Pharmacies are in the news: an Oregon pharmacist, with a glowing work record and several exemplary job reviews, is suing Wal-Mart Oregon for wrongful termination because he has had addiction issues, even though he has successfully completed treatment. CVS Pharmacy chain is refusing to fill prescriptions for doctors which IT believes are over-prescribing. Also the continuing debate on whether marijuana is less harmful than alcohol, and more on whether food and sex addictions are really addictions.
Howard: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. A few controversies seem to be brewing about some of the things that the DSM5, the just released Diagnostics Statistics Manual added food addiction and sex addiction. Sex addiction was in the news this week based on some brain studies that show that brain waves don’t react in the way other addictions present and so characterizing sex addiction in the same manner as other addictions is being called into question. We were just talking about food addiction and it seems pretty obvious that there’s a corollary between the addiction to food and the addiction to drugs and alcohol. You know, the basic criteria being tolerance, withdrawal, seeking larger and larger quantities, and the amount of time spent engaged in the behavior. There were also a couple of stories about pharmacies that are interesting and also the ongoing debate about the toxicity of marijuana versus alcohol. People are coming down on both sides of that and I don’t know what the true answer is. And of course, the true answer will be found by following the rats.
Darryl: Well, that’s a bevy of interesting stuff, Howard, and I’m not sure what’s of interest to our audience but the most fascinating things to me are the pharmacy studies, being a pharmacist myself and because it is happening that’s right here in our town of Medford. A pharmacist by the name of Doran I’m not sure if it’s Dr. Doran or Pharmacist Doran has with some other pharmacists filed a multimillion dollar suit against Oregon Wal-Mart because he was fired or he was let go I think, and the reasons were his previous history of drug abuse and subsequent treatment for drug abuse – based upon that they deemed that he was not able to perform his job.
Howard: And that was after they already hired him.
Darryl: He had been an employee for awhile and had been given nothing but stellar performance evaluations and with many commendations. He never received a bad commendation, never did anything inappropriate but all of a sudden he gets a dismissal notice saying that he is unable to perform his job. The news articles are only presenting his side of it and I’m sure there are other sides of it, but it is clear to me that this is a major test case for the Addiction Equity Act that was passed in 2008. There has been almost 100 years of people coming forward to say addiction is truly a biological condition. It’s not a matter of weak will and not a matter of evil intent – that it is a very treatable and manageable condition and if people accept that they have this condition and participate in rigorous treatment for it, they end up wonderful people. It looks like Mr. Doran is a poster child for how someone can overcome this condition he is just a stellar employee, stellar person, conscientious in every way and low and behold he gets fired when Wal-Mart supposedly changed their policy, looked into the history of their pharmacists and deemed that he was unable to perform his job function based up on some past history of treatment for addiction. I support his actions and I hope he wins and tears the heck out of Wal-Mart and I hope the decision goes in his favor because this is going to be a test case for everybody who has an addiction and everybody who’s been discriminated against purely because of the addiction, not because of anything they did wrong or because of their job performance or anything else. And if he wins, it will probably be that huge support that this act needs and will give notice to everybody else in the United States that you can’t fire somebody just because they’re addicted. You have to give them an opportunity like you would if your employee all of a sudden got diabetes, or if your employee got asthma or hypertension and yet was doing a great job, I don’t think anybody gets fired for that. Addiction is a chronic persistent medical disorder and if you’re doing your job and your life is in order you’re not diverting, you’re not stealing, you’re not doing anything bad .and if you’ve gone through treatment and you’re doing everything to maintain your sobriety, I don’t think people should get fired for that so I hope he wins.
Howard: The other thing about this case is and I’m assuming that he divulged this information on his employment application, but what happens as more and more of our medical records become easily accessible as they become electronified? It’s a concern, you know it’s one of the many privacy concerns that are showing up and becoming quite evident lately not just from whistle blowers but from everywhere across the spectrum.
