The Checkup with Doctor Mike - The Medical Argument For Legalizing All Drugs | Dr. Ryan Marino

Episode Date: June 7, 2023

Dr. Ryan Marino is an Emergency Rom Toxicologist. That gives him unique insight into one of America's most complicated topics: drug overdoses. I invited Dr. Marino on the Checkup to discuss America's drug "problem", specifically about where the problems actually lie or if there is a problem at all. We also touched on the viral instances of police officers falling victim to fentanyl "overdoses" and whether or not those cases are actually real. This was a juicy interview about a fascinating and complex subject matter, so I'd love to read your nuanced takes down in the comments! Follow Dr. Marino here: Twitter: https://twitter.com/RyanMarino Instagram: https://www.instagram.com/drryanmarino/?hl=en Executive Producer and Host: Doctor Mike Varshavski Produced by Dan Owens and Sam Bowers Art by Caroline Weigum CONTACT: [e-mail]

I'm making you politician and ruler of the United States, where anything you say goes. What is your new policy? All drugs are legal, but they will be regulated by the FDA. That is Ryan Marino. And based on his statement, you might think he has no idea what harm drugs can bring to society. Turns out, Ryan actually is a drug expert, but probably not the kind you're thinking of. Allow me to introduce you to Dr. Ryan Marino, Emergency Room, Talk. psychologist. This is a unique specialty of medicine that makes him an expert on something we see in

TV, movies, and the news all the time, drug overdoses. Dr. Marino knows all about drugs and what they do, but perhaps more importantly, he knows what they don't do. Exhibit A, you've probably seen news stories that sound a bit like this. Dramatic body cam video capturing the moment Corporal Scott Crane of the San Diego County Sheriff's Department is promising his trainee. Deputy David Fivai, he's not going to let him die after Fyavai was exposed to fentanyl while processing drugs at the scene of an arrest in early July. So what's happening in those videos? Like, I've even seen them with the police officers that are like, oh my God, she's overdosing. They give her an arcand, she wakes back up. Like, I think you even know what you mean. Yeah. Like what's happening there? Something is happening.

And I, like, I believe those are real symptoms. I can say that they are not a fentanyl overdose. They're not of opioid overdose. They are in, I think, every situation I can think of, and I've seen, I mean, all of these videos at this point, it's always the opposite. And so someone will, like, have a fear, anxiety, they'll be, like, rapidly breathing, all of these things that fentanyl would do the opposite of. And so, I mean, we use it in medicine. End of life, it takes away your anxiety, your fear. We use it for people who have, like, some lung problem, that kind of thing, where they feel like they're drowning or whatever. You can give fentanyl. it makes you feel like you can breathe okay even if you're not so my best guess and this is

purely speculation i don't want to try to like diagnose anyone who i haven't been involved with here um is that this is either some sort of like panic anxiety or the nocebo effect which is just like the opposite yeah the like evil twin for the placebo effect and so if you believe so strongly enough you've been conditioned you've been told that being near this white powder you're going to overdose and a lot of times in these situations like there was one maybe it's been a year or two now the san diego sheriff released this PSA video where they showed one of their deputies was like bagging up drugs in a car and someone the other deputy with him was like careful that's fentanyl like you could just overdose from being near it and then he goes down so it feels very conditioned

a lot of the time um but in that situation if you are having a nocebo reaction there's treatment would be a placebo. And so you give someone Narcan and they think it's treated them, even though they're like breathing very fast, they're not having a true overdose. That's why they think that the Narcan worked. And then people will say, well, I felt better after Narcan. So it has to have been a fentanyl overdose. And the rubber just never hits the road on these stories. But it's so pervasive that everyone's heard one of those stories. It's used in law enforcement trainings. I mean, the DEA put out guidance years ago about this. There was a website hosted by the CDC that said this for a while until it was taken down, I think, just last summer.

But all the, like, scientific data says that's impossible. Like, literally the physical laws of earth, chemistry and physics here say that it's impossible. And fentanyl has been around since the 60s. It's been in street drugs since, in the United States, since at least the 70s. Congress actually had a hearing in the 80s about whether it was going to be a risk to first responders encountering like fentanyl alpha methyl fentanyl these if anyone's familiar with like China White was a fentanyl analog and it was they decided it was not possible so it's kind of weird this has come back and it's like such a thing but uh the fact that it wasn't a thing until like 2017 um and it only happens it seems like in law enforcement I mean there's just a lot of red,

flags here. Even if you don't believe, if people don't believe what I'm saying about like the science and stuff, it's just none of it adds up. Ryan's entire mission is to provide proper education understanding around drug use. And despite what that might sound like, no, he doesn't want everyone to start doing drugs. But he doesn't want to ban drugs either. In fact, Dr. Ryan would love to see all drugs legalized with a catch. I do think that the government should be out of kind of like medicines and drugs. Do you believe prescriptions should go away and it should be all over the counter? Well, so I'm glad you asked that because I think they should be legal, but they need to be regulated.

