Have a Couple Beers and Call Me in the Morning

Catherine O’Leary’s cow.  Gavrilo Princip.  The hayfork of a drunk hired hand. 

Sometimes things have consequences all out of proportion to what we expect.  In my list, Catherine O’Leary’s cow is reputed to have kicked a kerosene lantern in 1871 and thereby cause the Great Chicago Fire, resulting in the death of some 300 people and the destruction of about a third of the city’s value.  Gavrilo Princip was a 19-year-old man who assassinated Archduke Franz Ferdinand of Austria, setting off a series of events that resulted in the Great War of 1914 – 1918. 

And the poor hired hand?  The story goes that one day when Wayne Wheeler was a boy, he was working on his family’s farm and his leg was poked by the hayfork of a drunken worker.  It traumatized him and he spent much of his life devoted to the abolition of alcohol, becoming the de facto leader of the Anti-Saloon League.  His efforts, organizing churches and other small temperance groups to implement a particularly effective form of pressure politics were instrumental in bringing about passage of the Eighteenth Amendment to the U.S. Constitution prohibiting “the manufacture, sale, or transportation of intoxicating liquors” within the U.S.  He claimed to have substantially written the National Prohibition Enforcement Act (a fact that the Act’s official author, Andrew Volstead, repeatedly denied) establishing executive power to enforce the Eighteenth Amendment.  The full text of the Volstead Act can be found here.  

During the 13 years that prohibition was in effect in the United States, alcohol consumption dropped by an estimated 30 percent as legal avenues for access disappeared and costs through illegal avenues rose higher than many people could afford.  It is generally accepted that the consequences of this experiment were mostly a flagrant contempt for the law and the rampant creation of illegal alcohol-distribution mechanisms. 

What is sometimes forgotten is the role that physicians played in maintaining access to alcohol.  They provided one of the few legal ways to obtain alcohol since the Volstead Act carved out an exception to “use liquor for medicinal purposes when prescribed by a physician.”  The alcohol prescription pads of the time look almost quaint today, with alcohol consumption as much a part of modern society as it was in the time before prohibition.  The idea of drugstores maintaining shelves of government-produced whiskey to dispense to those with prescriptions strikes our current mindsets as almost amusing.  It seems obvious to have been an exercise in futility trying to suppress a product so pervasively a part of the prevailing culture. 

The experiment on marijuana prohibition may similarly be coming to end, although that experiment has lasted far longer than the prohibition of alcohol.  In the early 1900’s, marijuana had been almost unknown in the United States, but it started to become more popular as Mexicans immigrated into the U.S., prompting efforts to ban it.  In these efforts, California has always been key, leading the way as other states progressively followed. 

California was the first state to ban marijuana in 1913, with many other states following in due course thereafter.  California was also the first state to soften its stance on marijuana consumption, allowing medical uses in 1996.  Again, many other states followed in due course.  And in next week’s election, California may again lead the way in fully relegalizing marijuana with its Proposition 19.  A copy of the text of the proposition may be found here.  It is worth noting that efforts to fully legalize marijuana in Alaska have failed, even though a 1975 case found personal use of marijuana at home protected by an unusually strong privacy provision in the Alaska Constitution.

In many ways, the currently availability of marijuana for medical purposes in a number of States mirrors what occurred during the era of alcohol prohibition, although marijuana is probably recognized for more legitimate medical purposes than alcohol.  During the period of alcohol prohibition, the availability of medical prescriptions made a mockery of prohibition efforts.  To be certain, there were many who believed in the therapeutic value of alcohol and there are genuine medical treatments to be had with alcohol, but most prescriptions were filled simply so that people could experience its intoxicating effects.  Similarly today, many believe that medical prescriptions for marijuana make a similar mockery of efforts to prohibit its use more generally.  Again, there are legitimate therapeutic uses for marijuana, but an honest assessment of medical-marijuana laws is that they have been used as a wedge to gain legal access to its psychoactive properties. 

Even if California relegalizes marijuana in next week’s vote, there is still the matter of federal drug-regulation statutes, which prohibit the use of marijuana throughout the United States.  In addition to the banning of marijuana use by several states, the federal government began to regulate its use nationally with passage of the Marijuana Tax Act in 1937.  A copy of the Act’s text may be found here.   What is perhaps interesting about the Marijuana Tax Act is that it included a specific exception for medical uses prescribed by physicians.

The current Controlled Substances Act, which was passed in 1970 in response to President Nixon’s declaration of a “war on drugs” and supplanted the Marijuana Tax Act, includes no such exception.  A conflict thus exists between federal and state law in the several states where medical uses of marijuana are permitted under state law.  The conflict was tested shortly after California decriminalized such uses in 1996 in the case of Gonzales v. Raich.  A copy of the full opinion can be read here.  While the case confirmed the authority of the federal government to ban the use of marijuana even in states that have approved it for medical purposes, the policy of the Obama administration has been not to enforce the federal ban with respect to medical users.  

The ultimate impact of California’s decision next week will be interesting and may well take years to understand fully.  But one thing is certain:  if the proposition passes, it is a certainty that similar proposals will be tried in other states and that additional pressure will be brought to bear on the federal government to follow the lesson of prohibition to its ultimate conclusion.

