatment on measures of brain structure, function, cognitive performance, clinical state, quality of life, and conventional medication use.
So that's what we're doing, we look at patients before they begin using cannabis, and we test the hell out of them, and we follow them over time. We see them again at three months, six months, one year, and now eighteen months and twenty-four months, and so far we're seeing extraordinary, extraordinary results.
DOUG MCVAY: You just spoke here at the Patients Out of Time conference, what do you hope are the takeaways that people take away. I hate that.
STACI GRUBER, MD: What do -- what's the take away that people can take away? I think the biggest take away message is that sort of in the words of the immortal Karen Carpenter, we've only just begun. Right? There's an awful lot that we have to do, but so far, what we know is pretty exciting.
It's pretty extraordinary, and we have some really unbelievable evidence, I would say, that, from a neurobiologic perspective, cannabis does change the way that you process information, and may even be changing brain function and structure. I think that's a big take away. We don't see decrements in medical cannabis patients after using. We see improvements in a number of areas, typically -- typically, that show decrements in recreational consumers. That's important.
DOUG MCVAY: Where can people learn about -- learn more about your work, obviously you're publishing, but is there a website for the project, how's that go.
STACI GRUBER, MD: Sure. DoctorStaciGruber.com, like www.doctorstacigruber.com, has a pretty comprehensive look at all of our work, not just in cannabis, but primarily these days that's what we do.
The MIND Program has its own page there, and you can see the latest publications which report a 47 percent reduction in opioid use in the medical cannabis patients after only three months of treatment. So, pretty exciting.
DOUG MCVAY: Terrific. Doctor Gruber, thank you so much.
STACI GRUBER, MD: Of course, my pleasure.
DOUG MCVAY: That was Doctor Staci Gruber from Harvard University. I caught up with her at the Patients Out of Time Twelfth National Clinical Conference on Cannabis Therapeutics, which was held in Jersey City in mid-May. Full disclosure: I work with Patients Out of Time doing website and social media management.
You're listening to Century of Lies. I'm your host Doug McVay.
Also speaking at that conference was Doctor Dustin Sulak. Dustin is a doctor of osteopathy based in Maine, he's done quite a lot of work on pain and opioids, and substitution of cannabis for opiate treatment. He spoke at that conference. Let's give a listen to part of his talk.
DUSTIN SULAK, DO: I love Patients Out of Time. There's something so special about the way that Patients Out of Time has maintained the heart and roots of the cannabis liberation movement that's been around for decades, and even in this time of great change in cannabis, there's something so integral about this community and this conference, and I just love to be a part of it. Thank you.
And so we have some new material today, quite a lot of it, even though, and I really appreciate the full hour to share it with you, we're going to move fast through some of it so we can get to the great content at the end.
So, here are my potential confluences -- conflicts and confluences of interest, and I put it that way because I'm always working to do what's best for my patients and what's best for patients elsewhere, and sometimes for a lot of us in the field, whether we're clinicians or in cannabis business, we have to deal with some of these things in order to best serve our patients, create a sustainable infrastructure for high quality, safe medicine that's used in the right way, and the best way, to help the most number of people.
So I'm the owner of Integr8 Health, which are my medical practices that my wife, Doctor Danielle Saad, who's here, helps me run, she's also the medical director. I'm an equity owner of a company called Healer, that does free patient education, all of our stuff is -- all the patient education we use in the clinic, it's all for free online. Programs for people that are new to cannabis, that are experienced with cannabis, that have specific goals using cannabis medically, it's all there.
We also do industry consulting, extraction and formulation. I was the owner of a testing analytic laboratory, no longer, but that's something that provides services to patients, and it helped me learn a lot about cannabis dosing because people were bringing in artisanal preparations from thousands of different producers in Maine, and we were getting to look inside of them and see what are the active constituents, and what dosages are people using, people who are getting results, people who aren't getting results, and that really informed our practice.
