Discussion of the implications of the new marijuana laws, and also the adoption of pharmacotherapy by the renowned Minnesota Model’s founder, the Hazeldon Foundation, with guest Dr Kevin McCauley.
Darryl: Hello and welcome once again to the CNS Addiction Podcast. I am Dr. Darryl Inaba here with Howard LaMere and today we are on the phone with Dr. Kevin McCulley. Howard, I think this is the first time we’ve had a repeat guest on our show! Back by popular demand – we had lot of complementary statements from listeners to Dr. McCulley’s interview in December. People wanted to know about his work with pain and his work with addiction, so we’re really happy to have Dr. Kevin McCulley back on the show. Welcome, Kevin!
Kevin: Well, thank you, Darryl. Thanks for having me again. I appreciate it very much.
Darryl: And just to remind everybody Dr. Kevin McCulley is a graduate of the University of Pennsylvania, medical college, and then joined the Navy where he served as a flight surgeon, first with the helicopter unit of the Marines, the Red Lions, and then later with the FA18 Hornet Squadron, the sharp shooters, where he was not only a flight surgeon, but also worked with pilots who had alcohol and drug problems. He is a tremendous asset to the science and the education of what addiction is all about. And Kevin, the reason I really wanted to get you back on the air not just because we had such a great demand for you from all of our listeners, but also because there are some major things that have happened in the news recently that wanted your take on. The first one is Colorado and Washington passing the recreational use of marijuana in the November general election. Marijuana has been prohibited since 1938, so after almost 75 years, those 2 states have made the use of marijuana recreationally a lawful thing. What are your feelings on how that may impact us in the addiction field, people in recovery, just the whole spectrum of what that means to society.
Kevin: Well, it’s a major change, isn’t it? No doubt about it and it definitely signifies a historical shift, not only in the public’s attitudes towards marijuana use, but also probably in policy as well. It’s funny because there was another time in the United States when exactly the opposite was true. In other words, alcohol was illegal, but marijuana was still legal before the passage of the laws against marijuana and while prohibition was still in effect back in the 1930’s. Now I guess, you know, things have changed again and it’s just another lesson why you can’t let the law determine your sobriety if you’re in recovery because for all I know, heroin will be legal sometime in the future. I doubt it, but you know, you can’t let the law necessarily keep you sober. But what’s interesting is, that there are actually 3 laws that could have passed. The referendum in Colorado and Washington passed. Colorado’s law was to regulate marijuana like alcohol and it passed by a margin, a slim margin, 54%. And the one in Washington passed, but the one in Oregon oddly enough was rejected and I think it says something about the intelligence of the voters in Oregon because apparently the way that referendum was drafted is that the policy was very, very loose. So, the voters said no to that. There was a great article in the magazine, “Addiction Professional”, featuring Ben Court who I actually got the chance to meet last year at the Western Symposium Conference in Colorado Springs and I think he made some really intelligent comments about the whole process – that you really can’t fight this legalization – I think you can try, but it looks like that’s the way the pendulum is swinging now. It looks like the better fight is to try to make sure that when these policies are drafted, that they have the proper regulatory structures in place to try to control manufacture and to try to regulate sales and to try to protect those who are most at risk and that would be young people. As these laws go through, the perception of risk is definitely going to go down as casual marijuana use becomes normalized. And with that decrease in the perception of risk, youth use will go up. That’s a very established correlation. When the risk perception goes down, more people more young people use marijuana and they’re the ones who are really most vulnerable. So, we’ll just have to try to do our very best to make sure that the policies are as mindful as they can be.
Darryl: Here in Oregon, I’m not so sure it was the intelligence of our voters or an interest in the science or whatever I think more than anything it was a recognition that we’re a big marijuana growing state and a big provider of medical marijuana and I think the growers and the procurers and the people who are making marijuana available recognize that if they made it legal for recreational use and everybody could have it, they would be put out of business very quickly by the American Tobacco Company and everybody else who are a lot better at marketing and selling their product than the current growers.
