Friday, September 27, 2019

CDC's Failure to Demand Urine THC Testing of All Outbreak Patients is Inexcusable and is Putting the Entire Nation at Risk

The CDC has irresponsibly botched its entire investigation of vaping-associated respiratory illness (VARI) by failing to recommend or demand that clinicians perform a urine THC drug test on every case patient, and this is putting the entire nation at risk while leading to terrible public policies that are causing immediate harm to thousands of people.

The CDC continues to insist that we have no idea what is causing this "mystery illness" and that "no single product" has been identified that explains all of the cases. This statement, which violates basic principles of epidemiological outbreak investigations, is the single communication that has confused policy makers and the public and hindered the ability of state health agencies to issue appropriate recommendations to the public to actually curtail this epidemic of life-threatening respiratory failure.

Contrary to what the CDC seems to be insisting, this outbreak is not going to be solved by identifying a single product common to every patient. Like all outbreak investigations, it is going to be solved by identifying a type of product that is common to an overwhelming majority of patients. And frankly, we already have that and it's called marijuana. There is just far too high a proportion of case patients who have admitted to using THC or CBD oils for this to be merely a coincidence.

Just overnight it was announced that a second Oregon patient has died. The reported cause? Vaping of THC oils. Of course, this didn't stop the Oregon Health Authority from recommending that Oregonians stop vaping nicotine-containing e-liquids. This non sequiter is striking: "A second Oregonian has died from a lung illness after vaping cannabis products, and state health authorities Thursday urged people to immediately stop using all vaping products." This is like reporting a series of deaths from eating Romaine lettuce and advising people to immediately stop eating all lettuce and cabbage. Except it's a lot worse because no harm comes from people stopping eating cabbage. Severe harm is already resulting from ex-smokers stopping vaping and returning to smoking or to the black market.

There are simply too many cases of patients who were vaping for years without a problem and then decided to try THC vape carts and then suddenly getting sick to dismiss the central role of marijuana vaping in this outbreak.

So why aren't the CDC and in turn, state health authorities issuing very clear warnings to the public to stop vaping marijuana, especially THC vape pens or vape carts that are purchased on the street?

It's because the CDC keeps repeatedly issuing the irresponsible mantra of this botched investigation: "No single product" has been linked to all cases. While I was working at CDC, I was not aware of a single Epi-Aid in which a single exposure was linked to all cases of an outbreak. There are always going to be a small proportion of people who forgot that they did have a little potato salad at the church picnic. And in this investigation, the problem is far worse. There are no legal implications and no stigma attached to admitting that you ate some potato salad. But for a youth to admit that they were using illicit marijuana vaping carts purchased off the street from drug dealers could have substantial consequences, not only legal ones but stigma-related ones as well as affecting their relationships with their parents.

The CDC itself admits that about 80% of the outbreak patients admit to using THC oils. My count from media reports puts that figure closer to 90%. How high does that proportion have to go before the CDC issues a clear recommendation not to vape THC and stops undermining its own findings by emphasizing the failure to find a common product in every single case? Apparently, it's 100% before they will take the appropriate actions and enable health authorities to put an end to the tremendous morbidity and mortality this outbreak is causing.

The Rest of the Story

The sentinel failure of the CDC in investigating this outbreak is its failure to recommend or demand that all case patients be screened (via urine drug testing) for THC. In people who vape marijuana regularly, THC can be detected in the urine for at least 4-6 weeks following the last exposure. Even in people who don't vape marijuana regularly, THC can be detected for between 7 and 10 days after the most recent use. This is not going to be 100% sensitive in detecting all THC use but it would certainly help detect a large proportion of the cases where a patient is using THC but did not report it.

Even if a small proportion of patients were screened for THC, it would provide valuable information. 

The recommendation to test for THC does not need to be justified based on the premise that youth patients are "lying" about their drug use:

1. There are thousands of counterfeit products on the market that are packaged to look like legitimate nicotine-containing products but which may contain cheaply made THC oils. There are even counterfeit JUUL-compatible pods that appear to be JUUL but are actually bootleg products and could contain THC oils. So youth may simply have no idea that they are using THC. This alone makes it inexcusable for clinicians not to test for THC in every patient.