And then I've done consulting work and speaking for some cannabis dispensaries and producers, and I'm also a course director for a CME program, and I'm on the board of directors for the Society of Cannabis Clinicians. If there's any clinicians here that are looking for a professional membership organization that they can be a part of that has access to colleagues who have been doing this for years or decades, and we provide support, please check out the Society of Cannabis Clinicians.
So here's the learning objectives for today. I was asked to kind of review the research from the last year, because last year, we also focused a little bit on this topic, more than a little bit, of cannabis and the opioid problem and what we can do, and there was a lot of need for more research, and actually quite a bit has come out since the last Patients Out of Time, so we're going to review all of that, or, just about all of it, and I'm going to give you my thoughts on those things.
We're then going to do a quick review of the role of the endocannabinoid system in reward and relapse, not nearly as deep as you received yesterday with Doctor Gerdeman, and describe a practical, clinical approach to using cannabis to help reduce and replace opioid medication. So I want to leave you with some really applicable, where the rubber meets the road, practical tips for making this a reality.
So, here's kind of the overview of how the talk is laid out.
Let's start where we left off last year. We had the father-daughter team, Bradford and Bradford, at Patients Out of Time in Berkeley, and they presented this data on medical cannabis laws and the associated decreases in prescribing, in the Medicaid system, of various classes of drugs. And you can see the decrease that was significant in nausea drugs, pain drugs, antipsychotics, seizure drugs, and so forth.
But what they didn't do here in the pain drug is divide this up into opioids and non-opioid analgesics. What they did do, that I really liked, is they showed, wow, if there was, you know, based on this decreased prescribing and dispensing, here's how much the states are saving each year. And if you look at New Jersey for example, about nine hundred thousand dollars for the state, and another nine hundred thousand for the federal government.
And so this is a pretty substantial savings, and this is just having a medical cannabis law, right, not intending to use it to substitute pharmaceuticals, just an association with having the law.
But if we look at a more populous state, like New York, the numbers are a little bit more impressive. Right? Seven and a half million dollars saved per year, just in Medicaid, not Medicare, not private insurance. So a huge amount of cost savings come from sparing prescriptions, and using cannabis instead.
Well, two authors in the Journal of the American Medical Association Internal Medicine, just the beginning of April, published another study that looked at some of this data and took a more indepth look at the pain drugs and opioid prescribing.
And so what they found, well, what they looked at was the time period between 2011 and 2016, and so that included these eight medical cannabis states that implemented their program during that time frame, so states like Maine and California, that had been doing this for a long time, weren't included. They wanted to kind of capture what happens when a state implements the law.
And then they did the same thing for the four adult use states, does that impact Medicaid prescribing of opioid medications? And they found out the answer was yes. And so if you look starting over on the left here, all opioids, here's the bar for medical marijuana laws, medical cannabis laws. About a six percent decrease that was significant, and just a little bit more for the adult use medical cannabis laws.
So just by having these medical or adult use laws, less overall opioids being prescribed.
They broke it down into schedule two opioids and then schedule three through five opioids, and you can see there were some different signals based on medical and adult use, but the -- the take home message is that this was something associated with decreased opioid prescribing.
Now if you look a little more closely at the data, I think it would have been more robust data, except that there were some confounders. What were the confounders? Well, the authors said that Illinois and New Hampshire were not precisely estimated, and these were two of the non-significant decreases, and then also Connecticut, even though it has a functional program, chronic pain is not one of their qualifying conditions.
So, if you're not going to be treating chronic pain, it's hard to really spare opioids, and that's where Connecticut fell on the chart. And then Maryland, they included the data from Maryland, even though the program was so-called active, the dispensaries weren't open and providing medicine to patients during the time frame here. So they had a program but it wasn't functional, and so that data didn't look good.
If you look at the states like Delaware, Massachusetts, Minnesota, and New York, those are even stronger signals, and again, if we look at the states that had legal adult use cannabis, you can see decreases in their opioid prescribing.
