Wednesday, September 25, 2019

Massachusetts Governor's Emergency Order Protects Drug Dealers at the Expense of Hundreds of Life-Saving Small Businesses

In a move that is a huge victory for the state's drug dealers, Massachusetts Governor Charlie Baker has instituted a 4-month ban on the sale of all vaping products in the state, including both nicotine-containing electronic cigarettes sold at retail stores and vape shops and cannabis vaping products sold at legal cannabis dispensaries. The ban, which was approved by the state Public Health Council on Tuesday, goes into effect immediately and was motivated by the recent emergence of an outbreak of vaping-associated respiratory illness (VARI) that has affected more than 530 people across the United States and has resulted in nine deaths.

The primary suspected cause of this outbreak of severe, acute respiratory failure which often takes the form of lipoid pneumonia or an eosinophilic chemical pneumonitis is the widespread black market sale of illicit marijuana vape cartridges, many of which contain a viscous oil that is used as a thickening agent to help drug dealers obtain a higher price for the THC vape carts they are selling. There were recently two major drug busts which recovered thousands of oil-laden THC vape carts, and testing of THC vape carts provided by numerous case patients in New York State revealed that all of them contained high levels of vitamin E acetate oil, the thickening agent that has recently come into widespread use by illicit drug manufacturers (as well as some legal manufacturers).

Although the CDC has misled the public into thinking that nicotine-containing e-cigarettes like JUUL are causing the outbreak, the application of basic epidemiology principles should tell us that this cannot be the case. Since JUUL and many other nicotine-containing e-cigarettes sold at retail stores have been on the market for at least several years, it does not make sense that we would all of the sudden see these products causing severe respiratory failure. Moreover, since there are millions of adult JUUL users, we would be seeing a lot more adult cases of this disease if it were being caused by JUUL or similar products.

Clearly, whatever is going on is affecting primarily youth and primarily males. What kind of vaping products are used primarily by youths? The answer is black market products. Since adults can legally access cannabis vaping products in states with legalized recreational or medical cannabis, it is primarily going to be youth who use the black market THC oils that are being distributed by the drug dealers.

The strongest evidence that the primary culprit is black market THC oils is the fact that the most common presentation of the illness is a lipoid pnemonia. This is a disease that is known to be caused by oil inhalation. Virtually all, if not all, nicotine-containing electronic cigarettes sold at stores are made with water/alcohol-based e-liquids, which do not cause lipoid pneumonia. In contrast, the THC vape carts that are in wide circulation are loaded with a viscous oil. When this oil is heated and then cools when it reaches the lungs, it solidifies and basically cakes the alveoli and also induces severe inflammation (as the body's immune cells try to get rid of the oil). This explains the typical radiographic appearance in the cases, which is actually part of the case definition.

If there are any nicotine-containing e-liquids that are using an oil-base, they are almost certainly being sold online, not by retailers or vape shops. But Governor Baker's order focuses on the latter.

The Rest of the Story

So why, in the face of this severe epidemic of respiratory disease that has been associated with the widespread use of oil-laden THC vape cartridges sold on the black market, is the governor banning the sale of legally produced and sold nicotine-containing e-liquids that have not been confirmed to be causing any cases?

The answer, I believe, is that this is an easy political victory. It looks great to upper middle class suburban parents (voters) that politicians are stepping in to protect their children. And it takes no political courage to go after hundreds of small business owners who don't have the political power to put up a legal fight. It would be far more difficult to actually confront the real problem, which would require the governor to go after the drug dealers who are distributing illicit THC vape carts that are winding up in the hands of youth throughout the state.

Sadly, Governor Baker's action is going to make this problem much worse, not better. Eliminating nicotine-containing e-liquids is not going to prevent further cases from occurring because those are not the products which appear to be causing the outbreak in the first place. Moreover, the kids who are selling e-liquids in our middle schools and high schools are not going to simply shut down their operations. They are going to switch over to selling the e-liquids that remain available, which will be the black market THC vape carts that are actually causing this outbreak.

This emergency order is also going to have other severe adverse health consequences. It is going to shut down hundreds of vape shops which are literally life-saving businesses: they are helping tens of thousands of smokers to quit smoking and to remain off of cigarettes. Essentially, vape shops are smoking cessation clinics. Most of the owners have themselves quit smoking by switching to e-cigarettes, and they can provide personal advice and counseling to their customers. This is much more effective smoking cessation counseling than most physicians can provide. And that's why it's been so widely successful.

Don't be fooled. A four-month temporary suspension of e-cigarette sales is, for most small businesses, a permanent ban because they are going to have to shut down. Most small businesses can simply not survive having no revenue for four months. And if they have a large supply of e-liquids in inventory, they could be out hundreds of thousands of dollars. They will never recover.

This ban is also going to lead many ex-smokers to return to smoking as their e-liquids disappear and it becomes too inconvenient to obtain them. In addition, this order is going to create a new, unregulated black market for e-liquids.

But the worst outcome, by far, will be the misdirection caused by this move. It takes our attention off the widespread problem of marijuana vaping among middle and high school youth in Massachusetts. That is the public health emergency we face, but apparently, we're not willing to face up to it because it's a lot more politically expedient to go after small businesses than drug dealers.

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