The Federal Government Should Consider Medical Marijuana a Potential Ally in the Fight Against Opioid Addiction

Originally published on the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics Bill of Health blog.

The United States is in the midst of what many are calling an opioid epidemic. According to the American Society of Addiction Medicine, more than 1.9 million people in the U.S. have a substance use disorders involving prescription pain medications, and another 580,000 have substance abuse issues with heroin. The human costs of these rates of addiction are staggering.   Of the approximately 50,000 lethal drug overdoses that happen each year, almost 20,000 are the result of prescription opioids, and another 10,000 are the result of heroin. While prescription painkillers traditionally aren’t as dangerous as heroin, the connection between the two is well established. According to a 2013 survey, about 80% of heroin users started out abusing opioid painkillers.

Despite continued efforts at nearly every level of government, the rates of opioid addiction and overdose have continued to climb. However, researchers have identified an unlikely ally that may have quietly been slowing the rise of opioid use in certain states: medical marijuana.

study recently released by Columbia University’s Mailman School of Public Health suggests that medical marijuana availability is linked to decreases in opioid usage. The study looked at opioid prevalence in autopsy reports from fatal car accidents over 14 years, and found that states that passed medical marijuana laws in that period saw a relative decrease in opioid prevalence compared to states that didn’t. While this study is making a splash, it’s just the most recent piece in a long line of research into the connection between medical marijuana availability and opioid use. One study published in Health Affairs in July showed that states which implemented medical marijuana laws between 2010-2013 saw a significant decrease in Medicare Part D prescriptions filled for medications for which marijuana is a possible alternative therapy — including opioids. Another study from 2014 showed a 25% decrease in deaths from prescription pain medication overdoses in states that implemented medical marijuana laws.

Unfortunately, as these medical marijuana success stories roll in, the federal government has been characteristically slow to adapt. While many were hopeful that the Drug Enforcement Agency (DEA) would reclassify marijuana as a Schedule II drug — opening up the possibility for more research and for medical availability in all 50 states — the DEA confirmed in August that it would be maintaining its Schedule I classification for marijuana. This means marijuana will remain classified with the most dangerous drugs including heroin, ecstasy, and MDMA — subject to more stringent regulation than cocaine, which is a Schedule II drug.

Whether or not one supports full marijuana legalization, the evidence for the positive effects of medical marijuana in combating the opioid crisis is at the point where the federal government should start taking it seriously.  The DEA’s position is that the science to support marijuana as a medical therapy isn’t yet sufficient to warrant reclassification, pointing to the fact that the FDA has not yet authorized its use for medical purposes, which is understandable. But it’s not clear that argument withstands a cost-benefit analysis in light of recent research. As previously noted, states that implement medical marijuana laws see a decrease of 25% in prescription pain medication overdose fatalities. Given that the U.S. has about 30,000 overdose deaths a year from heroin and prescription opioids, every year the federal government waits to seriously consider nation-wide medical marijuana potentially raises the opioid fatality count by 7,500. So while the instinct to wait for more research is understandable — and one that I would support in many contexts — waiting is not a costless decision.

It’s also not clear there is much to be gained by waiting on the FDA. To get through the FDA approval process, medical marijuana would potentially go through clinical trials, but those only require the drug be tested on about 1000 people for a limited time. This makes a lot of sense as a barrier to market entry for brand new chemical compounds that have previously only been administered to animals, but it’s unclear that it would add significant insight in the context of medical marijuana — a substance used by an estimated 22 million Americans in 2014.

The opioid epidemic isn’t going anywhere any time soon, and the impact it’s having on our communities is absolutely devastating. Despite years of public attention and many initiatives at every level of government, there has yet to be a solution implemented to effectively combat opioid addiction on a national scale. Congress passed an attempt at a solution over the summer, but only allocated about half of the requested funds to the endeavor, which doesn’t bode well for its long-term chances of success. It’s time to think outside the box. The substantial costs of inaction and the possible benefits of medical marijuana are such that its potential should no longer be ignored. Helping to pave the way for medical marijuana across the country is not something the federal government should do lightly — but neither is failing to recognize an ally in the fight against the opioid epidemic as its death toll continues to rise.

