We consider the growing popularity of e-cigarettes from the perspective of harm reduction – while the nicotine addiction continues, the e-cig doesn’t have all the tars, resins and carbon monoxide of smoking tobacco. Also some thoughts on harm reduction through substitutions – like excessive exercise, obsessive 12-Step meetings, etc. PODCAST.
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Transcript (edited)
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions I am Howard La Mere. Today I want to talk about harm reduction. There are a number of stories that popped up that are in one way or another related to harm reduction in the context of drugs and addictive substances. David Nutt, a professor of Neuropsychopharmacology at the Imperial College in London came out with a statement saying that the laws banning cannabis actually psychoactive drugs in general, but especially cannabis and magic mushrooms are too severe and block serious scientific research. Another article talks about the phenomenal rise of e-cigarettes, electronic cigarettes. As we all know, smoking is the #1 or #2 health danger in this country and likely in the world. So, the tobacco industry currently is something like 80 billion dollars in the U.S. and the e-cigarette has taken a chunk out of that in the years that it has been around and it hasn’t been around that terribly long, but it is definitely attracting a lot more interest. And the interesting thing is that various governments tried to get in the way of sales as they seem to have done with a number of other harm reduction techniques. And one has to ask why? And so I’ll ask that question, Darryl.
DARRYL: Well, Howard, it’s a global market. Nicotine or tobacco generates billions and billions of dollars every year on a global basis. In America as you mentioned, only 80 billion dollars and I’m sure that’s multiplied by at least double or triple if you look at worldwide sales and e-cigarettes according to the New York Times are at a crossroads. They’ve risen to a point of prominence that major U.S. tobacco companies have invested in them and every tobacco company here in the United States can see the writing on the wall that this is a potential money maker. In Europe or globally, e-cigarettes have increased 30 percent over the last 3 years up to 2 billion dollar market and continues to grow. It’s become almost chic to pull out an e-cigarette akin to what it was like smoking cigarettes when they first became available in the early 1900’s and in the 50’s when Hollywood glamorized smoking. It was a very, very chic thing. It was an in thing to do. Today there are very classy shops, uptown shops in Paris where people wait in line when a new flavor of nicotine liquid e-cigarettes comes out. These liquids are flavored from peach and pina colada to Marlboro and Lucky Strike people are interested in trying different exotic flavors that are and line up to try the latest. So it seems clear that, well, it’s always been clear addiction sells. I mean if something is addicting, it’s going to sell even if it makes you feel bad, it’s going to sell.
HOWARD: I think that’s what we call consumables.
DARRYL: Feeling bad but still consuming
HOWARD: You don’t buy it just once.
DARRYL: And the issue is if something is addictive and consumable somebody will make money from it. And of course the FDA is concerned about this because people are ignoring the whole addiction issue and maybe even the health issues. They’re correct in saying there has been no long term research on inhaling these nicotine liquid products what health issues they’re going to cause.
HOWARD: They haven’t been around that long.
DARRYL: There’s been absolutely no studies done and they are becoming much more sophisticated. These new products are 4 to 500 dollars for a computerized e-cigarette, the flavors are more and more exotic and the computer that dispenses the substance is able to actually measure how much a person is using and release it accordingly. I think people see the writing on the wall that this is going to become a huge market and the FDA tried to regulate it as a drug delivery system, as a drug device system and amazingly they lost. We have a sort of an exemption for tobacco. I don’t know if the exemption was toward nicotine or exemption toward tobacco that said if something.
HOWARD: I think tobacco was grandfathered in because it’s such a legendary part of the country.
DARRYL: Maybe it was tobacco. This isn’t tobacco. This is the active chemical of tobacco, nicotine. But there is a ban on selling anything that’s carcinogenic and yet there’s an exception for tobacco because it was so important to our society or agriculture or whatever. Now we have nicotine. I don’t know if the exception bans nicotine, but the FDA could not control it. They couldn’t ban the substance and so it’s exploding is this going to become the new thing? Some people are actually predicting that within the next 10 years or so, e-cigarettes are going to outsell tobacco.