2. Many youth simply don't know what they are vaping in the first place. Data from the Monitoring the Future study and other national surveys reveal that youth are unable to accurately report what they are vaping. They may not actually know what is in the cartridges that they are using. Youth are most commonly obtaining their vaping liquids from other kids at their schools, not directly from a retail store. So they are not getting an ingredient list or being told exactly what is in the liquid. They truly may not be aware of exactly what they are vaping. Under these circumstances, it is bordering on public health negligence for the CDC not to recommend that patients be screened for THC use.

The CDC has been insisting that a small proportion of cases have occurred among patients who did not use THC. The truth is that they have no way of knowing that. Unless the patients have been tested for THC, it simply cannot be said that cases have occurred among patients who only used nicotine-containing e-liquids. This is why I believe it is so irresponsible that the CDC has repeatedly given the impression that it knows that a substantial proportion of cases do not involve THC. They actually have no way of verifying their contention that "no single product" ties together all the cases. It is entirely possible that a single product - marijuana and counterfeit vapes - does tie together all the cases.

The CDC's failure to conduct this investigation properly (as outlined above) is not only putting the entire public at risk because we are failing to properly communicate the role of black market THC vape carts, but it is also leading to bad public policy that is already having devastating public health consequences as well as putting hundreds of vape shops out of business and creating massive job loss and financial harm for small business owners.

The final question that I want to tackle in this commentary is why the CDC is failing to recommend THC testing of every case patient. There is no legitimate public health justification for this failure. The only explanation is that the CDC does not actually want to tie all the cases together by detecting marijuana use in a large proportion of patients who reported using only nicotine-liquids because that would let legally sold, store-bought nicotine-containing e-cigarettes off the hook. The CDC's actions tell me that they actually desire to be able to tie these cases to traditional e-cigarette use. They are apparently going to hold out as long as possible before admitting clearly that THC carts are playing a major role in this epidemic.

The CDC's irresponsibility is perhaps best demonstrated by the testimony of a CDC deputy director at this week's Congressional hearing. She testified that one possible cause of the outbreak is something about the act of vaping itself. In other words, she testified that something about the process of vaping itself may be causing this outbreak, rather than the specific products that are being vaped.

Sorry - I hate to have to use this type of language but my conscience does not allow me to express it any other way:

This is complete bullshit.

People have been vaping for the past 12 years without any problems. Millions of smokers who quit smoking by switching to vaping have experienced dramatic improvement in their respiratory health, not rapid progression to respiratory failure. The act of vaping is not causing this outbreak. It is something in the e-liquid or that results from the heating of the e-liquid that is responsible.

At an August 23rd press briefing, one CDC official had this to contribute to a reporter's question about why there has been an upsurge in cases: "We do know that e-cigarettes do not emit a harmless aerosol."

Instead of that meaningless observation, the official could have instead explained that one major change we do know about is the use of a new thickening agent that had not been used previously - vitamin E acetate oil - and could have pointed out that the overwhelming majority of cases were associated with vaping black market THC cartridges. But he was apparently more concerned about creating the perception that e-cigarette companies continue to insist that their products are harmless and then attacking this straw man than actually providing a useful answer to the question.

I get the idea that the CDC really doesn't know anything about vaping. They keep talking about it as if it is some great "mystery" and we don't have any clues about what may be going on. The truth is that we have an immense amount of information, but they are just not putting it together. They keep discounting the information that they do have. The cannabis experts actually know far more about the outbreak and its potential causes than the CDC does. In fact, some cannabis experts actually predicted this outbreak before it occurred because of the changes they were observing in the production of black market THC vape carts and the counterfeiting of legitimate products that they observed.

Although I'm convinced that the CDC's failure to recommend THC testing, its failed communication on the potential causes of the outbreak, and the actions of policy makers to ban electronic cigarettes are all contributing towards making the outbreak worse by obscuring the potential role of marijuana vaping, it is not too late to prevent further deaths by initiating THC testing of case patients. I hope that the CDC will institute this recommendation immediately.

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