Hospitals Should Think Before Performing Searches for Law Enforcement

Originally published on the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics Bill of Health blog.

In 2012, a Jane Doe suspected of transporting drugs was detained by U.S. Customs and Border Protection (CBP) agents without a warrant, and brought to University Medical Center in El Paso, Texas. Medical Center personnel — under the direction of the law enforcement agents — performed an X-ray, CT scan, and cavity search before determining that the woman was not in fact carrying any controlled substances. A few months after suffering this traumatic — and possibly illegal — event, the woman received a $5400 bill from the Medical Center for the services rendered as part of the search.

While the woman was compensated to some extent — she settled lawsuits with University Medical Center and the CBP to the tune of $1.1 million and $475,000, respectively — her story, and stories like hers, raise important questions about the ways in which hospitals should (or shouldn’t) work with law enforcement to perform invasive searches.

It’s understandable why hospitals and medical professionals are inclined to cooperate with law enforcement requests for invasive procedures and cavity searches — law-abiding citizens often don’t want to obstruct law enforcement agents from doing their jobs. But in the course of bringing suit against University Medical Center, Edgar Saldivar of the ACLU of Texas noted that the hospital and many of its personnel didn’t know where the obligation to assist the CBP stopped. Many medical professional don’t know that — according to the CBP’s own Personal Search Handbook — they are under absolutely no obligation to comply with requests by law enforcement to perform cavity searches with or without a warrant.

Not only are hospitals and medical professionals not required to assist with invasive searches, but as the case of Jane Doe demonstrates, they can be liable if they help in instances where they shouldn’t. They aren’t agents of the state, and therefore are neither compelled to perform any actions pursuant to a law enforcement request or search warrant nor legally protected if they violate someone’s rights while assisting in the execution of such a request or warrant.

The potential for substantial liability alone should give hospitals pause when deciding whether to assist with a cavity search. But putting that aside, is this something that hospitals should be having their physicians and medical professionals do at all?

Medical professionals occupy a unique ethical space. We leave our lives in their hands, in part because we trust that they will act in our best interest as patients. We believe that their responsibilities to patients trump those to bottom lines or government agencies, and that’s why we dutifully consent to procedures when our dentists say we need cavities filled or our doctors say we need colonoscopies. The trust that physicians receive entails an ethical obligation to live up to those expectations. This is not to say there aren’t limits on the lengths to which doctors should go for their patients — I’ve written before on some of these limitations — but it’s not clear hospitals should be putting doctors in situations where they feel pressure to actively subvert the interests of those for whom they are caring.

This is not to say that physicians should never assist law enforcement with searches. There may be situations in which a hospital or medical professional could reasonably conclude that the suspect is better off at a medical facility under professional care than undergoing whatever alternative method of cavity searching the officers have in mind. At the end of the day, though, the person being searched is a patient, and hospitals and physicians should be sure that the procedures being performed are indeed in that patient’s interest, and not just a means to law enforcement’s ends. While cavity searches are not particularly dangerous procedures, all medical procedures come with risk, and subjecting a patient to that risk for the sole purpose of assisting with a law enforcement investigation may very well violate the “do no harm” ideals embodied in the Hippocratic Oath.

There are no black and white answers here, but one thing is clear: hospitals and medical professionals need to give this issue significantly more thought and attention. The ACLU’s experience with University Medical Center showed that its personnel were caught off guard — not knowing what their duties were to law enforcement or to the individual being searched, and not thinking about the possible ramifications of cooperation. As a result, they subjected an innocent woman in their care to a traumatic, violating experience and cost the hospital $1.1 million. Hospitals should be training their personnel for these situations. Doctors should know they have no obligation to assist with law enforcement searches, and both physicians and institutions should have carefully thought out their responses to such a situation before one presents itself.

No patient should ever have to worry about a physician in charge of her care violating her rights, and no physician should ever feel pressured to violate a patient’s rights in the name of law enforcement. There is a lot that hospitals can do to help prevent these situations from arising, protecting both their personnel and their patients. The millions of dollars they’ll also save avoiding lawsuits is just the icing on the cake.