Darryl: Well, I’m not sure about Mr. Doran’s case. It was published in the Oregonian and there was another article in our local Mail Tribune Medford Mail Tribune. I think it’s a landmark case but some of the details are not clear. He was hired, I think, by Wal-Mart before his addiction become evident and before he went into treatment after he was terminated he applied to other pharmacies. I forget where he is working now, but he clearly stated “I have this condition and I’ve taken care of it.” He revealed what he had done and they hired him and he is performing extremely well. So, the original case stems from when he was working for Wal-Mart. I don’t know when this was discovered or disclosed but he was well into his recovery and functioning very well when they terminated him for a past history of addiction. But you bring up a tremendously interesting point, Howard, and that is what someone applied today for a job and were straight and honest in answering the question “have you had a past problem with drug or alcohol abuse?” and somebody says, well, I did have this problem and I’ve taken care of it myself. A company doesn’t have to tell an applicant why they didn’t hire them, all they have to say is something like “this person wouldn’t fit well into our organization, .the chemistry wasn’t right. It’s easier to prove that you were discriminated against because of age, or race or gender or something like that, but it’s difficult to prove it was for a medical condition. So how this will play in term of disclosures in a person’s medical records and what vulnerability they will experience is hard to say. I would think that it’s a positive when people disclose and are able to talk about what they’re doing and how they’re processing their issues and their treatment because it gives an opportunity for employers to understand. If I was an employer, I would want to hire a recovering person. I would want to hire a recovering doctor as my doctor. I would want to hire a recovering pilot as my pilot. I would want to hire a recovering anything because recovering people, I believe, make the absolute best employees. They are more honest. They’re more open. They do things with much more talent and ability than most of the non-addicted population. They’re intelligent and they’re going to be great as long as they maintain their recovery and that’s what should be covered in an interview. there needs to be assurances that the candidate continuing to work on this lifelong condition that needs to be managed and monitored. And if the person is committed to that – then you’ve got a great employee. So, if people are up front and companies are using this to discriminate against hiring them just because they were in treatment and are now doing well, I believe that’s a true violation of Americans With Disability Act. I think it ‘s a true violation of the Addiction Equity Act of 2008 and I think people who do that should be made accountable and should suffer fines or whatever is necessary to change their policy so that they don’t discriminate against people with addictive disorders.
Howard: It’s troubling that it happened and it will be interesting to see how it resolves.
Darryl: The other pharmacy story you mentioned that caught my eye involved the CVS Pharmacy chain, a large pharmacy chain in the United States and how they analyze the data on what doctors are prescribing and how much and if they determine a doctor is outrageously prescribing a lot of opioid narcotics and a lot of narcotics for a variety of things they give them a chance to explain the reasons. If for example an oncologist treats mostly endstage cancer or endstage rheumatoid arthritis or something, then CVS will continue to allow that doctor’s patients to get their prescriptions filled by CVS pharmacies, but if a doctor can’t fully explain why he’s issuing so many medications and there is a suspicion that too many narcotics are being prescribed by an office, CVS Pharmacies are exercising their prerogative to deny filling prescriptions for that doctor and that’s an amazing thing. In the article it says that CVS was recently scrutinized by the local state and federal authorities for being too quick to fill prescriptions for narcotics and they got slapped on the wrist so this is the result. They’re really cutting off any doctor they think is prescribing too much. But that raises interesting legal questions too, doesn’t it, Howard? Say a patient goes to a doctor who has been identified as prescribing too many narcotics , but you are seeing the doctor for a legitimate reason – say an excruciating back problem, disk problem, that is pre-surgical and the doctor prescribes you something for the pain and the only pharmacy within say 20 or 30 miles of your house is a CVS – you get there to fill your prescription and they tell you, nope, we aren’t filling narcotic prescriptions from that doctor. I’m not sure that’s a good medical outcome. Or I’m not sure that’s even ethical or maybe not even legal. I think it’s discriminatory in a way and there should be other ways to deal with this issue. I don’t know if local pharmacies should be held accountable I think that is the job of DEA. I think we have state boards of pharmacy. I think we have a lot of agencies that should be monitoring schedule 3 prescriptions and the doctors who are prescribing them and they are the ones who should be attacking the doctors and scrutinizing them, not the pharmacy. I have worked with doctors who get so annoyed with restrictions and having to answer dozens of questions that they refuse. Pharmacies call and say doc your patient is here and we notice you’ve prescribed a lot more Vicodin than you normally do and we have to note in our books what the need is and how the patient is doing and all that. I’ve had doctors say screw you, I don’t have to justify my medicine to anyone and just hang up. You know, I think there are some problems with this. I understand the need and I understand prescription drug abuse and I know overdose deaths are the leading cause of preventable death in America outnumbering auto accident deaths, but for a pharmacy to say or a pharmacy chain to say they’re going to identify doctors who they believe are over prescribing and cut them off I’m not so sure that’s a good thing to do.