Even Hell Hath Its Peculiar Laws

The legend undoubtedly has origins that predate the short German chapbook published in 1587 that tells the story of Johann Fausten.  A scholar at Wittenburg, Dr. Fausten’s thirst for knowledge is unquenchable.  When he feels that he has learned all that he possibly can, he turns to magic and, seduced by the power of the black arts, summons Mephistopheles as the representative of Lucifer.  The two negotiate and hammer out an agreement to be signed in blood in which Dr. Fausten will sell his soul in exchange for twenty-four years of power and Mephistopheles as a servant to his every whim.  Dr. Fausten indeed enjoys a time of great power, but in the end it is seen as a pittance when measured against the loss of his soul to eternal damnation.

The lesson of the legend of Faust, which recurs time and again in the course of human events, is that there are bargains we make that have consequences far worse than we imagine when we are seduced by the power that we can temporarily achieve with the bargain.

Physicians, confronted with the increasing resistance to antibiotics, are beginning to flirt with a seductive possibility.  The story of antibiotics is one that is well known.  It was 1928 and Dr. Alexander Fleming was working at St. Mary’s Hospital in London as a bacteriologist.  One day, he returned to a plate culture of staphylococcus to find it contaminated with a blue-green mold.  It was probably a moment of frustration, to find the contamination, but there was something interesting about it.  Bacteria colonies next to the mold (Penicillium) were being dissolved.  Fleming grew the mold in pure culture, leading to the discovery of penicillin, a substance produced by the mold and that had antibiotic properties.  Penicillin itself was not chemically isolated until World War II, earning Howard Florey and Ernst Chain the Nobel Prize in medicine.

The discovery of antibiotics revolutionized the treatment of infectious disease.  Physicians were given a miraculous cure for battling bacterial infections and through the last half of the twentieth century, it became commonplace for those who fell ill to rely on the availability of a simple pill to cure much disease.

But the promise of antibiotics was in some respects short-lived.  The mechanisms of natural selection operated on the genetic structure of bacteria when they were exposed to antibiotics, causing them to mutate into resistant strains.  Already in the 1950’s — little more than ten years after the isolation of penicillin — it was apparent that tuberculosis bacteria had undergone mutations to make it resistant to streptomycin.  Over time, things have worsened.  Widespread use of antibiotics has resulted in so many resistant bacterial strains that many antibiotics are all but useless.  And so enters the possible Faustian bargain.

As more and more antibiotics were being discovered, some were found to have high toxicity.  One example was chloramphenicol, which can produce aplastic anemia in some patients.  There is no known way to predict who may or may not get this side effect and it is generally fatal.  It can also cause inner-ear damage that produces tinnitus and balance problems and may be linked to chronic lymphcytic leukemia.  But even so, many physicians are now looking to chloramphenicol as a viable antibiotic in treating bacterial strains that have become resistant to even the most powerful antibiotics that are currently used and safer.  Many feel they have little choice.  There are few new antibiotics being developed and these old ones have the advantage that they have been so little used that bacteria have not had a chance to develop resistance.

The legal issues related to the use of antibiotics centers around regulatory approval processes.  This week, Lannett Co. in Philadelphia announced that it has formulated capsules of chloramphenicol with ingredients from a Spanish supplier with the intention of seeking approval from the Food and Drug Administration for oral use of chloramphenicol “as a drug of last resort.”

Is this a compromise of the type that Faust made with Mephistopheles, a bargain for greater power now over the treatment of infectious disease that has consequences we do not fully appreciate?  Only time will tell, but what is certain is that after less than a century, physicians are already seeing the need to compromise as the wonderful promise of Alexander Fleming’s discovery appears to be reaching its limits.

Wonder Drug

Perspective can be everything.

A few years ago, after alarmist reports about the dangers of the compound dihydrogen monoxide, many people responded and called for government regulation.  The reports noted such dangers as severe tissue damage after prolonged exposure to its solid form, its corrosive effects on metals, its presence in tumor biopsies, and numerous reports of death associated with its accidental inhalation.  But even in the face of such dangers, there was no prohibition on its use in numerous household products, including as an additive to baby food, in cough medicines, shampoos, shaving creams, and in all the coffee served at coffee houses throughout the United States.

Dihydrogen monoxide — H2O — is, of course, simply water, and the list of its possible hazards, while accurate, was deliberately couched in a way that made it sound more dangerous than it really is.

What if people were told of the amazing properties of a drug that is currently being investigated by researchers?  One that has the ability to fight multiple sclerosis, Crohn’s disease, and other forms of inflammatory disease.  It is also known to alleviate pain, reduce nausea in some patients, and to ease the impact of many sleep and mood disorders like stress, anxiety, and depression.  Researchers are currently testing its effectiveness on rheumatoid arthritis, Tourette syndrome, epilepsy, and schizophrenia, among others.  There are even recent reports suggesting that it shows promise as a cancer treatment by killing malignant brain, skin, and pancreatic cells without harming surrounding healthy cells.  Wouldn’t they be outraged that the government continues to ban this drug merely because it also has some psychoactive properties?

The drugs that seem to have all of these wonderful properties are derived from marijuana, which remains banned throughout most of the U.S.  Currently, only fourteen U.S. states allow medical uses of marijuana, but the medical-marijuana movement is active in seeking decriminalization in the other states.

The perception among many — and the perception is accurate to a large degree — is that those who actively seek decriminalization of marijuana do so mainly because they want to experience its psychoactive effects.  Its “medical” uses are used as a cover to argue for legalization so that, quite simply, they can get high legally.  But even if that is a motivation among many, it does not diminish the fact that there are legitimate medical treatments that use marijuana and that an understanding of those treatments is critical in deciding at what level the government should regulate its use.