This transcript has been edited for clarity.

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

I was sitting around my Santa Clara Valley, California, home this fine morning, trying to figure out what I might talk about for the Medscape audience. I like to discuss topics I know at least a little bit about from personal or professional experience. I also like to choose topics that the typical Medscape reader also knows at least a little bit about, so I can push some sensitive buttons to try to stimulate instructive dialogue.

Psychoactive drug use by Americans is one such topic.

I began serious work in this field in South Texas in the late 1950s, drawn by the huge number of cases of lung cancer I was seeing at autopsy and the virtual universality of tobacco cigarette use (not yet called nicotine addiction) among them. The landmark Hammond and Horn JAMA paper[1] did not appear until 1958 and was largely scoffed at early on, as was fatty liver cirrhosis and ethyl alcohol. Then in 1962, in San Francisco, we ran into acute amphetamine poisoning and soon thereafter experienced the "speed freak" epidemic.[2]

After that, clinical toxicology[3] and street drugs[4] in Los Angeles taught me so much. (Sorry, but those references are probably still behind paywalls.) And there is much that followed, but let's move to this decade, to open access.

On Medscape, some recent discussions include:

That's a lot!

How is the United States doing on all of these drug issues in 2019? Not very well, I would say, although we must always remember that the United States is a large country, with huge diversity of geography, politics, people, knowledge, cultures, beliefs, mores, standards, experiences, and outcomes. One state, county, city, or neighborhood experience with some drugs may differ drastically from others, even nearby, so generalities are fraught. Nonetheless, I venture into awarding 2019 grades at US efforts to address these issues:

Alcohol: C–. We have largely beaten drunk driving, but binge drinking, youth boozing, mass advertising—including advertising aimed at young people—and widespread consumption are thriving.

Tobacco: B+. Where I live, I may go months without even smelling tobacco smoke. Age limits for legal access are increasing, and e-cigarettes are helping many smokers to cut down. Widespread marketing and sales of legal oral products such as Swedish Snus could also help a lot of smokers.

Nicotine: D–. Whereas vaping nicotine may help many combustible tobacco addicts, failure to control marketing and sales of noncombustible nicotine vehicles to vulnerable young people is creating whole new generations of nicotine addicts.

Methamphetamine: F, in many environs. We have a poor knowledge base for therapy, as well as inadequate funding for prevention and law enforcement.

Heroin: D–. Heroin use fluctuates wildly based upon geography and economics; availability of successful treatment is similarly variable.

Opioids: F–. This is a multilayered issue: research, pharmacology, education, manufacturing, marketing, distribution, sales, the omnipresent "grease" of money, charlatans, failed morality, ethics, professionalism, institutions, regulators, and law. Finally, some prosecutors are pursuing criminal charges for criminal actions, and jailing some who are convicted, rather than allowing guilty executives to be "punished" by corporate fines, which are no deterrent for bad human behavior.

Cannabis: A to F, depending on political boundaries. "The people," having learned from experience, have been the driver for good-sense law reform. But most professionals, organizations, institutions, and governments, especially federal, have continued to be the problem, not the solution. Legal medical marijuana now works for large swaths of our population; recreational marijuana is not far behind. Still to be done: freeing hundreds of thousands of prison inmates falsely incarcerated for nonviolent cannabis charges.

Magic mushrooms: A for Denver, Colorado. Not legalization, but decriminalization. Expending significant law enforcement resources chasing this trivial issue is so senseless.

Drug politics: B+ to F–. Highly variable by state, region, education level, ideology, economics, ethnicity, bias, and culture. In general, "conservatives" wish to conserve their comfortable past and present; "progressives" perceive situations that need change and work to achieve such. The status quo versus change is incompatible and destined for strife.

Who is hurt by all of this? The American population, writ large. The drive to take psychoactive drugs is overwhelming to many people. Widespread availability presents no effective barriers to access. Education at all levels has been lacking. Hypocrisy and greed are rife. No large groups have escaped the ravages of this multifaceted problem.

Am I hopeful? Hope springs eternal, it has been said. But eons of reality dampen enthusiasm. Humans are frail. Drugs are available. Major problems will continue. Huge, disruptive initiatives in other countries such as Uruguay, Portugal, Canada, and Mexico need to be watched as experiments, the results of which could sensibly inform future US drug policies.

That's my opinion. I'm Dr George Lundberg, at large at Medscape.

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