Howard: It’s definitely a questionable thing. Let’s talk a little bit about alcohol and marijuana toxicity since that is in the news – albeit one sided the advocates of marijuana legalization and medical marijuana maintain that it’s much safer than alcohol and then NIDA maybe the DEA responds saying, no it’s just as bad, maybe worse. So, what’s your opinion on that, Darryl?
Darryl: That’s an interesting question and ever since the 60’s when marijuana use and drug use was considered to be benign and non-consequential and elicited a scare tactic response from conservative people in our government there has always been that question. If marijuana is supposed to be so bad or if heroin is supposed to be so bad, then let’s look at the profile the toxicity from aspirin, from cigarettes, from nicotine. Let’s look at these side by side and compare the problems caused by marijuana or other drugs of abuse. Why is aspirin legal without prescription? Why is tobacco legal? Why is alcohol legal and why is marijuana illegal? And you know, there are some good arguments but I think it is sort of cavalier and non-thinking for “Politifacts” to publish a statement that they believe that marijuana is much less toxic than alcohol. Well that raised the hackles of the National Institute of Drug Abuse who immediately responded saying that was an inappropriate . an irresponsible statement. They are 2 different drugs, they do 2 different things to the body. We have much more scientific research on alcohol and we don’t have very much on marijuana. The information that we’re getting on marijuana shows more reports of toxicity, more and more reports of problems, but just to come out willy nilly and say that alcohol is less dangerous than marijuana is an untrue statement because there aren’t the facts to validate that conclusion. It is an interesting point counterpoint and one that has been around ever since I started working in this field in the 1960’s and one that is magnified now that Colorado and Washington has had their hempfest they’ve legalized marijuana. Recently in the state of Washington up near Seattle, dopers got together and smoked out in the open to celebrate their new freedoms. Many states are considering the question of legalizing and maybe taxing marijuana. One thing I haven’t heard about in Washington or Oregon is an estimate of how much revenue they’re realizing by the taxation and legalization of marijuana – that would be interesting. In your mantra of looking at the economics of things, I would probably think all this is a smoke screen with cloaks and daggers and points and counterpoints, but if the analysis comes through and determines that Washington state has just now balanced their books with hundreds of billions of dollars from taxing marijuana, I imagine that every state is going to follow suit and legalize marijuana in an instant.
Howard: Absolutely. To make a long story short, the jury is still out.
Darryl: The jury is still out and they were quick to point out well, Colorado was quick to point out that although Obama seems to be negative about decriminalizing or legalizing recreational marijuana as happened in Washington and in Colorado, there seems to be tacit approval from the administration, meaning they legalize it, they’re smoking it out in their hempfests. The media sometimes does special reports on marijuana medical marijuana being a valid treatment for some conditions and the government isn’t responding. So states take that as tacit approval that although federal law supersedes any state law and federal law still considers marijuana a schedule 1 illicit drug, they’re not doing anything to people smoking it in Colorado or Washington. It seems that although Obama says that he’s against it, it’s going to be approved by the federal government as well.
Howard: Well, the administration gives mixed signals on the issue so it’s really hard to figure that out. And of course, it’s up to Congress and Congress has not been known for acting very rapidly on anything lately ..lately being the last several years.