HOWARD: That would be amazing.
DARRYL: Well, tobacco companies have been doing this for a hundred years. They’re smart. They know how to flavor things. They know how to tease things out.
HOWARD: We’ve talked before about menthol being a popular flavor component. The U.K. has decided that it’s going to follow the FDA and attempt to regulate it and put it under the medical umbrella.
DARRYL: That will be interesting because I have a feeling they’re going to be able to win as well because I don’t know if there’s been long term or any research on nicotine per se. There’s been research, of course, on tobacco and how dangerous that is.
HOWARD: But it all comes down to the question of: is it positioned as a medical treatment for smoking or is it simply a different form of amusement?
DARRYL: I think that’s a great question, great perspective. I think it’s sort of inferred and I’ve seen it inferred that way from people who sell it also people who use it and in the ads this will help you quit smoking tobacco.
HOWARD: If you want to.
DARRYL: And it seems to work for a lot of people. For some people it didn’t work at all and they went back to tobacco and some of those people went back to tobacco then went back to the e-cigarettes once they found the 4.99 or the 49 dollar e-cigarette just didn’t quite do it that it was the 200 dollar model or 300 dollar model that actually gave lot more nicotine boost. The thing that’s being missed here is that nicotine, not tobacco is addictive. And somehow tobacco and nicotine got lumped together which created ripples in the laws that continues to persist and continues to grow. It’s kind of shocking to me that smoking has been relegated to kind of a secret thing. You don’t want to tell people you’re a smoker. You hide you go outside and don’t let people see you smoking. But what’s happening in Paris and what I’ve seen in the people I know who have gone to e-cigarettes, they’re kind of proud of the e-cigarette thing and just blow the vapor out. So, this product is in a phase of being chic. Whether it does major damage to the brain or to the body, we don’t know. We do know nicotine is addictive but we’re talking about harm reduction and this is definitely a harm reduction product. There are no completed studies, but it looks like there are not a lot of major biological problems as there are from exposing your body to the tars and to the resins that are in tobacco. But there may be some other medical consequences we don’t know of yet.
HOWARD: Let’s draw a corollary to the other kinds of harm reduction that have been tried and implemented. Needle exchange comes to mind. Methadone comes to mind. And I’m sure there are others. Do you see any corollaries?
DARRYL: Well, I think harm reduction is indeed a viable approach. You intervene, not the addiction but mitigate the medical problems the addiction causes. I view harm reduction with the understanding these things do cause addiction (as in methadone) as well as the harm that we’re trying to prevent. Addiction itself is very harmful and therefore, you know, a good thing to consider while you’re trying to keep yourself healthy is maybe trying to keep yourself real healthy through abstinence and recovery. But having said that, we certainly have seen a great intervention in the spread of HIV with the needle exchange processes, the bleach bottles, the passing out of condoms, these have almost stopped it in its tracks. HIV is still around but we stopped the explosive epidemic a major harm reduction success story. Another example is almost an underground self made movement the dispensing or the availability of Naloxone, Narcan, the antagonist to opiates. This follows the growth of both prescription opiate abuse and an increase in heroin abuse the availability of this in cities like San Francisco and some states allow this antagonist to be sold in a syringe so people can have it in their medicine cabinet so if someone overdoses they don’t have to die. And it’s being credited with saving lives already, so that’s harm reduction that is effective. The one thing I heard on the harm reduction aspects of e-cigarettes is that it is not a treatment for nicotine addiction, but a true harm reduction replacement quit smoking cigarettes and get your nicotine through e-cigarettes. If a person smokes e-cigarettes over their lifetime, it is equivalent to smoking about 18 minutes worth of a tobacco cigarette and that was very convincing to a couple of my friends who said, hey, we haven’t been successful quitting smoking, so let’s try this – they spent a little money on the more expensive items and they’re doing well on it. They like it. If these will ever be allowed in the workplace or in casinos or other public places is yet to be seen because I don’t think the side stream effects have been determined. You can certainly see the vapor coming out of people’s mouths and there is probably some escape of the nicotine in the liquid. But whether or this will harm individuals who are exposed to it and don’t smoke for instance, for every 8 people who die of nicotine or tobacco addiction every year, one person dies who didn’t smoke at all but was exposed to the side stream secondhand smoke. Is it harm reduction if somebody continues to become more addicted and therefore more dependent upon nicotine? I’m not sure yet. This will be a good test case for defining harm reduction. When harm reduction is applied to something like heroin is it valid if we support the continued use of heroin through clean needles and other harm reduction techniques and people continue to use and could overdose or die or might have some sort of horrible thing happen to them with their addiction. I consider it harm reduction only if the harm that they are experiencing through their use of a substance decreases. If they are harming themselves more – if they’re overdosing, if they’re experiencing more biological problems even though they’re using clean needles I’m not sure that fits my definition of harm reduction. I know we have to look at a different way of identifying it. The comments by Dr. David Nutt, who I still think has one of the most amazing names for a drug czar in this field, may be validated in that the laws make it difficult for people to do research. But the key:
HOWARD: The laws were clearly political. They weren’t scientific from the get go.