Now, the -- so the adult use marijuana laws overall were associated with nearly ten percent lower spending on opioids, and they calculated that this is eighteen hundred dollars per a thousand enrollees being saved on opioid prescriptions being dispensed, and of course the data would change a little bit, but if we extrapolated this to the giant Medicaid system across the country, that has 67 million participants, we're talking about a savings of around 122 million dollars, potentially.
So this is starting to be big numbers, and this is just opioids alone, not all these other classes of drugs that cannabis is saving.
What are my thoughts? Well, one of the things about this study is that they're looking at number of prescriptions, they're not looking at morphine equivalents. So basically, if I'm prescribing someone 80 milligrams of morphine three times a day, and I get them down to ten milligrams of morphine three times a day, that's a huge improvement in the patient's health, in the potential for harm at the public health level, but that's not going to change this data, because it's the same number of prescriptions being dispensed.
So in my mind, what this data is actually looking at more is people who are getting off of opioids, when there's less prescriptions altogether it's not so much showing a taper, it's more showing the discontinuation, and I think that that's -- that's huge, that's a great ultimate goal, but not always what we can do.
The other thought is that adult use is often medical use, and this was revealed by a Forbes study in Colorado, where they found the number one reason that people were using adult use cannabis was to help them sleep. Right, there's a continuum, and it's so healthy for us to think in a continuum, a gradient, not medical or adult, it's always both.
And so many people that are using it for adult use, they get sick, whether it's acute or whether it's chronic, and they start using it medically, or maybe in their adult so-called adult recreational use, what they're doing is using it to enhance the quality of their life, because they feel better, and maybe less likely to use some of these other drugs, and to me that's certainly medical.
So these authors concluded, these findings suggest that medical and adult use marijuana laws have the potential to reduce opioid prescribing for Medicaid enrollees, a segment of the population with disproportionately high risk for chronic pain, opioid use disorder, and opioid overdose. This is a big point, right, these are people who are low income, have very challenging social and economic situations.
Nonetheless, marijuana liberalization alone cannot solve the opioid epidemic. As with other policies evaluated in the previous literature, marijuana liberalization is but one potential aspect of a comprehensive package to tackle the epidemic, and I completely agree with this. It's one aspect, and I think that we need to take this data and the rest of what I'm going to show you today and see how can we use this one aspect and make it as powerful and safe as possible, and then build the rest of the strategy, because not one thing is going to do it all.
In the same article -- excuse me, the same issue, there was another article by the Bradford and Bradford team and some of their colleagues that looked at Medicare Part D prescribing associated with state level medical cannabis laws, and looked specifically at the opioid prescribing.
They found that there was an eight and a half percent reduction in opioid prescribing overall associated the a state medical cannabis law. It was fourteen point four percent reduction in states that had dispensaries, and six point nine percent reduction in states that allowed home cultivation only.
So a bit of a difference there, and both are absolutely important.
If you look specifically at some of the data there were significant decreases in hydrocodone, morphine, those were the two that showed up the strongest. Again, this was only looking at prescribing by drug name, and did not convert the doses into intensity measures like morphine equivalents, so we're not looking at people who are reducing their dose, we're looking at less number of overall prescriptions.
So again, very powerful, but I think the dosage reduction data, which is hard to get at this big data level, that would reveal a lot also, because I'm sure people are decreasing their dose. That's what I'm seeing in the clinic, and these authors had a similar conclusion, combined with previously published studies, suggesting cannabis laws are associated with opioid mortality, these findings further strengthen arguments in favor of considering medical applications of cannabis as one tool in the policy arsenal that can be used to diminish the harm of prescription opioids. I absolutely agree.
What are my thoughts on that study? Medical cannabis laws are associated with people getting off opioids, even when there's no specific program. No education. Often, opioid use disorder is not even a qualifying condition in the state where they have these laws, but it's still taking a big bite out of the problem.
