There are knowns and there are unknowns, but the hardest to stomach occurs when the evidence is revealed about the thing that you know and still it steals your breath.
We knew about the relationship between opioid manufacturers and distributors and the public, but now we know: over a seven-year period, 76 billion pills flooded American pharmacies. The question, of course, is what do we do?
Before I share a personal experience with opioids, followed by potential solutions, let me mention I take no issue with pharmaceuticals or doctors. Both play critical roles in extending and bettering human life. In my Big Think column, I regularly cover research in science, health, and fitness. What works is what we need to harness and exploit, regardless of from where it arrives.
Yet if the people and institutions we are supposed to trust abuse their relationship with us—in the case of opioids, that is indisputable—then we need to force the system to change. We need to be active participants in our health care, not defaulting to advice from those with compromised interests, and certainly not buying into commercials with quick cuts and bright colors designed to distract from the numerous lines of small text sprinting by.
One year, 240 pills
Over an eleven-month period in 2014-15, I had two surgeries at UCLA Medical Center in Westwood: one for testicular cancer, the other a meniscus tear.
I really enjoyed my time at UCLA. I only left when my insurance option vanished and I joined Kaiser Permanente under my wife’s plan. My general practitioner was great, the oncology team amazing, and the orthopedic team—there’s serious work in patient relations needed there. But I still trusted them to do a good job with my knee, which they did.
The problem in both situations occurred post-surgery. First, cancer.
A small incision six inches below my belly button created an entry point for the removal of my right testicle. Minimal pain, most of my mobility retained, I began doing Feldenkrais exercises the following day. Three days later I was in the gym modifying my workouts. So I found it somewhat odd that I had received 30 Oxycodone tablets with a script for three more refills. They’d given me access to 120 pills for a cut that I stopped feeling after two days.
I took one pill the morning after my surgery, which resulted in a stomach ache. Four hours later I ate a 5 mg cannabis cookie and the pain subsided.
A month later I underwent my one and only round of chemotherapy. It didn’t hit me for nearly 24 hours, but when it did, I immediately gained enormous respect for people that endure multiple injections. My oncologist had given me more pills of some sort, but I only reached for the edibles.
On my follow-up, she asked me how it went. “Great,” I replied, adding an addendum.
“You gave me access to 120 opioid pills. I know that you’re restricted by law to not discuss marijuana, but following both my surgery and chemotherapy, cannabis helped alleviate my pain and made me hungry again. I truly hope the medical profession can change quickly enough to reflect methods that work because the others are dangerous.”
She smiled while pursing her lips tight, like words being shoved back inside.
Roughly a half-year later I’m back at UCLA dealing with the ravages of a recurring meniscal tear. You spend your life devoted to a passion and, as the gods laugh, your undoing is an awkward millennial clipping your thigh when the basketball is halfway across the court. A lagging running injury that first occurred while training for a half-marathon during a Brooklyn winter defeat finally made me admit defeat.
A week after the surgery I had to ask my surgeon why there were four holes in my leg instead of three, the number of incisions I was informed of before succumbing to anesthesia. You can imagine my surprise when unwrapping the cotton gauze to discover a mysterious cut.
“It was a really bad tear. Half of your meniscus was folded under the other half. We had to make another incision to get to it.”
“But you didn’t tell me about it after the surgery.”
Some excuse about Do I know the number of surgeries I have to conduct in a day, which, while deserving of its own essay, signals a moment for digression: 30 Oxycodone pills, three refills. 120 pills. 240 in less than a year.
I walked out of surgery without crutches. The following day I’m practicing Feldenkrais, three days later back in the gym performing mobility exercises.
Again, I take one pill. Like the last bottle, I flush the other 29. I never bother mentioning cannabis because I never see him again.
And this was supposedly a bad tear.
I’m above average for opioid prescriptions, at least that year, at least where I live. Los Angeles County averages 21.9 pills per person, per year. That’s still a ridiculously high number, but relative to Charleston County, South Carolina, at 248.3 pills per person, Angelenos will more quickly see their plastic surgeon at the slightest hint of existential distress or psychological duress. Other regions of the country are being pumped full of painkillers.
People are in pain, for many reasons. There are legitimate uses of opioids when temporary and targeted to a population in actual need, as designed. If they are the best short-term solution, so be it.
But we know that’s not what’s happening.
The Democrats are currently mired in a debate about incrementalism and radical change in preparation for the 2020 election. In pain management, in cases of both physical and mental health, we are in no position to rely on incremental changes.
Over 70,000 Americans died from opioid abuse in 2017. The annual increase in overdoses correlates perfectly with the rise in pills sent to pharmacies nationwide. Opioid distributor Miami-Luken alone pumped 11,390,120 pills into circulation between 2006–12. Others were not far behind.
Pain is a signal that something is wrong. Amazingly, our brains send similar signals for physical and emotional pain; Advil has been shown to help relieve emotional distress (intriguingly, in women; in men, it appears to exacerbate it, though earlier research contradicts that claim). While there are plenty of cases of chronic physical pain that need ongoing medical attention, pain tells us something is awry, regardless of whether it stems from nerve disorders or a broken heart.