Darryl: Well, we have 3 parts of government, the executive branch, judiciary branch, and legislative branch and I don’t know if it’s up to Congress. We definitely have an executive and a judiciary branch. We have a National Drug Control Policy. We have all of these entities that can make changes and even though medical marijuana has been legalized in 18 states, there are still federal busts and the federal government says, we’re the supreme law. So, there are branches of government that could do things but Colorado says since they’re not – we’re fine.
Howard: But isn’t it Congress who authorizes what drugs are on that list?
Darryl: On the controlled substance abuse list?
Howard: Yes.
Darryl: I guess overall Congress controls the legislation the Controlled Substance Abuse Act was an act of Congress. It was a federal act and each state has their own version because each state has the right to their own version of the Controlled Substance Abuse Act. What Colorado and Washington did was repeal their Controlled Substance Abuse Act within their own states and determines that marijuana is not part of that.
Howard: Right. Well, again, something that’s in play and we’ll just have to watch it. And it looks like we are out of time once again. We’ve got more?
Darryl: Well, Howard .you mentioned so many things that were interesting!
Howard: I know but we only have so much time!
Darryl: Let me just quickly say this about eating disorders and sexual
Howard: Oh I did want to talk about that.
Darryl: Sexual addiction. Eating disorders have a lot more evidence in terms of brain studies and genetics and maybe should move out of its own special class. They’re not part of compulsive disorders. They’re not part of substance related addiction disorders. But I think it was Nora Volkow, head of NIDA, who started looking at eating disorders and the science of it, she was on the correct tract. I think eating disorders are now being linked very closely with all drug addiction disorders. A couple studies that were recently done – one by Washington University in St. Louis, Missouri found that eating disorders and alcohol abuse or alcohol addiction share the same genetic factors. You find that in identical twins and you find it in fraternal twins – and some of the genes that link the 2 of them together have been identified. The linkage has a genetic component as well as an environmental component . Another study just recently published this week came from the University of Texas in San Antonio, that school seems to love the mice studies as you mentioned. They like the rat studies. They like the mice studies.
Howard: Yes .follow the rats!
Darryl: Follow the rats is what you said! And a funny thing is – that is what they did I don’t know how they came up with this but when they restricted the rats’ food -, causing a low intake of calories and sugar and food, those rats became much more prone to addiction and alcoholism than rats who had no food restrictions. And I think that sort of a linkage has to do with this chemical dopamine in the brain. When food is restricted it results in poor dopamine concentration in the brain and drugs do the same thing so the condition creates a craving for anything that stimulates production of dopamine. In the rat experiment I think it’s more about survival. I can’t see a rat getting loaded. I just can’t. They turn to alcohol because of low dopamine, they would turn to heroin, or to marijuana or anything that replaces that extra dopamine that’s not there anymore. So I think the food and alcohol addictions are intrinsically linked. I think they should be put into the same category. I think they are addictive and related disorders. And as far as sexual addiction, I haven’t read all the studies on the brain they’re doing, but I’ve seen other studies on brain imaging that seems to indicate it is again over hypersensitivity to dopamine and then a depletion that results in certain individuals being vulnerable to pornography and engaging in sexual activities more frequently and with more intensity than most other people. And I think sexual disorders do exist. I’m not sure what the brain patterns they’re looking at are telling them, but I think it is good that studies are being conducted. The DSM-5 did place eating disorders as their own separate category and they have full recognition and classification, sexual addiction and, being addicted to pornography, are conditions that are described but they are relegated to “needing further study or further evaluation”, I kind of disagree with the conclusion that they aren’t true addictions and I believe eventually they will be proved to be true addictions.
Howard: Well, I have not looked at the brain wave studies, so perhaps a more careful reading of those studies will reveal more lead to more research and better conclusions. We are out of time, so we’re going to wrap it up for today. Thanks for listening. As ever, you’re welcome to drop us a comment. We love to hear from you. Make a suggestion or ask a question. You can do that at the CNS website, cnsproductions.com, and there’s a couple different places there as well as it’s the location, of course, of the podcasts. So until the next time, thank you, Darryl, and we will see you all soon.
Darryl: Thanks Howard.
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