Mind and Body

Dr. Michael Fine dispenses views on medical marijuana, social policy

Outgoing director of the R.I. Department of Health offers his candid views on the state’s need to own its addiction problem, to stand on science, to invest in research, and to admit that its social policy on marijuana has been a disaster

Photo by Scott Kingsley

Dr. Michael Fine, outgoing director of the R.I. Department of Health, gives an in-depth, frank interview on medical marijuana, the need for better research, and the need for a more reasonable social policy based on science.

By Richard Asinof
Posted 3/23/15
In a candid, frank fashion, Dr. Michael Fine offers his insights on medical marijuana, the need for more, better research, and the need for the state to own – and admit to – it’s addiction problems. Fine also said that the state needed to admit its social policies to control marijuana have been a disaster.
How much of the tax revenue under proposed legislation to legalize, regulate and tax the sale of marijuana will be dedicated to funding treatment and recovery programs, and not just be tucked into the state’s general revenue fund? What are the ways that Rhode Island’s colleges and universities can set the stage to participate in new research opportunities on the medicinal properties of marijuana cannabinoids? What is the position of Rhode Island’s congressional delegation in working to change the designation of marijuana from a Schedule 1 drug? Is there a way for the R.I. General Assembly to rewrite the current law governing the authorization of medical marijuana to include RNs and PAs?
An increasing number of Rhode Island’s elderly residents, including many aging Baby Boomers, are becoming part of the state’s addiction and substance use epidemic, often through the use of prescription painkillers and anti-anxiety drugs. If Rhode Island is serious about owning its addiction problems, it needs to recognize the depth of the problem across all demographics. The link between victims of sexual abuse and sexual trafficking and its relationship to addiction also needs to be part of the conversation.

PROVIDENCE – With just two weeks left on the job, Dr. Michael Fine wanted to talk about drugs.

In his four years serving as director of the R.I. Department of Health, Fine has been at the forefront in confronting the epidemic of accidental drug overdose deaths, making it a public health priority, pushing for addiction to be seen as a disease, and in championing recovery efforts. [See link to video of Dr. Fine's interview below.]

Last year, in response to the growing number of deaths, Fine helped to mobilize a collaborative statewide initiative to make Narcan more available – which may have saved as many as 500 lives in 2014, he said.

Fine has also pushed the envelope in building good data and publicly reporting the numbers.

But Fine also talked candidly about the need for Rhode Island to own its addiction problem, and to admit to it.

“We have to own this problem, as a state and as a nation,” he told ConvergenceRI. “This isn’t happening someplace else, to somebody else. This is all of us.”

Fine continued: “It’s the prescribers; it’s the dispensers; it’s the whole world of advertising that wants to convince us all that life gets better with a pill.”

The one number he can’t get past, Fine said, is this: “80 percent of the people who will die from accidental drug overdoses started on prescription medicine.”

One of the remedies, Fine continued, is that prescribers need to be more careful about how much they prescribe, when they prescribe, and to whom they prescribe, checking the prescription monitoring database.

“Is it onerous?” Fine asked rhetorically, and answered: “It is.”

But much more terrible, he added, “are the 238 deaths [in 2014], and probably 10,000 to 20,000 drug-addicted Rhode Islanders.”

Swirling beneath the surface of the epidemic in drug overdose deaths and addiction in Rhode Island, in New England, and the nation is the troublesome question about what to do about marijuana.

Colorado, Washington state, and the District of Columbia have legalized it; many states, including Rhode Island, have adopted rules for the use of medical marijuana as a form of compassionate and palliative care, using marijuana to relieve the symptoms of pain and nausea.

Legislation has been proposed in Rhode Island to legalize, regulate and tax the sale of marijuana, and it is now pending before the R.I General Assembly.

There are those who argue that there are significant medical benefits to be derived from the use of marijuana, and in particular, cannabidiol, one of the cannabinoids found in the marijuana plant, which is said to have anti-cancer properties.

One problem is that marijuana has been classified as a Schedule 1 drug – a drug with no medicinal value – under federal law. As a result, no research can be conducted outside of federal control.

