Taking a vape break…

e-cigarette

E-cigarette use is now more common than cigarette use among teens [1], and has become increasingly popular with adults who wish to quit smoking by using a safer alternative to cigarettes. In case you have been living under a rock, e-cigarettes are devices that allow you to heat and inhale nicotine, the main substance that makes cigarettes addictive, without getting the rest of the harmful chemicals.

But unlike cigarettes, e-cigarettes are relatively new and little research has been done on them. A PubMed search using the keyword “smoking” (of tobacco products) yields 124389 results. “Electronic cigarettes” yields a modest 328. And while long-term health outcomes will take some time to appear, many argue that whatever the results, e-cigarettes are bound to be the lesser of two evils.

But do e-cigarettes actually help people quit? One UK study found that daily e-cig use was associated with more attempts to quit and far fewer cigarettes smoked, but was not associated with having fully quit smoking at one-year follow-up [2]. However a larger study, also from the UK, found that compared to those who tried to quit with an over-the-counter nicotine replacement therapy like gum or the patch, e-cigarette users were more than twice as likely to have quit [3], perhaps because in addition to administering nicotine, e-cigarettes also replace the all-important physical habits of smoking: holding something in your hand and mouth, inhaling and exhaling.

As Farsalinos and colleagues (2015) recently argued:

“Most of the tobacco cigarette’s toxicity is related to the combustion process. Models of harm reduction applied to tobacco suggest that switching from inhalation of combustible products to a noncombustible nicotine delivery product would likely result in a vast reduction in tobacco-related death and illness. Currently available evidence raises no doubt that electronic cigarettes (e-cigs) are by far less harmful than smoking (although probably not absolutely safe) and have the potential to be the most effective tobacco harm reduction products due to their unique property of resembling smoking and providing satisfaction to the user” [4]. 

But it’s that little side note – probably not absolutely safe – that needs to be addressed.

What Farsalinos and colleagues argue is that regulation is necessary to ensure some level of quality control, but as e-cigs are neither tobacco nor medication, the regulatory process could instead follow the example of food standards by excluding chemicals known or suspected to be harmful and ensuring products aren’t contaminated. Impurities are a concern, however one analysis of 20 vials of e-cig liquid found that the nicotine level written on the labels nearly matched the detected levels, and while some impurities and nicotine degradation were found, these weren’t at levels high enough to likely cause harm [6].

There is a lot of debate in the research community about whether or not e-cigarettes represent a lower, similar, or higher risk of cancer as compared to cigarettes, with journal commentary sections running wild. Because they are quite new, studies can only look at the products and make toxicological inferences; unfortunately, for real-world outcomes we simply have to wait and see [7]. What the toxicological experiments reveal is mixed – some argue that e-cigs produce formaldehyde levels with 5 to 15 times the cancer-causing risk as cigarettes [8] while others argue this highly publicized experiment was fundamentally flawed because it used extreme coil-temperatures (creating a phenomenon known as ‘dry-puff’) that actual e-cigarette users would never tolerate [9]. In any case, potential harms are difficult to assess when constant modifications to the technology and the absence of regulatory measures allow for extensive variation in the content of e-cig liquids and the heating mechanisms of various e-cig models.

And those e-cigarette models keep getting fancier and fancier: besides smartphones, e-cigarettes may just be the closest we get to that slick, 1960s outer space-like version of the future that is so much more endearing than the actual future we wound up with (Tinder, bad loans, and melting sea ice): glowing chrome robot flutes emitting plumes of vapour that smell like cheesecake… it’s delightfully absurd and probably a minimal harm compared to the many other toxicities in our environment. [although full disclosure – as an ex-smoker, this writer’s gauge of what is acceptable risk might be different than someone who has never poisoned themselves so deliberately!]

Yet many others are concerned that the high-tech/seemingly low-risk appeal of e-cigs will renormalize smoking or act as a ‘gateway’ drug for youth is common. Some point out that smoking rates continue to decline, citing that only 1% of youth who have never smoked a cigarette use e-cigarettes, while others argue otherwise [10].

What are your thoughts about e-cigs? Is more research required to form an accurate opinion about them? Is the government right to ban e-cigarettes in addition to cigarettes in non-smoking areas? Or do e-cigarettes potentially offer another way to help tobacco smokers kick the habit? Do you see this as a growing industry or just another fad? Let us know in the comments.

[thanks to Armen Slikhanian for background research and the first draft of this post.]