The efficacy of cannabis in pain relief has predominantly relied on anecdote. As the NCBI reports, THC shows promise in helping certain ailments, though in other cases it seems to intensify pain. Since marijuana is still a Schedule 1 drug, researchers have been hesitant to experiment. In the wake of widespread legalization for medical and recreational usage, that is quickly and thankfully changing.
One important marker: in states that have legalized marijuana, opioid usage goes down. Efficacy rates of marijuana might be contentious, but the potential for overdosing is not. You’ll find no chart regarding marijuana like the one above. Once the stigma of illegality is overcome there is the potential for even more positive results, as distrust and efficacy are often at odds in brains susceptible to the placebo effect: we don’t create the totality of our reality, but we certainly invent the stories we want to tell ourselves.
In most situations, physical pain is mitigated through regular exercise, good postural habits, and a healthy diet. For mental pain, from heartbreak and depression all the way through to suicidal rumination, the evidence is building for one class of alternatives.
The 32-year SSRI experiment, beginning with Fluoxetine in 1987, has proven to be predominantly ineffective, particularly as a long-term solution. With 13 percent of Americans taking antidepressants (a 65 percent increase in 15 years), there’s too much at stake for an incremental approach.
Which is why the federal government needs to declassify psychedelics. The studies are supporting potential efficacy for a variety of ailments. The story of danger, like the story of the opioid crisis, was a targeted attempt to silence minorities and radicals in American society. Organic life requires chemistry, which serves as the delivery mechanism for all treatments, sanctioned or not. What matters is whether or not it works as intended.
There are a number of psychedelic substances making headway in American culture. Below are the top four.
Ketamine: This anesthetic, first synthesized in 1962, was approved for use in treating depression by the FDA on March 5. This is a breakthrough for a community that’s been reliant on SSRIs for over three decades. Recreational users will experience mild to severe hallucinations (the infamous K -Hole is the single worst psychedelic experience I’ve ever endured; dosage matters) and enter a trance-like state. Under proper supervision, it is being touted for rapid-acting depression relief. Ketamine has also shown positive results in treating postoperative pain and acute pain, and as an alternative to opioids in the emergency room. Under its clinical name, esketamine, it is the first psychedelic to be approved for prescription use.
MDMA: Look no further than MAPS for extensive research on this incredible substance. The organization is devoting over $26M in an effort to make this an FDA-approved prescription medication by 2021. First synthesized in 1912 when Merck scientists were developing solutions for abnormal bleeding, it was initially used as an appetite suppressant. While there are no hallucinations, MDMA binds to serotonin-2a receptors, as does LSD and psilocybin; it also binds to dopamine receptors, part of the reason it feels so good. MDMA has shown positive results in treating PTSD, social anxiety in autistic adults, and existential distress. It has also been used in marriage counseling, as well as to treat pain in late-stage cancer patients and, anecdotally, chronic pain.
#377: Psychedelics - Microdosing, Mind-Enhancing Methods, and More
This episode features a panel that I moderated in front of a standing-room-only crowd at the Milken Institute's Global…
LSD: Little clinical research on LSD has been done, but that hasn’t stopped an entire movement of people from microdosing this powerful psychedelic to lift their mood (reddit/microdosing has over 62,400 members). A pilot study in anxiety reduction is underway. Albert Hoffman is nearly a mythical figure. He first synthesized LSD in 1938 from the fungus, ergot, shelving the concoction for five years until instinct told him to pull down the jar from a laboratory shelf. A few drops sunk into his skin; he started hallucinating on his bike ride home. While LSD itself has spawned countless personal mythologies, at a small enough dose it appears to help alleviate depression and anxiety.
Psilocybin: It’s impossible to know how long “magic mushrooms” have been used ritualistically—numerous millennia, probably longer. The active ingredient, psilocybin, is in over 200 varieties of mushrooms. As with non-hallucinogenic mushrooms, dosage matters. Psilocybin is especially toxic when combined with other drugs, especially alcohol. A study at Imperial College London found that psilocybin helped alleviate severe depression. And, of course, the famous NYU study that found that psilocybin helped end-of-life patients make peace with their destiny that rekindled interest in psychedelics.
I’ve watched a number of friends battle a variety of addictions, but nothing was as painful as watching someone very close to me nearly die of opioids. His job is physical and demanding. One prescription led to another led to another led to…
Fortunately, he’s recovered, not having become another statistic. A lot of people cannot write that about someone they lost because a group of men in a board room discussed methods for maximizing profits and the person you loved just happened to be a sacrificial lamb in their billion-dollar plight.
I’ve enjoyed psychedelics, recreationally and therapeutically and simply because I’m a curious person, for twenty-five years. Are they the answer? Depends on the question you’re asking. They’re not a panacea, but they’re certainly not as dangerous as alcohol or cigarettes or over-the-counter medications. That’s another lie that’s been sold by men maximizing profits, only this one political capital.
We need to explore psychedelics seriously. Too many people are suffering from too many wrong reasons. The time has come to rewrite a narrative that never served us in the first place.