And so like alcohol is the classic example, prescriptions as well. Like when you get a prescription, you know you're not going to get fentanyl in it. You're not going to get xylazine in it, whatever. Your Adderall isn't going to kill you. And so alcohol, I mean, we had alcohol prohibition and people will always. argue that maybe there were some benefits from reduced kind of drinking, but people were literally getting poisoned. Alcohol had methanol in it, it had all these weird substances. Ginger Jake was like a famous one in the toxicology literature.

What's that? People, it was this like alcohol substitute to get past the weight, the government would weigh things to see if there was alcohol in it. And so people would drink this like ginger flavoring thinking it had alcohol in it and they ended up with like spinal disease and like chronic paralysis issues with mobility and so it was called like jake leg and people had issues with walking um but yeah so alcohol is legal and like not that alcohol is safe or everyone should be out drinking alcohol but you go to a bar you're like you're supervised someone will cut you off if you get too rowdy they can like maybe help you get into a car uh it's illegal for you to drive

while you're drunk, those kind of things. That's where the government should step in, I think. Like if someone wants to go home after work and smoke marijuana or shoot heroin, I mean, why do I care about that as long as, like, they're not harming anyone else. They're not harming themselves. Well, they are harming themselves. If you're shooting heroin. Well, I mean, people use heroin without having problems from it.

you think there's a way to use heroin not for pain but for pleasure and that would not be a problem for them yeah for so it's again this is like very subjective data okay but depending where you look i mean the majority of people and up to like almost most people who use heroin don't end up with like addiction don't end up with complications from it and it's not just like trying heroin it's people can use like every day even and i i know plenty of people from working with them and stuff. And how is that different than someone taking percocet, let's say a long term? It's not. But yet we say percocet can be so addicting and problematic. I mean, compared to other things, opioids definitely have higher rates of addiction than like a lot of other medicines and even like mind altering substances. So it's, I don't think everyone should just be prescribed percocet, but if someone, like, wants to go out and people are going to access opioids if they want them. So I'd rather have someone be able to, like, go use heroin in a safe space than buy, like, fentanyl cut with gabapentin and diphonine and xylosine. It's a very risky

experiment you're running, though. But, I mean, before we ended up with this, like, we weren't having 100,000 people die every year. Sure. At that time, though, it wasn't yet. It wasn't yet where the, I forgot who is it, was it, was a Purdue, was telling doctors, oh, this isn't addictive at all, just prescribe it. Everyone's going to love you. Your press gainy scores are going to improve because your patients are going to say you treated their pain better. So like, yeah, so industry definitely has, is a problem. But I mean, the U.S. government, like, people have used heroin for, it was discovered in like the late 1800s, I think. And it was a prescription medicine. It is still a prescription in most of the world. It's just been banned in the

United States since 1924, but the U.S. government destroyed the world opium supply, which they made heroin from in the early 2000s. And so that was like Afghanistan, northern Mexico. And that's where fentanyl came from because they didn't do anything about the demand. They only got rid of the supply. And so when people were using heroin, like our rates of heroin use haven't really change and still people call it heroin. They sell it on the street. Everyone says heroin. There's no heroin anymore. It's just fentanyl. If you can even get fentanyl now. But it was like 6,000 people a year would die from overdoses. And I mean, that's something that if these people could go in like a supervised center or, I mean, even if they just had like a buddy with them, they had Narcan,

which the nasal Narcan wasn't available until like 2016. Those could have all been treated. But now people get fentanyl. People get whatever. Weird. stuff and like a hundred thousand are dying so yeah and also i i think it depends which group of people we're talking about when i say group of people i mean demographics location um if you're living amongst the poorest in our country you likely have higher rates of trauma that's statistically already been shown and then if you're becoming one of those people who will occasionally use heroin to come home after a long day. How long until the combination of, it's almost like a drug interaction, if you will, the trauma being a drug and then the heroin being a drug until it becomes

out of control. Yeah. And I think that becomes probably. For opioids and these kind of things where you get dependence and you need higher and higher doses and you get withdrawal symptoms and people are more likely to start using like more of the drug and more often as well. And one important thing I mean when it comes to like opioid addiction, most people who have like quote unquote addiction who are using all the time are actually using just because the withdrawal is so miserable. So like they wake up in the morning and they're having like diarrhea. They're throwing up their nose is running. They're crying. I mean, you can't go to work. You can't do anything. So it's not that people like want to use that they're even able to get high anymore.