A second problem is that medical marijuana patients in Rhode Island and elsewhere can face legal problems arising from the conflict between federal and state laws. Three U.S. Senators have introduced new legislation that would reclassify marijuana as a substance with a recognized medical use.

Advocates of medical marijuana also believe that it is important to remove the stigma of medical marijuana use.

Fine weighed in on medical marijuana, saying that while he believed that there was “thin” medical evidence supporting its use, there was a clear need for more scientific research.

Fine also wanted to talk about the need to change the state’s policy toward marijuana, to move toward a policy based on science, and one that recognized that Rhode Island’s “social policy about marijuana has been a dismal failure.”

The challenge, Fine continued, was to create a public policy “that protects people against addiction that doesn’t undermine the integrity of medicine as a profession.”

Fine did not endorse or take a position on any specific legislative proposal to legalize marijuana; he did talk about the need for a policy that reflected a more realistic, reasonable social agenda.

“Remember, as director of the Department of Health, I don’t take a position on legislation,” Fine told ConvergenceRI last week in an interview, responding to a question about pending legislation before the R.I. General Assembly. “I think the science suggests that a different way of dealing with marijuana would be reasonable.”

The concise challenge, Fine said, framing the issue, “is that marijuana is too widely available, and it is associated with adverse outcomes among some adolescents. At the same time, whether or not it should be medical is questionable.”

“We are living some big lies,” Fine said. “To a certain extent, intelligent public discourse depends on us telling the truth. What the science does is, it gives us access to the truth.”

As to legalization, regulation and taxation of marijuana, Fine offered this advice. “I think that there’s a legitimate argument [to be made that] that is reasonable social policy, given that we haven’t succeeded in reducing marijuana use among adolescents now.

But what we need to be thinking about as we do it, Fine stressed, were two things: “How [do] we make sure we use any tax money that’s raised to really fund substance abuse treatment. The evidence suggests that there is going to be a side effect of increased use [of marijuana].”

Second, he continued, “We need to do our very best to make sure that adolescents don’t have access to this drug, because there is good evidence that shows the relationship between marijuana use among adolescents and a number of adverse outcomes.”

Here is the interview with Fine, including a video produced by Scott Kingsley of DuoPictures.

ConvergenceRI: How would you assess the work done by the R.I. Department of Health during the last four years confronting the epidemic of accidental drug overdoses?
One of the things about the last four years is the extent to which we’ve been able to stand on the science, which is a critical piece of what the Department of Health always must do.

ConvergenceRI: There was a recent story in the Patriot-Ledger that talked about how Rhode Island has focused on creating good data around the epidemic, better than compared to Massachusetts.
The numbers are important, so we actually know what is happening. Deaths are tragic, but they are the tip of the iceberg. It’s important that we all understand how big the iceberg really is.

In our work to develop good data sources, we have focused on understanding the iceberg.

Not only do we track and frequently report deaths so that people understand what’s out there, we track the number of overdoses in emergency departments and report on those on a regular basis. We track the [number of] times Narcan has been used.

Those are critical, because when you hear that Narcan has been used something like 2,000 times last year, then you begin to understand that had we not developed the Narcan policy, we might have lost 500 more Rhode Islanders in 2014.

It also let us understand about the use of fentanyl.

As bad as fentanyl is, and as good as Narcan is, none of this would be necessary if people weren’t using, and that’s the epidemic that we must confront.

ConvergenceRI: Rhode Island as a state is now considering legalizing marijuana, regulating and taxing its use. Does that change the paradigm by removing it from the control of the cartels as an illicit drug? Does it open the door for better research to improve the science around the value of medical marijuana, so that it’s not guesswork?
I think those are great questions. Let’s see if I can take them one at a time.

It’s pretty clear to me that our social policy about marijuana has been a dismal failure.

You can still buy, I’m told, marijuana in every boys room or girls room in every high school in the state.

That’s a big issue. We have, according to the evidence, more marijuana use in Rhode Island than any other state in the country, including Colorado, although the survey was [conducted] before Colorado formally legalized it.

There’s really good evidence that shows the dose response relationship between adolescent use and five different poor outcomes, related to adolescents.

