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Editorial Comment 9/3: Tools of the (drug) trade

by William Haning, MD, DFAPA, DFASAM | September 3, 2019

Editorial Comment:  Tools of the (drug) trade

The creative intelligence is ethically neutral.  It can confer therapeutic benefit or lethality with equal facility.  The moral compass of its owner determines the direction of its effect: in its most mundane form we encounter it during our brighter patients’ justifications for drug or alcohol use. More sociopathically, it creates underground cocaine factories linked by tunnels to airstrips, submarines for drug transport, abbreviated synthetic pathways for methamphetamine and MDMA.  Even with benign intent, particularly when the consequences are not carefully examined, its products can undermine the intended therapeutic effect.   The history of drug usage is ultimately also a history of the technology of drug administration. 

Just as those of medical researchers, the imaginations of dealers and distributors seem particularly receptive to the challenge of how to introduce a drug into the subject human. This extends even to the old classics such as alcohol, exemplified by the depth bomb, the Spanish leather wine sack (bota), and arguably inhalable ethyl ether.  Devices and routes of administration that were intended to serve medical treatment include the hypodermic syringe and hollow needle, the steam nebulizer, the inhalant cartridge, the transdermal patch, and chewable gums (nicotine). I would be disappointing our caffeinated readership if I didn’t mention therapeutic enemas, particularly coffee.

The progression seems always to be from a moment of inspiration, through multiple improvements and modifications.  An Incan porter discovers that a coca leaf, chewed or immersed in soup or tea, gives a mild increase in clarity and a momentary relief of oxygen hunger.  S/he somehow discovers that the effect is improved and prolonged with the addition of lime, placed as a wee sandwich between gum and cheek.  Some bright lad/lass somewhere refines the active ingredient – cocaine - and the race is now on to determine how most profitably to administer it: insufflating by nose, injecting in muscle, injecting intravenously, smoking (wasteful), free-basing (much more efficient).  Mustn’t forget the enema.

What stimulated this diatribe was in part a piece from Saturday’s New York Times that surveys the U.S. cases of vaping-associated pulmonary illness: https://www.nytimes.com/2019/08/31/health/vaping-marijuana-ecigarettes-sickness.html . The lung features prominently in this ASAMW, and we are reminded that the lungs provide a highly porous, delicate, fragile barrier, ultimately of only one cell’s thickness (alveoli), between the world and our blood streams.  A parallel example comes from 3 decades past, when revelation of the inhalation use of methamphetamine arose with case reports in Japan, almost concurrently in Hawaii, of pulmonary edema (1988-9,https://www.ncbi.nlm.nih.gov/pubmed/2592191 ).

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(We would like to think that you enjoyed Labor Day.  You are mostly doctors, so we won’t delude ourselves that you all took the day off; but hopefully you enjoyed it, all the same. – ASAMW Staff & Editors)    

- Bill Haning, MD, DFASAM