Kevin: That’s an interesting take on it. I didn’t think of that.
Darryl: And actually that is pretty intelligent because that is what I suspect would happen. It just changes who makes money on marijuana. The legal providers, big business, or the mom and pop people who are just growing and make their living off of it. The other thing I was curious about is prevention, doing primary prevention, especially directed at young people who have never used drugs before. If they perceive the harm from a drug is less because it is a legal substance, then they’re going to abuse more. That relationship has clearly been made by every study I’ve ever seen. The other thing about primary prevention is primary prevention should be resourced and targeted to those who will never use again. So target for people who’ve never used, but also targeted for those in the recovering community. Those are the people I’m deeply concerned with because that is the group I work with and in their treatment, we stress that they have to avoid all addictive substances and even compulsive behaviors because of the fact that their brain is susceptible to developing the compulsions. They, therefore, must not only give up heroin or methamphetamine, but also give up nicotine and marijuana. But with the legalization issue, I’m fearful that many will look at marijuana again, and maybe feel it is less harmful or less addictive. A lot of people don’t even think marijuana is a drug and they may end up using it to only have a major relapse. When I was at the Haight (Haight Ashbury Free Clinic), we actually believed at one time that marijuana could help treat heroin addiction, that it could help decrease the craving, decrease the withdrawal symptoms, and we didn’t mind it if our clients smoked marijuana while they were trying to kick heroin. But when we looked.
Kevin: And how did it go?
Darryl: Exactly. What I’m trying to say is that people who kept smoking, relapsed back to heroin use much more rapidly and much more dramatically than people who gave up all addictive substances. So, I was wondering if you’ve had any take on that or have any feelings about how it’s going to impact the recovering community.
Kevin: Well, I know it’s a cruel statement to make, but in many ways, the disease is on the side of itself. If a person really has a substance dependence problem, if they have an addiction, I think that the truth will out and you know, it’s certainly a reasonable assumption to say, well, I can get off alcohol or I can get off opioids by trying marijuana, but what we know is that they all do the same thing. They stimulate a lot of the same areas in the brain and so a person will rapidly find themselves back to their drug of choice. I think that there is very good data to support that and certainly there is experience in the recovery community. So, I think that people will learn that lesson quickly and I hope that they will return to, the principles that guide most abstinence based recovery and understand that marijuana is a drug, period. Alcohol is a drug, period. So in a sense, they are in the same boat as they were with alcohol. I mean, alcohol was legal, we could go to Safeway and buy alcohol and try to get off heroin that way or get off cocaine that way and the results are very predictable. I’m hoping that both the disease will out in its behavior, but also the principles of recovery will out in their effects, as well. And people will quickly realize the mistake and they’ll recognize that the problem is intoxication and that there are certain things that vulnerable brains cannot do and intoxication is one of them. So I hope that people will not linger too long in that experimental zone where they are trying to fix their personal and social and spiritual problems with an intoxicant.
Darryl: Well, I’m hoping they never go there because one of two main things we’ve always tried to teach our clients is that relapse is a part of every major chronic persistent disorder and so it is a part of addiction and shouldn’t be looked on as shameful, but as an opportunity to get back into treatment as quickly as possible. At the same time, we say that we know that each relapse seems to be more devastating than the one before, creating more catastrophic consequences, and we always hope no casualties occur. Your comments befit the situation and will hopefully help some people avoid even thinking that they can use marijuana if they’re in recovery.
The other thing that astounded me was the announcement by Hazeldon, viewed as the flagship of recovery treatment in the recovery world and an organization that has been doing this for far longer than anyone else – a place that promotes the understanding and the treatment of addiction, and has been totally abstinence based – avoiding all medical inventions – just announced a couple of weeks ago that they are endorsing the use of Suboxone, not just Suboxone detoxification, but actually Suboxone replacement therapy in the treatment of opiate addiction. This is just amazing to me. What’s your take on that and how do you think that’s going to affect the field?
