When the medical community makes mistakes, it’s like shooting down a few hundred airplanes every year. That’s a dramatic metaphor that has stuck in my mind since I first heard it from a doctor, and an apt way to describe a pathological marketing system that allows companies to push dangerously addictive drugs to the public, and to doctors. It could describe both the mistakes of opioid makers and the emerging problem of nicotine addiction through vaping.
Starting in the 1990s, drug makers encouraged the term “opioids” to replace the scarier term “narcotics,” as they began aggressively marketing a new set of painkillers. Opioids were once reserved for people with terminal conditions, such as cancer, but an influential 1986 paper started a trend toward opioid use as a “humane” way to treat other painful conditions. By 2014, doctors in the United States wrote a staggering total of 245 million prescriptions for opioids. Meanwhile, while teen smoking rates have plummeted, vaping among teens is soaring. 20.9 percent of high school students surveyed in 2018 admitted to vaping, up from 11 percent in 2017.
The medical community’s error in both cases comes down to a failure to respect addiction as a disease. Doctors should have been trained to recognize and understand addiction, and they, as well as insurance companies, regulators and others have failed to balance the risks of addiction with the benefits of alleviating pain or helping a patient quit smoking.
The problems with opioids are now obvious, but we are only beginning to learn about the risks of vaping. As with opioids, some in the medical community initially hailed the devices used for vaping — electronic cigarettes — as beneficial, since they are likely to drastically cut the risk of lung cancer in people with incurable nicotine addiction. These addicts could satisfy their drug cravings without the cancer-causing tar they would get from cigarettes.
The downside is that for non-addicts, starting an electronic cigarette habit is likely to cause addiction, and that in turn puts users at risk of other problems. First, there are unknown long-term risks. Nobody knows what might happen to people after vaping for 20 or 30 years. And now there’s a rare but immediate threat: Over 500 people have been treated for an acute lung disease, from which at least seven have died so far. This is a small number compared to the 480,000 annual deaths associated with smoking, but some young people are now switching from vaping to smoking, reasoning that the risk of lung cancer decades into the future is preferable to even a tiny risk of dying of a weird new disease before their next birthday.
How can the medical community respond? One solution is to develop, standardize, and test electronic cigarettes as a prescription medical device, and advise a ban on the marketing that promotes them as a multi-flavored form of recreation. Methadone has uses for helping heroin addicts, for example, but we’d be horrified if companies started to market it as something fun and cool — particularly if they aimed their marketing at kids.
In the U.K., the medical community has acknowledged that e-cigarettes could benefit addicts, and various sorts of clinical trials are underway to document harm-reducing potential. To do that here in the U.S. we need a standardized device, Nora Volkow, an expert on the neuroscience of addiction and the head of the National Institute on Drug Abuse, explained in an interview. It’s impossible to test the great variety of devices out there now, some of which can deliver extreme nicotine doses equivalent to an entire pack of cigarettes. The flavors and potential to smoke cannabis add to the complications — and there’s some evidence that this new acute lung diseases is tied to cannabis, even if not all patients admit that’s what they were vaping.
Smoking and vaping may not be known for giving people the intense high associated with cocaine or opioids, yet the power to addict is anything but mild, Volkow said. She has looked at the way this drug affects the brains of laboratory animals, and explained that nicotine gets into and out of the brain rapidly, altering circuits involved in rewards and, in essence, training the brain to get repeat hits. The drug alters reward circuits that affect the way the brain responds to other forms of pleasure.
Both nicotine and opioids cause two separate neurological effects: dependence and addiction. Dependence is a disruption of people’s body chemistry, leading to withdrawal symptoms if they stop. Opioid patients can develop extreme nausea and vomiting from withdrawal, while nicotine users tend to get irritable and fatigued. When people are addicted, however, the brain undergoes long-term changes and they can crave a drug even years after quitting. That’s good reason to stay away from nicotine, but also good reason for the medical industry to help those who are already afflicted.
With opioids, the benefits were clear, while the risks were underplayed. Today, companies like Purdue Pharma and Johnson & Johnson have been asked to pay heavily for their role in that crisis. With vaping, while reports on the sudden deaths have led to categorical calls for a ban, Volkow sees a different road forward. “If you analyze what’s responsible for the deaths and study how you can potentially use the devices in a way that’s beneficial [to nicotine addicts]…then my perspective is we should look into it.”
In both cases, some of the casualties might be alive today had doctors better understood addiction as a disease — one that medicine can help treat, but in some cases has helped spread.
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