DARRYL: And because they were political and not scientific, there are loop holes, or allowances in these laws for legitimate research and I guess what he’s complaining about is that those allowances will only be applied to people who’ve got the funding, people who’ve got institutions behind them, people who’ve got a history of doing this research but if you are just a doctor in the field or someone interested in exploring how marijuana works the law prohibits that kind of use. There is ongoing research exploring marijuana medically, ecstasy medically, and Ketamine medically. If you have a valid research capacity and you’re following all the laws, even though the substance is classified Schedule One, you can do research on it, but it costs a lot of money to and maybe the laws really limit who can get involved with it.
HOWARD: It sounds like it’s really hard to get into. We touched briefly on a few other harm reduction techniques and a related aspect is transferral and what I’m thinking about here is another article about people using exercise as a form of either coping with their addiction or acknowledging the fact that it is an addiction onto itself because it releases brain chemicals that are very analogist to the ones that psychoactive drugs release. How do we characterize this?
DARRYL: Well, I’ve always been an advocate of exercise. There are positive addictions that can promote health versus negative ones that take health away. And exercise could do both. Something can have positive effects on your life as well as negative effects on your life. And the key to controlling those effects is or monitoring it and knowing when something enters your life in a negative fashion and then intervening or doing something about it so it doesn’t have negative effects on you. Exercise, definitely releases your own brain chemicals, endorphins, especially are going to be released and many opiate addicts I know have gotten into recovery through jogging or other kinds of exercise. Now, if they get so obsessed with it and that can happen because their addiction pathway is already tweeked if it becomes so obsessive that it causes major hip replacements, broken ankles, sore muscles, and things.
HOWARD: That seems to happen to everyone these days!
DARRYL: Well, it does happen to some extreme runners. You sometimes see runners with a brace on after a hip replacement and they are out there trying to jog and keep up with everybody else. What’s up with that? That’s kind of crazy if you ask me.
HOWARD: And they’ve got a sprained ankle or broken
DARRYL: That’s addiction. Yes, that’s addiction.
HOWARD: That’s nuts! That’s what that is!
DARRYL: Well, we call it nuts because we are normies. If you’re an addict, it’s part of what you do. It’s part of what you need to do. Many people think that 12-step programs, or a spiritual devotion is an addiction in and of itself and that many addicts will go from being dependent on cocaine or heroin or Vicodin and all of a sudden experience organized religiosity that is pleasing to them and they become obsessed with that pleasing thing. I was just talking to someone recently who said that their dad was an alcoholic their whole life and they really were hurt by it and they missed him because he was always gone every night drinking and then he finally got sober, he finally got into AA and 12-steps, but she said, you know what? He still was gone every night because he was addicted to going to those meetings so he never showed up at home. So there are positive and negative addictions. We do know that exercise releases those brain chemicals. I’ve been impressed with what’s called “laughter yoga” a yoga practices where you force yourself to give a big hearty, belly laugh, that releases oxytocin, the feel good love chemical in your brain, so it’s something to feel good about.
