Addiction Medicine Policy: First, Do No Harm


January 05, 2015

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Hello and welcome. I'm Dr George Lundberg, and this is At Large at Medscape.

As I see it, being a physician is all about individual patient/person care:

Helping patients stay healthy;

Helping them get well if ill; and

Managing their chronic diseases when cure is illusory or impossible.

For public health (and policy), there are the same big three aims, multiplied many times and including prevention of patients' harmful effects on others. "Illness" equals the state of being harmed. Practicing medicine and public health is preventing, eliminating, reducing, controlling, countering, diminishing, lowering, or lessening the likelihood of harm to an individual and to many individuals.

I have been writing and speaking about drugs of abuse in the public arena since about 1969. If you are interested, check PubMed or Google. Or you can search and find similar offerings of mine on many electronic pages of Medscape.

Most organized civilizations have attempted through the ages to get rid of the harmful effects of addicting substances by getting rid of the substances or drugs. Great idea. Never has worked. A free society simply cannot do that successfully.

So, if one accepts these premises, then harm prevention, harm diminution, and harm control are what the practice and policies of addiction medicine must be all about.

In the big picture of public policy in 21st-century America that reflects the rubric of preventing, diminishing, and controlling great harm from three common addicting agents, three evidentiary truths have emerged:

1. Tobacco (because of tight nicotine addiction) kills more Americans than anything else, other than old age. On the basis of substantial current evidence, e-cigarettes allow the otherwise uncontrollable nicotine addiction to continue, but without the killer pathologies produced by tobacco smoke. Their use by serious nicotine addicts should be maximized.

2. Cannabis, while seriously harmful for some people, overall has vastly less potential for harm than almost any of the other psychoactive and addicting agents. Enforcing the American laws pertaining to cannabis has been hugely harmful to individuals, families, society, and economics. The intelligent American public has acted on its good common sense by voting to change those laws dramatically, at long last. Our local, state, and federal prisons should be emptied of vast numbers of nonviolent inmates who were wrongly incarcerated for simple cannabis possession. One could make a case for replacing them one by one with the evil-spirited politicians and law enforcers who, out of ignorance or ideology, put them in the slammer. Approval of medical marijuana is a no-brainer. Decriminalization and regulation of cannabis for entertainment is almost as simple a call.

3. Opioids. The USA is now in the throes of new waves of drug trouble. This time, it was hatched from the "law of unintended consequences." The Joint Commission, the Federation of State Medical Boards, and many others wishing to counter pain—and under the influence of Big Pharma drug money—have succeeded in making pain the fifth vital sign, which seemed like a good idea at the time. Not so good? Americans have a lot of pain. US physicians are, especially now, striving for high patient satisfaction scores. Ergo, many prescriptions for pain-relieving substances. However, oral opioids often addict and can kill by overdose. Not only can, but do. A lot. Recent strong education and narcotic policy changes may begin to turn this ship around.

These are three big issues. Great improvement in reducing harm in all three big drug arenas is within our grasp. Don't blow it.

That's my opinion. I'm Dr George Lundberg, At Large at Medscape. I look forward to your comments.


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