Sunday, September 08, 2019

A Flood of Irresponsible Actions and Advice on Respiratory Disease Outbreak

There is a wave of irresponsible recommendations and actions that are taking place in response to the outbreak of more than 400 cases of severe, acute respiratory disease and five deaths that have occurred in the United States. Since there are far too many to write an individual commentary on each, I am combining three of the most important examples in this post.

1. Dr. Thomas Eissenberg Implies that the Respiratory Disease Outbreak is being Caused by Traditional (nicotine-containing) Electronic Cigarettes

In an op-ed piece in The Guardian entitled "Vaping Is Risky: Do Not Do It If You Care About Your Lungs," Dr. Thomas Eissenberg--a professor at Virginia Commonwealth University--advises the public to discontinue all vaping and ties the recent outbreak of severe, acute respiratory disease to nicotine-containing electronic cigarettes. He writes: "For the past seven years, a steady stream of scientific studies has uncovered potential health risks associated with vaping. These risks include nicotine dependence, airway injury, and cardiovascular disease. Now we must add debilitating lung disease to that list. Lipoid pneumonia is one such disease, probably caused by inhalation of oil-containing vapor: the body’s immune response to oil in the lungs involves inflammation that can be fatal."

I find this to be irresponsible. It implies that lipoid pnemonia is being caused by traditional, nicotine-containing electronic cigarettes and that these products are implicated in the respiratory disease outbreak. Most if not close to all traditional, nicotine-containing electronic cigarette liquids are not oil-based, but water and alcohol-based. They are nearly uniformly made up of some combination of propylene glycol, glycerin, water, nicotine, and flavorings. Thus, there is little risk of lipoid pneumonia associated with traditional e-cigarettes.

What is almost certainly causing the recently reported rash of lipoid pneumonia cases is the vaping of THC oils, which are - as the description suggests - oil-based products. While the regulated dispensaries that produce legal, recreational THC e-liquids for vaping generally implement complex procedures to eliminate oils from their products, black market manufacturers do not. This means that there are many bootleg marijuana vape pens and vape carts on the market that contain oils. These oils are not vaporized when heated because their boiling point tends to be above the temperatures achievable with the vaping pens. Instead, the liquid oil droplets are inhaled into the lung. This is a disastrous situation as the oil essentially coats the alveoli in the lungs and makes it impossible for the lungs to work. Macrophages (scavenger cells) try their best to get rid of the oil by encircling the droplets but not before the patient may experience respiratory failure. This is why when a patient with lipoid pneumonia undergoes a bronchoalveolar lavage, pathologists are able to detect "lipid-laden macrophages" in the lung cells. This has been a common feature of a large number of the observed cases in the outbreak, and the overwhelming majority of these cases are due to the vaping of illicit THC oils purchased off the black market.

Lipoid pneumonia does not need to be added to the list of diseases caused by legal electronic cigarettes sold by stores or e-cigarette companies. It needs to be added to the list of diseases caused by vaping marijuana carts purchased from illegal drug dealers.

Furthermore, the recommendation that every ex-smoker stop vaping if they care about their lungs is exactly the opposite of what we should be telling them. The most important thing you can do if you are an ex-smokers who has quit smoking is to not go back to smoking. But that is exactly what is going to happen to the overwhelming majority of ex-smoking vapers if they follow the advice provided in this op-ed. Yes, in an ideal world, one free of addiction, we would simply advise anyone using any drug to stop. But that doesn't really help us in the real world. In the real world of drug addiction, we have something called harm reduction. For people who are unable to immediately stop their drug use, we (public health practitioners) advise them to switch to an alternative that is much safer, even if it still involves addiction. For heroin users, it would be irresponsible to put out an op-ed saying: "Shooting Up with Heroin is Risky: Don't Do It If You Care About Your Health." Instead, what we do is everything in our power to recruit and encourage people addicted to heroin to get into treatment programs, most of which work by providing a safer alternative, such as methadone or another opiate agonist. For people who are addicted to smoking and cannot quit using traditional NRT or other drugs, we should be encouraging them to, not dissuading them from, switching to electronic cigarettes.

2. New York Governor Andrew Cuomo Urges All New Yorkers to Halt Vaping

In an alert issued today, New York governor Andrew Cuomo urged everyone in the state to immediately stop vaping. As quoted in an NBC News article, Governor Cuomo stated: "There is an investigation ongoing. Nobody knows exactly what it is. There is some suggestion that is linked to Vitamin E, et cetera. Our health guidance is no one should be using vaping products, period, until we know what it is."

This is inexcusably irresponsible in two ways:

First, the governor completely undermines what we do know about the causes of the disease outbreak by substituting an explanation of the link between marijuana vaping and most of the disease cases and replacing it with a dismissive "et cetera." No - it is not "et cetera." It is the terribly serious and important information that the vast majority of cases of lung disease have been caused by vaping illicit THC oils purchased off the black market. There is simply no excuse for the governor to be hiding this information from the public.

Second, for the reasons stated above, it is terrible advice to tell everyone to immediately stop vaping. Ex-smokers who have quit smoking by switching to vaping should absolutely continue vaping, because if they don't, they will almost certainly return to deadly cigarette smoking. These are people who are addicted to nicotine and are not simply going to stop using nicotine overnight because the governor tells them to. If they heed his advice, we are going to have a large increase in the number of smokers in the state of New York.

Although the New York State Department of Health also issued the same warning, I am not blaming the department because it is quite clear that they were forced to do so by the governor. If there are any additional cases of respiratory disease in New York that result from young people using black market THC vape carts or vape pens, it is - as far as I'm concerned - partly on the shoulders of the governor, who bears some responsibility for those illnesses and if they occur, deaths.

3. Senator Dick Durbin Blames the Outbreak on the FDA and Believes that the FDA Should Be Controlling and Preventing these Diseases

According to an article in The Hill, Senator Dick Durbin (D-IL) has told the FDA commissioner to "stop this vaping epidemic" or resign. He was apparently referring to an alarming outbreak of severe respiratory diseases that have affected more than 400 (mostly) young people and caused five deaths. Durbin pointedly asked the FDA commissioner: "Will FDA act now that 193 people across 22 states have severe lung illness associated with e-cigarettes? Will FDA act now that a person in Illinois has died?"

I think Senator Durbin should have done his homework and examined the scientific evidence regarding the cause of the 193 people having severe lung illnesses and the person in Illinois who has died. Right now, it appears that the major cause of this outbreak is the production and distribution by a small cartel of illegal drug manufacturers of illicit, bootleg THC oil-containing vape pens and carts. Thus, the FDA likely has nothing to do with this outbreak and there is really nothing that the FDA can do to prevent further cases. Why? Because the FDA does not have jurisdiction over the illegal production, distribution, and sale of illicit drugs. The FDA has jurisdiction over legal drugs, not illegal ones.

In other words, Senator Durbin is turning his ire against the wrong person. Who Senator Durbin should be angry at, and who he should call into his office for an explanation, are the drug manufacturers and distributors who are running a multi-million dollar business out of producing and selling illicit THC cartridges for vaping that are being used by thousands of young people across the country who are obtaining these products on the black market.

The FDA does not currently have any jurisdiction over these dealers. To the best of my knowledge, the DEA (Drug Enforcement Agency) is probably the government agency with the most direct jurisdiction at this time. If Senator Durbin wants the FDA to try to get to the bottom of this, then what he should do is immediately introduce legislation to give the FDA jurisdiction over illicit cannabis product manufacturing, distribution, and sale. That's the only way that we are truly going to get to the bottom of this, unless the DEA is able to put an end to it.

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