HOWARD: I’ve always known laughing is good.
DARRYL: It is. It feels great. It releases a lot of endorphins too as well as oxytocin. There are studies show that certain yoga poses cause an increase in the brain’s GABA level the natural chill out or relax chemical, by up to 30%. So all of these things are tied into natural chemistry and I think it’s a healthy way to get away from the toxins in drugs which are external which are synthetic which mimic your natural brain chemistry and therefore cause those natural brain chemicals to stop being produced. Exercising instead of shooting heroin usually makes it easier and easier to produce those feelings that you want to feel. I guess you can get off on wanting to exercise as much as you can but you stay healthy because your brain is producing a natural substance. The DMS identified an actual exercise addiction that can hurt people, but if you get into it that deep, it’s easier to reproduce the feelings, the feelings get stronger and stronger, and you stay fairly healthy as compared to using heroin to produce the same feelings in your brain. So, I’m not so sure where I stand on all that, but I still think positive alternative addictions are much better than sticking with the drugs and the toxins that people put into their body.
HOWARD: Well at least it’s different and there’s always something to be said for something different. Because hopefully it’s not worse, but it’s different. And it’s doing something.
DARRYL: Speaking about different let’s look at the DSM-5, I guess they copped out on some of the things that they couldn’t clearly classify like caffeine and internet gambling and they decided to put them in a new category that’s not exactly in substance related and addictive disorders, but in a category called, Conditions for further study. So they’re mentioned, they’re not ignored, but they’re not fully accepted even though they do give the whole symptomatology and the diagnostic criteria for caffeine addiction and what it can cause. It’s related as a condition for further study and not fully accepted.
HOWARD: Well, I guess we can anticipate some revisions
DARRYL: We mentioned David Nutt earlier and I am reminded of an article about how the UK is treating alcoholism over the last 10 years, prescriptions to treat alcohol addiction, alcoholism, in Great Britain has risen 75% and just within the last year it was up another 6% and medications are being developed rapidly. The medicalization indicates an understanding of addiction that it’s beyond harm reduction. There are actual differences in the unconscious mind that need to be addressed to help people get healthy and medications like even the old standby Antabuse have been revisited. In Europe, maybe in Great Britain too, they released Selincro I think it is called Selincro, chemically nalmefene is like Naltrexone really it’s an oral based opiate antagonist that has more specific effects it sits on and blocks those receptors. It is being examined as something that blocks the stress mechanism it blocks receptors in the VTA and the stress experienced by people once they get addicted they continue to feel just lousy unless they get a medication that helps them deal with it if they don’t deal with it they continue the addiction. So, this medication was released in Europe a couple of weeks ago and I was expecting it here in this country as well because nalmefene does the same things as Naltrexone, which is sold as Vivitrol or Revia, but it isn’t associated with the liver problems that the old Naltrexone had. So, these are the changes that are happening. It’s an interesting time and similar to where e-cigarettes are at a crossroad in terms of how our laws are going to deal with them maybe addiction treatment is at a crossroad as well.
HOWARD: I think as we have a better understanding of how the brain and mind function we may be moving on from what do you call it? The badness
DARRYL: Stigma.
HOWARD: Stigma. The stigma that’s been associated pretty much forever with addiction whether it be alcohol addiction or other drug addictions. Perhaps we’re seeing some movement on that front.
DARRYL: Isn’t it strange in terms of e-cigarettes in Paris where it’s very chic people aren’t hiding their use it’s a whole change in attitude because nicotine is still addicting, but now it’s the perception of nicotine addiction isn’t as bad.
HOWARD: Right. It is interesting, and will continue to be and we will continue to talk about it. But that’s all the time we have for now. Darryl, thank you and thanks to those of you listening. Comments, questions, and suggestions are always drop us a note on our website cnsproductions.com. Please check back soon for the next in the series and visit our website, www.cnsproductions.com