What if we had programs and education? Could we make it stronger? States with no medical cannabis laws can likely make a significant improvement in the opioid epidemic simply by legalizing medicinal use, even home grow only. We don't -- these states that still -- there's lots of states that don't even have laws, so many of us in this audience are spoiled and a lot of us aren't.
All they have to do is make it legal for people to grow their own medicine in their own back yards, and use it, and they can take a big chunk out of the opioid problem. They don't need a big regulatory system, just basic human rights.
Imagine what we could -- [applause] -- imagine what we could do using medical cannabis with intention, and with collaboration. What if we had a collaboration of all these different programs that are funded and working hard to find solutions to the opioid problem? What if we were working together with them? What if we were really figuring this out, oh my gosh.
Now, Patients Out of Time -- if there's even been patients out of time, it's now. There are over a hundred and fifteen people dying of opioid overdose in the country every day, and we could take six, seven, eight, fourteen maybe percent chunk out of that every day, ten fewer deaths, just by admitting that people have a right to grow their own medicine in their own back yard and use it as they wish.
Now is the time, we can't wait around for this. This has to happen now, and there's too many states that still don't have laws.
We've had a lot of success, right, but let's -- we can't sit back and relax, there's still a lot of work to do.
Some more data that came out of recreational cannabis legalization in Colorado, looking at the opioid deaths from years 2000 through 2015, and what they found was after they legalized adult use, they already had medical for a long time, they found that there's less opioid related deaths per month, about point seven per month, and I think the picture says a lot, because you can see this increasing trend in opioid related deaths, right up until the time that they legalized adult use and that that became available to people, and now we're starting to see a decline.
That's pretty impressive. It will be nice to follow that out a few more years and make sure that that's a strong trend. I think it will be. Right? And that's just one state. Again, imagine what if we had descheduling, federal legalization, what would we do to that 115 people dying a day, can we chip away at that number just by changing the laws? Even without collaboration and education and thoughtful programs around this, I think that we can, just by changing the laws.
Now, how is this possible? Why are we able to just change a law and suddenly see opioid use, opioid related deaths, hospitalizations, and so forth, decrease? Because the cannabinoids and the opioids work together. Here's a review article that came out in the last year, that looks at 19 pre-clinical studies that basically gave an opioid and a cannabinoid to rodents and pain models, and what they found was that, when you add THC to morphine, the effective dose of morphine is three point six times lower than the effective dose of morphine when it's used by itself.
When you add THC to codeine, the effective dose is nine point five times lower than the effective dose of codeine on its own. If we saw even a fraction of that drug potentiation in our patients, this would be a major win, and we are seeing it. This is happening, and for the first time we have some really high quality human data that came out of Ziva Cooper's group, just a few months ago, from New York, that looked at an experimental model of pain and the combined effects of various doses of oxycodone with either placebo THC and real THC.
So there were six sessions, people received different combinations of either zero milligrams oxycodone, two and a half, or five, and either zero percent cannabis -- zero percent THC cannabis, or NIDA five point six percent THC cannabis. In joints. And these were already cannabis users in New York, so -- but anyways, they were exposed to the cold pressor test, which is dunking their hand in ice water, letting it sit there until they first feel pain, keeping it there as long as they possibly can then withdrawing it, rating the pain.
They rated how much they liked the cannabis, how much they liked the pills they were given, and all that was put together. They were also given a chance to buy more puffs of cannabis at the end of the day, using some of their study money. More puffs of the NIDA five point seven percent cannabis. Not too many took them up on that offer though.
DOUG MCVAY: That was Doctor Dustin Sulak, speaking at the Patients Out of Time Twelfth National Clinical Conference on Cannabis Therapeutics in Jersey City back in mid-May.
And that's it for this week. Thank you for joining us. You have been listening to Century of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I’m your host Doug McVay, editor of DrugWarFacts.org.
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We'll be back next week with thirty more minutes of news and information about drug policy reform and the drug war. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!
DOUG MCVAY: For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.