[They include] high-school graduation rate, college graduation rate, drug addiction, suicide and depression, all directly related to frequency of use by adolescents.

We have to own that; that is not a joke in a state where we lost 238 Rhode Islanders to drug overdose [deaths last year].

We know that 80 percent of people who died of drug overdoses got started on prescription drugs. So, we have to own the prescription drug [problem].

And, we have to look really seriously at medical marijuana itself.

I think [what we’ve done, here at the Department of Health] has been considered a success. We implemented the compassion center program, and we got three compassion centers up and running.

We did what the legislature charged us with doing, and I think we did it faithfully and without conflict, which is a good thing.

But, truth be told, in that process, I looked at the medical evidence supporting medical marijuana, per se, and I was actually surprised that the medical evidence suggesting that marijuana is medical is thin to none.

What we see [with] marijuana [is that] it probably has an impact on symptom control. It helps people who are very sick feel better, and that’s a good thing.

From a compassionate perspective, it’s good that people have access to what it is they need to feel comfortable.

Alcohol is also effective at symptom control.

We know, physicians know, that alcohol is probably one of the world’s great cough suppressants, and that it can be very useful from time to time.

But marijuana and alcohol clearly have addiction potential, and we have to look at that as we design social policy.

ConvergenceRI: Can you explain a bit further what you mean?
From the perspective of medicine as a profession, the direction toward medical marijuana really undermines the integrity of medicine as a profession.

When I, as a physician, prescribe one of a hundred different medicines, I write a dose, the duration, and a frequency; I write that into a prescription.

Based upon years of training, and years of referencing good, double cross-over clinical trials, I know the likely effect of that prescription, and it’s part of my professional responsibility to assess the effectiveness, or lack thereof, as well as the side effects, or lack thereof, of that prescription. That’s the medical process.

What we do with marijuana and its authorization is not a medical process. It’s a substance whose strength we don’t know, whose impact on the individual we don’t understand.

The good news is that we’re helping the suffering of people; the bad news is that it is not a medical process.

Using the medical process to provide a pathway to people who are suffering, I think, is problematic.

It asks physicians to do something that they really aren’t specifically [trained] to do.

ConvergenceRI: Isn’t the problem related to the federal government prohibiting research on marijuana because it’s been characterized as a Schedule 1 drug, prohibiting anyone outside the federal government from doing research on it?
That’s right

ConvergenceRI: So, it would seem to me that you would have to change the designation of marijuana in order to do the comprehensive research that you would like to better understand the ways in which marijuana works medically?
Remember, marijuana isn’t a single substance, there are multiple substances contained in the smokes and the edibles. Clinical research is critical if we’re going to make marijuana a truly medical process, so that we can understand dose and frequency and duration. And, that we understand the likely clinical outcomes.

ConvergenceRI: There is now a bill before the R.I. General Assembly, with Sen. Josh Miller as one of the sponsors, to legalize marijuana, to tax and regulate it. As you have discussed before, about having too much product on the street, is this a way to take it out of the hands of the cartels? Is it a way to regulate marijuana in a different way, to take the pressure off the criminal justice system?
I think that there is a legitimate argument [that can be made] that [legalization, regulation and taxation] is a reasonable social policy, given that we haven’t succeeded in reducing its use among adolescents now.

But there are things we need to be thinking about if we [are to] do it.

One of the things that we need to be thinking about is how we can make sure that we use any tax money that’s being raised to really fund substance abuse treatment [and recovery programs].

The evidence suggests that there is going to be a side effect of increased use.

And, we need to do our very best to make sure that adolescents don’t have access to this drug. Because, clearly, there is good evidence that shows the dose response relationship between marijuana use among adolescents and a number of adverse outcomes.

ConvergenceRI: Just to be clear. Does that mean you’re advocating or suggesting that legislation proposed by Sen. Miller would be a positive step forward?
Remember, as the director of the Department of Health, I don’t take a position on legislation. I think the science suggests that a different way of dealing with marijuana would be reasonable.

ConvergenceRI: Do you think the Miller legislation is reasonable?
I haven’t actually looked specifically at that legislation. I don’t know it well enough to take a position on it, even if I was in the business of doing that, which I’m not.