Kevin: Well, I have a cynical answer and a more faithful answer. The cynical answer is that Hazeldon simply read the writing on the wall and especially with NIDA (National Institute on Drug Addiction) and SAMHSA (Substance Abuse and Mental Health Services Administration) pushing what they call their blending initiative, where they even have recommendations to put young adults on buprenorphine as treatment for opioid addiction, that they just simply realized that that was a force that could not be overcome. I mean, doctors prescribe medication, so I don’t know what to say that’s just what they do. And so, if there’s evidence to support that, then that would have been a tie that would they would have not been able to overcome. I have a more faithful answer though and that centers more on the fact that this is, I think, a very brave and courageous move that must have been arrived at through great soul searching and probably heated discussion and emotional debate and although I know that there were many people involved in this, I know that the Hazeldon medical director, Dr. Marvin Seppala was right at the center of it. And there’s a really, really good essay in Time (November 5, 2012)by Maria Szalavitz she has written some really good articles lately, especially on the website, “The Fix”, but she is primarily a correspondent for Time Magazine. Marv you kind of have to know Marv to understand that he was exactly the person to affect this culture shift at Hazeldon. He is a very soft-spoken guy. He is always smiling, very pleasant, very low key exactly who you would want your doctor to be. And he’s not just an expert in addiction, he was also the first youth participant, youth program participant who went through Hazeldon and so he’s an insider and yet he, like many addiction physicians have been watching this evidence build on the side of medication assisted treatment, buprenorphine. And I think that he said that at least in their young patients there was a high relapse rate after discharge and even significant risk of death and he looked at the harm and in his words, he said, we needed to push for a change, we needed to do the responsible thing and I think out of that will come something that’s very, very important – a bridge between, evidence based medicine and the wisdom that has been accumulated over the decades in more traditional abstinence based treatment. I guess it depends on how to define abstinence. If you look at the Betty Ford Centers consensus panel on what is recovery abstinence is based on not using medications outside of a doctor’s prescription. And so it still kind of fits with what they’re talking about. I see this as a way of bringing together the benefits of 12 step recovery, which are very hard to quantify, very hard to operationalize in the traditional research setting and the benefits of medication therapy, which at least in the short-term, you know, are very clear. They are very quantifiable benefits. And I think that what good will come out of this is that Hazelton will be following these patients into the future and they will have a cohort that they can follow and figure out, okay, what are the benefits that are realized long-term. You know, where are the problems that we need to look at. But I think that this is a great move, a courageous move, and I think, you know, Marv Seppala is exactly the right person to affect that change and I definitely applaud it and Hazeldon itself.
Darryl: Hey, Kevin, that was very sagacious interpretation of what’s happening. Another aspect I looked at was maybe Hazeldon the icon, the flagship is acknowledging what we’ve all wanted in terms of defining addiction that it really is a medical disorder. It’s a biological condition and like other biological conditions we treat them medically. So why shouldn’t we look at the treatment of addictions medically as well? What you said is quite true. Here in Oregon, Dr. Jim Shames, our public health medical director, examined the number of deaths from heroin and from Oxycontin, Vicodin, and methadone here in our area and he monitored it while we began more treatment with Suboxone and , buprenorphine and compared to data from France and other parts of the world, we had a dramatic decline. So it really does save lives and I think that’s important to take into consideration. So, you’ve hit it right on the head. But right now, I’m afraid we’ve run out of our time today. It was great talking to you, great listening to you. I hope you don’t mind if we call you back from time to time. You seem to have your finger right on the pulse of what’s happening in this field and contribute a lot to this field.
Kevin: Thank you for having me. As usual, Darryl, I’ll come any time. I really appreciate the opportunity. Thank you.
Darryl: Thank you.
Howard: That wraps our pod for today. Thanks for visiting the CNS Podcast. Please check back soon for the next in the series and visit our website, www.cnsproductions.com