[1] Miech, R. A., Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2014, December 16). National press release, “E-cigarettes surpass tobacco cigarettes among teens.” University of Michigan News Service, Ann Arbor, 16 pp.

[2] Brose, L.S.; Hitchman, S.C.; Brown, J.; West, R.; McNeill, A. (2015). Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up. Addiction, 110(7), 1160-1168

[3] Jamie Brown, J.; Beard, E.; Kotz, D.; Michie, S.; West, R. (2014). Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction 109(9), 1531-1540.

[4] Farsalinos, K. E., & Le Houezec, J. (2015). Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes).Risk Management and Healthcare Policy8, 157–167. http://doi.org/10.2147/RMHP.S62116

[6] Etter, J.F.; Zäther, E.; Svensson, S. (2013). Analysis of refill liquids for electronic cigarettes. Addiction, 108(9), 1671-1679.

 [7] West, R., & Brown, J. (2014). Electronic cigarettes: fact and faction. The British Journal of General Practice64(626), 442–443. http://doi.org/10.3399/bjgp14X681253

[8] Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med 2015; 372:392–4. doi: 10.1056/NEJMc1413069.

[9] Bates, C.D.; Farsalinos, K.E (2015). Research letter on e-cigarette cancer risk was so misleading it should be retracted. Addiction 110(10), 1686–1687.

[10] Hall, W., Gartner, C., & Forlini, C. (2015). Ethical issues raised by a ban on the sale of electronic nicotine devices, Addiction, 110(7), 1061-1067.

[image source: http://www.engadget.com/2013/12/18/smokio-connected-e-cigarette/]

Naloxone Distribution for Canada’s Opioid Overdose Epidemic – Does it save lives?

Naloxone-Kit

Lots of people have been prescribed an opioid at some point in their lives – in fact, Canada is the second-largest per capita consumer of prescribed opioids [1]. And about 99 000 Canadians used opioids recreationally in 2012 [2] (although the real number is probably higher. If Statistics Canada called you up one day for a survey, would you honestly tell them you take OxyContin for fun from time to time?).

With these high rates of both prescribed and non-prescribed usage, both Canada and the United States have seen huge increases in opioid-related overdose deaths in the past few years. Part of the problem has to do with how many opioids are prescribed, because that means there are more opioids to go around to both those with and without a prescription. As Dowell, Kunins, & Farley (2013) put it:

From 1999 to 2010 the number of people in the United States dying annually from opioid analgesic–related overdoses quadrupled, from 4030 to 16 651. Patients’ predisposition to overdose could not have changed substantially in that time; what has changed substantially is their exposure to opioids. During this same time, the amount of opioids prescribed also quadrupled [3].

Similar prescription increases have been reported in Canada. While rates can differ a lot between provinces, high-dose opioid prescriptions went up by 23% between 2006 and 2011 [4]. Many people who die of opioid overdoses held an active prescription in the weeks preceding their deaths [5, 6], and geographical studies show that where more opioids are prescribed, more overdose deaths occur [7].

Prescribed drugs are a main source for those who use opioids recreationally: drug diversion occurs via theft, prescription forgery, and ‘Dr Shopping’ [8]. One American study found that in 2010, 60% of abused opioids were obtained directly or indirectly through a doctor’s prescription [9].  In Canada, a study of youth in grades 7-12 in Ontario found that 14% had used prescription opioids recreationally in the past year, and most (67%) of them had obtained the opioids from someone within the home; those students also ranked opioids as the fourth easiest drug to obtain (following alcohol, cigarettes, and cannabis) [10].  A Toronto study of opioid users entering detox treatment found that 37% obtained their drugs through doctor’s prescriptions, 26% from both a prescription and street dealings, and 21% from street sources only [11].

The links between physician-prescribing of opioids and increased overdoses has led many to argue that we need to start prescribing less and monitor more. Many voices, both within and outside the medical community, are suggesting we start limiting opioid prescriptions by basing prescriptions on physical functionality rather than reported pain levels and emphasizing alternative forms of chronic pain management, or that we increase opioid-safety by screening patients for high-risk of dependency or co-prescribing naloxone with opioids [12, 13].

In an effort to reduce the harm of this opioid explosion, organizations have started distributing naloxone to people who use these drugs. Naloxone is an antagonist that blocks the effects of opiates and reverses the effects of an overdose. Through these programs, naloxone vials are given to opioid users and their friends or family members so that they have it on hand in case of an overdose emergency. Think of it as the opioid-EpiPen: upon injection, it quickly bumps opioids out of their neural receptors for about 45 minutes, giving the person time to regain consciousness and access medical care. The earliest program started in Edmonton in 2005, and since then many other provinces and municipalities have launched their own.

