Dilute NFL Draft urine drug tests should drive conversation around drug culture – why allow opioids vs. cannabinoids?

Today is draft day and everyone knows about the two dilute urine tests that occurred during the combine from two draft prospects. The best explanation for the two dilute tests is that Peppers and Foster drank very high volumes of water, used other masking agents or diuretics in an attempt to avoid a positive test for marijuana. The explanations from the two players posited highly unlikely explanations that simply do not hold up scientifically or in reality –  something about cramps and the need for high volume water ingestion as well as diarrhea as explanatory reasons for drinking a lot of water.

These two players will enter the NFL – and even with all this controversy, they will still enter the NFL – already in “the program”.

Ok. Fine. Marijuana is illegal. Marijuana is a banned substance. The players knew the test was going to take place. Many even call the test (unfairly) an “intelligence test”  given the known date and time of occurrence. Certainly there would be some difficulty in condoning the NFL or anyone to support or approve marijuana use – but why test for pot? What is the value add of asking the question? 

There are certainly some issues with the marijuana delivery system in terms of wellness – i.e. smoking is a health hazard, regardless of the chemical in the inhalant and the drug concentration is unregulated with the user taking on unknown risks of those ingredients. But why test for this drug while we essentially encourage use of other drugs – such as prescribed opiates? 

The message marijuana testing sends to employees in a high impact occupation that will result in acute pain does seem a little confusing in the overall context of our national health care problems. The NFL is currently facing litigation from former players that believe their use of opioid medications was encouraged to mask serious pain in an attempt to continue playing, leading, in their view to downstream problems with dependence and pain following their playing career.

But the issue is not the NFL – they are a company, they are hiring employees, they are conducting drug testing like many large employers do during this phase of the recruitment process. The real issue is the societal context of how we perceive specific drugs given cultural biases, marketing, and historical artifacts (i.e why is alcohol legal and marijuana not legal even in face of drunk driving accidents, assaults, and numerous life ending medical conditions related to the use of marijuana?). The conversation here is  really about us and where we want to go next with drug policy, pain control, medicalization of disease, culture of drug use, scientific testing of specific drugs for specific reasons – i.e there is still very little evidence based medicine demonstrating positive health benefits of marijuana use but there is also very little evidence demonstrating positive health benefits of chronic opioid use – and chronic opioid use has known serious outcomes – including dependence, addiction, and death. For a great perspective on the downstream damage and effects of opioid addiction, read this amazing write up by Ryan Leaf who served prison time after robbing a house to steal opioid pain medications and then attempting suicide prior to his arrest.

 

Every night I treat multiple patients in the Emergency Department (ED) who primarily are there secondary to opioid dependence. I have been trying to pin down a number in my own head the past few months and, overall, if you think about patients that present with chronic or acute on chronic problems, or just outright drug seeking behavior, that percent might approach 50%. For better or worse, the primary purpose of ED visits for up to 50% of my patients is for non-acute pain. Non-acute meaning that the purpose of your ED visit today is not because of a heart attack happening now, a trauma such as car crash or fall or assault that occurred within the day, a laceration, a surgery in past few days, an acute infection with belly pain – like an appendicitis. You know, the things I think most people think of when they think of ED visits.

The first round of analysis of these numbers does not portend in value judgement or imply there is a problem with this distribution of acute vs. chronic pain. I am work at a specialty care, tertiary ED where people from all over the state come to seek care with our very specialized, only that person does that thing in our state type of doctors. So, I expect there to be some rare diseases associated with difficult to manage, often life long pain. Sickle Cell Disease is a great example. The reoccurring venous occlusive crises may be as painful as metastatic cancer pain but the person lives much longer. Therefore, the Sickle Anemia Patient will likely become dependent on opioid pain medications and seek care those drugs during their ED visit (just like I seek Zyrtec or Claritin when my allergies act up – and will not stop until I find an antihistamine out of fear of my eyes swelling completely shut and my voice becoming inaudibly hoarse – or perhaps how you are are in the morning when you need your coffee? We are all drug seekers – just different drugs and different acceptance in society given both real and perceived impact.

So, in the ED, we get acute pain patients that just underwent a preceding event that is likely causative of their symptoms (there is a blockage in the coronary arteries cutting off blood flow to the heart, the femur is broken in half after slamming into the dashboard of the car, you get the picture..). Then, we have our chronic pain patients secondary to an organic disease state – like Sickle Cell Anemia, Diabetic Neuropathy, and Inflammatory Bowel Disease such as Crohn’s to name a few examples. These patients are likely opioid dependent given the long disease course. They may or may not be addicts. Addiction has social implications involving disruptive behavior and poor life choices aimed at obtaining drug outside of physiological need, while dependence implies that opioid Mu receptors depend on the presence of the agent, often in higher and higher quantities, to function normally.

The bucket of patients that becomes difficult to sort out involves those patients with possibly painful conditions that reoccur on an intermittent basis – these are our patients who might have had a remote trauma like a car crash and then developed back pain. Perhaps every 3 months that patients rolls into the ED and requests opioid medications, some of them also seeing a pain management physician outside of the ED in between encounters. Other similar encounters include patient’s with pain and history of acute on chronic or exacerbations of pain related (per the patient) to uterine fibroids, ovarian cysts, pancreatitis, and…one of the most difficult conditions of all…Fibromyalgia (a syndrome that many doctors are unclear on the organic cause and how this may or may not be different than depression). Speaking of depression, many of our patients that have a substance use disorder have concomitant mental health problems – personality disorders, bipolar disease, schizophrenia and other forms of anxiety and adjustment disorder.

We remember the real addicts during our shifts because they make our lives most difficult – but the real addicts are actually the lowest percent of the distribution of patients seeking opioids. They just take a lot of time as the link between an organic cause and the pain appears flimsy and the history in the medical record is full of prior visits and multiple scripts for oral opioid medications.

There is some recognition now outside of medicine regarding just how damaging the effects of opioid dependence and addiction can be on individuals, families and even entire populations in towns across the United States. One of the common refrains of marijuana users is that marijuana doesn’t kill anyone – I am not sure if that is actually true or not as we don’t really keep any specific data linking mortality and marijuana (although I have taken care of 3 people during my career that developed and died from lung cancer solely from smoking marijuana and 1 trauma where the driver of a car had a blood alcohol level of 0 but had admitted to smoking pot all day before ramming into another car and killing that passenger). Nonetheless, the magnitude of impact of morbidity and mortality from marijuana use probably do not rival the number of opioid related deaths in this country – which is around the 30,000-35,000/year mark as of 2015 according to CDC data from 2017.

The dilute drug tests were stupid – but only blaming the players for the stupidity just lets us off the hook for our own myopia in our ability to create a societal context that creates safe delivery of appropriate agents for management of traumatic pain and high performance stress. Instead, we shift the blame to players and force the easiest route – or at least legal route – back to making decisions that lead to increased opioid use even in the face of compelling data for definitively linked adverse effects of those drugs over time.

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