ConvergenceRI: How would you characterize the best way in which Rhode Island can move forward?
I think we have to stand on the science. And, to be really clear about the science. We have to own that there are some associations between adolescent use [of marijuana] and drug addiction. And, to create social policy that minimizes that, or at least mitigates it.

That’s something we have to own. We also have to own that the evidence supporting marijuana as a medical process is pretty thin. And, if we’re going to continue its use in a medicinal way, we ought to commit ourselves to doing the research that’s necessary to determine whether it’s medicinal, or not.

That seems like a rational approach.

ConvergenceRI: Are there things you would like to see the federal government do?
I worry about the wink-and-nod process that now exists with Schedule 1. Noboby’s supposed to mess with it, but a bunch of states are, and nobody’s enforcing it.

I would rather have us look at it in the face and say: let’s find a way to do the research we need to do.

Let’s find a way to design a social policy – at the federal and state level – that recognizes the difficulty of perfect control, and that owns the adverse outcomes, because they [exist] for some people.

I think that kind of coherent policy development is important if people are going to have confidence in our government and our policies.

ConvergenceRI: In terms of prescription drug use and abuse, there’s been some pushback from folks saying that some of the new proposed regulations are onerous. What is the documented relationship between prescription painkillers and addiction?
I think we have to own this problem, as a state and as a nation. This isn’t happening someplace else to somebody else. This is all of us.

That means that it’s prescribers, it’s dispsensers, it’s the whole world of advertising that wants to convince us all that life gets better with a pill.

We have to look at our markets, and how our markets work, and how they are affecting the fabric of our lives.

The one number that I can’t get past is that 80 percent of the people who will die from accidental drug overdoses deaths started on prescription [painkiller] medicine.

Nobody meant to do that. It means that prescribers need to be really careful about how much they prescribe, and when they prescribe. We [doctors] all need to be careful about checking with the prescription monitoring program.

Is it onerous? It is. That's terrible.

But more terrible are the 238 deaths [from accidental drug overdoses in 2014] and probably 10,000 to 20,000 drug-addicted Rhode Islanders.

That [creates] a huge drag on the economy; it has a huge impact on our families. And, it is something we have unintentionally created together.

ConvergenceRI: Are there any questions that I haven’t asked that I should ask?
I think it’s been a really interesting four years [serving as director of the R.I. Department of Health]. We did five different Hospital Conversions Act applications. We working through the issues around Pentec [related to nurses dispensing narcotics to pain pumps by an out-of-state company], not to everyone’s satisfaction, but we worked through them.

We thought really carefully about the issues around retail-based clinics, and worked through those issues in great detail.

In all cases, I would like to think that we worked out a position that was really based on the science.

ConvergenceRI: In terms of moving forward, are there resources that need to be developed to make sure that the science is properly invested in?
We ought to be paying attention to investing in the science around the use of firearms, because that science got stopped 20 years ago, and it has only recently been restarted.

We ought to be clearly investing in the science around how we best invest in public funds to create population health outcomes.

There’s evidence that suggests only 10 percent of population health outcomes are related to medical care. And yet, we spend $3 trillion a year on medical care, much of it unnecessary or unhelpful.

And, looking at the science around wise and prudent choices around what kinds of medical and health services we actually need, what kinds are harmful, and what kinds are overused.

It’s really important that we build a health care system that takes care of everybody.

ConvergenceRI: Any last words?
I have one regret. I had colleagues who were very disappointed – who are nurse practitioners and PAs, when, according to the best reading of the law, that they were not authorized to dispense medical marijuana.

There was a real struggle internally. And that [decision] was fired by our lawyers; not by our position.

So, who gets to be authorized turned out to be an arm-wrestling match, based on the way the law was written. I spent a huge amount of time personally, trying to argue with the attorneys, that everybody who could practice at the level of primary care ought to be able to authorize [medical marijuana].

And I wasn’t successful, and it was a heartbreak. Because I think it proved to be divisive among colleagues who ought to be working and thinking and growing together. For that, I am still sorry that people felt disrespected.

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