Editorial Comment 9/8/2020: A letter from Honolulu

1990 Marked the first reference to methamphetamine use by inhalation in Hawaii.  A case study, involving a pneumonitis with severe respiratory compromise, made sparing reference to signs of intoxication. The case in question was submitted not by an addictionist, but rather by a pulmonologist who recognized that: 1) the pathophysiology was less important to the community than the epidemiology, 2) a drug that had been relatively unrepresented in the usage community had arrived, and 3) the drug was being employed in a novel form: volatilization and inhalation. Taking advantage of the 800 square feet of alveolar bed available for absorption of the drug, inhalation as a swift and convenient form of intoxication went from being a foothold to becoming a running-trail.

The drug was ideally suited for rapid dissemination within Hawaii. It had demonstrated its utility in populations of laborers performing menial and arduous work in a variety of settings, among southern California garment and field workers, at construction sites among carpenters and masons nationwide, and of course in the kitchens of restaurants of all types - a culture characterized by the late Anthony Bourdain as use at work leading into intoxication and brief sleep, leading again back into work. Hawaii then and now is a service economy; and while considerable employment and skills development exist in service to the military presence, in shipyards and airfields, it is highly reliant upon the hotel and visitor industry. The last is the successor to the agricultural industry that characterized Hawaii in the 19^th and well into the 20^th centuries and carries on the tradition of long hours and low or even minimum wage pay. Stimulant use became a vehicle for the many who must contend with raising a family in an environment with living costs comparable to San Francisco, New York, the Chicago Lakefront and California’s Orange County.  Cheap, pure in its imported form from Korea and the Philippines, methamphetamine did not become the dominant drug of use - alcohol’s position has never been completely supplanted by any of the variety of other intoxicants -  but it is certainly the strongest contender for the throne.

As this is written, on September 4^th , Sen. Brian Schatz (D-Hawaii) released notification that a $4 million SAMHSA grant has been authorized as augmentation of existing grants specifically targeting methamphetamine use.  From the release: “Hawai‘i has experienced some of the worst effects of meth misuse, making it an important public health priority. In 2016, Hawai‘i had 6.8 meth-related deaths per 100,000 residents — three times the national rate of 2.4 deaths per 100,000 people. Meth-related deaths on the islands have outpaced opioid-related deaths for each of the past five years.”  Noteworthy is that Hawaii has also experienced comparative success in its management strategies for those with addictions, a reflection of energy and leadership within the State’s Department of Health Behavioral Health Services Division.  But at least as noteworthy is how little funding we dedicate to effective treatment approaches.  …Coincidentally, the state spends $4.5 million per year tobacco use prevention, which is 33% of the amount recommended by the Centers for Disease Control.