However, opioid users who don’t hold a valid prescription are often hesitant to call 911 in the event of an overdose for fear of legal repercussions [14]. The institution of ‘Good Samaritan’ laws – which grant immunity from possession charges to people calling emergency services in the case of an overdose – could potentially quell these fears and help save lives [15].

If you use opioids, would you carry naloxone around in case of emergency? Would you call 911? The Government of Canada [16], the World Health Organization [17], and the United Nations [18] have argued for the expansion of such initiatives. But naloxone distribution could be more effective if it was bolstered by supportive changes to prescribing practices to curtail opioid availability, as well as changes to drug laws that would protect those who use them without a prescription from persecution in the event of an emergency.

 

References

[1] International Narcotics Control Board. (2013). Annual Report. Retrieved from: https://www.incb.org/incb/en/publications/annual-reports/annual-report.html

[2] The Canadian Tobacco, Alcohol and Drugs Survey (CTADS) (2013). Health Canada. Retrieved from: http://healthycanadians.gc.ca/science-research-sciences-recherches/data-donnees/ctads-ectad/summary-sommaire-2013-eng.php

[3] Dowell, Deborah, Kunins, Hillary V., & Farley, Thomas A. (2013). Opioid Analgesics—Risky Drugs, Not Risky Patients. JAMA, 309(21): 2219-2220. doi:10.1001/jama.2013.5794.

[4] Gomes, Tara (2014). Trends in high-dose opioid prescribing in Canada. Canadian Family Physician, 60(9): 826-832.

[5] Fischer, B., De Leo, J.A., Allard, C., Firestone-Cruz,M., Patra, J., & Rehm, J. (2009). Exploring drug sourcing among regular prescription opioid users in Canada: Data from Toronto and Victoria. Canadian Journal of Criminology and Criminal Justice, 51: 55–72.

[6] Gladstone, E.J., Smolina, K., Weymann, D., Rutherford, K., & Morgan, S.G. (2015). Geographic Variations in Prescription Opioid Dispensations and Deaths Among Women and Men in British Columbia, Canada. Medical Care, 53(11): 954-959.

[7] Fischer, B., Jones, W., & Rehm, J. (2013). High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005 – 2009. Pharmacoepidemiology and Drug Safety, 22(4): 438-442.

[8] El-Aneed, A., Alaghehbandan, R., Gladney, N.,Collins, K., MacDonald, D., & Fischer, B. (2009). Prescription drug abuse and methods of diversion: The potential role of a pharmacy network. Journal of Substance Use, 14: 75–83.

[9] Lembke A. (2012). Why doctors prescribe opioids to known opioid abusers. N Engl J Med., 367:1580-1581.

[10] Paglia-Boak, A., Adlaf, E.M., & Mann, R.E. (2011). Drug use among Ontario students, 1977-2011: Detailed OSDUHS findings (CAMH Research Document Series No. 32). Toronto, ON: Centre for Addiction and Mental Health.

 [11] Sproule, B., Brands, B., Li, S., & Catz-Biro, L. (2009). Changing patterns in opioid addiction. Canadian Family Physician, 55: 68–69. 

[12] Albert, S., Brason II, F.W., Sanford, C.K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project  Lazarus: Community-based overdose prevention in rural North Carolina. Pain Medicine, 12: S77–S85.

[13] Coffin, P., & Banta-Green, C. (2014).The dueling obligations of opioid stewardship. Annals of Internal Medicine, 160, 207–208.

[14] Banjo, O., Tzemis, D., Al-Qutub, D., Amlani, A., Kesselring, S., Buxton, J.A. (2014). A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open, 2(3): E153–E161.

[15] Davis, C., Webb, D., & Burris, S. (2013). Changing law from barrier to facilitator of opioid overdose prevention. Journal of Law, Medicine & Ethics, Spring, 33–36.

[16] Ambrose, R. (2014). Government response: Second report of the Standing Committee on Health, Government’s Role in Addressing Prescription Drug Abuse”. June 16. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6676682&Language=E&Mod

[17] World Health Organization (2014). Community management of Opioid Overdose. Retrieved from: http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/

[18] United Nations Commission on Narcotic Drugs. (2012). Resolution 55/7: promoting measures to prevent drug overdose, in particular opioid overdose. United Nations Economic and Social Council: Vienna, March 16.

 

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