And so I mean, I think that's an important distinction. But yeah, at the end of the day, like I personally am very pro-legalization. I don't think that everyone should go out and try heroin, that heroin is safe, anything like that. But just the alternative seems so much worse. And if we were able to take our like drug war budget and put that towards housing, childcare, food providing, yeah, all of those things. I mean, I think even just educating people, like giving them Narcan, whatever, the amount of difference that could make rather than just like paying for this drug police army

and keeping prisons full doesn't really help anybody. of obviously as we've seen like the U.S., I mean, is doing the worst and any nation in the history of the world has ever done in terms of drugs. And in our prison system as well with the huge numbers. For decades now, the U.S. has been embroiled in debate on whether or not we should legalize marijuana. While to the naked eye, it would see marijuana doesn't pose as strong a health risk as alcohol, which is legal, whether or not that's actually true is a little bit more murky.

That's because according to the United States, State's Drug Enforcement Agency, marijuana is a Schedule I substance under the Controlled Substances Act, meaning it has no currently accepted medical use in treatment in the U.S., and there's a heck of a burden when it comes to organizations being legally allowed to study the drug. As long as this classification remains in place on the federal level, it creates a whole world of problems for physicians like myself trying to understand what health impacts this drug can actually have on the human body. The laws are just so convoluted when it gets into this because I mean at the federal level marijuana is schedule one it's illegal it's

thought it's literally on paper said to have no medical benefit there's no safe use whatsoever but then state by state I mean you can have it medical you can have a recreational and then there's the farm bill from a few years ago where they made these analogs of THC legal now hemp farming thing right yeah yeah and even like regular THC which is delta 9 THC is like the actual one that gives you the psychoactive effects from the cannabis plant is now legal up to a certain percentage. And so if you get like a 40 ounce drink, I mean, that could have a thousand milligrams of THC in it and be legal even though it's a huge amount. But that's because the concentration. Yeah, it's way more than anyone should ever be doing. Wow. But see,

that's the scary part of it all. And initially, I remember I was invited to speak on television about CBD being added to general products. And my big concern with it was you have it in FDA-controlled substances as a treatment for things. And when it comes to an FDA-approved substance, I mean, you know this better than I do, that dosing is a huge requirement of deciding whether or not something is indicated or not or approved or not. And yet, CBD being added into sodas, burgers.

Like, I remember going to a diner, and they're like, here's a CBD burger. And as a person in the world, you could be, like, pregnant and consuming huge amounts of CBD throughout your day that add up. And no one has any idea because it's just like an additive now. Yeah. That's scary. And that, I mean, it gets into kind of, like, wellness too. They put it in everything.

It's in, like, soaps, shampoos. That's been a problem. The military has much stricter guidelines on kind of, like, drug use and testing. And people have, like, tested positive for cannabinoids because they were using a, allegedly like soaps or shampoos that had CBD. Oh, wow. So, I mean, yeah, it's just getting into kind of like the legal aspects, it's so convoluted, and we let a pregnant person can take as much CBD as they want,

and who even knows if what you buy or get is actually CBD? Yeah. And they've done testing, and I think, like, close to half of the products either didn't have CBD, and a bunch of them had actually, like, THC, which is the illegal one. so yeah i don't think anyone benefits from the way we do this and it it also inhibits like studying the effects too well yeah when you keep it schedule one that prevents uh institutions that receive federal funding from studying it right that yeah you have to get like special permission from the federal government yeah something i mean clearly something needs to change

but i think politicians are worried about their reputation or how they're labeled when they start advocating for that, which is silly, but kind of the PR-focused social media world that we live in these days. I'm curious your take, and this may be a loaded question, do you think CBD works for the widely purported uses that the supplement industry claims? That is a loaded question, but not really. There's no evidence that it works for anything other than those very rare seizure conditions, and that's at a very high. dose, nothing you could ever get from like your bodega, your gas station, whatever, where people are, even Whole Foods, I don't know, where people necessarily get CBD. But there's no evidence

that does anything. I mean, I think people will tell me all the time that rubbing CBD oil really helps their arthritis. And I think if that works, that's great. That's better than being in pain or having to like turn to other things. But yeah, the evidence isn't there. So when you see a professional athlete come out with a balm for their knees or a pill for their post workout inflammation. How do you feel? I don't feel great about it because at the end of the day when people are selling you those products like they have to have something behind it. Otherwise they're just kind of scamming you. I mean, they'll say it works for me. Yeah. I mean, we've seen it with Quedith Paltrow, we have our little coffee cup that you brought. Thank you for my housewarming

present. Coffee is a friend, not an enema. But we see that with Goop-esque companies all the time. And I don't know, I find it hard being a doctor, fighting back against that because you and I really want to be evidence-based physicians. But in order to be an evidence-based physician and say those products don't work, we need to prove they don't work. saying that there's no evidence that they work is the honest thing which is what you said but it's not powerful enough to dissuade people from you yeah for sure and so i mean that's why i support like i don't want to medicalize cannabis i don't want to medicalize all these like if people want to try something go for it they should be informed on like what the actual evidence

supports what the harms are and so if CBD like really helps someone who has had i don't know PTSD, insomnia, arthritis, whatever these conditions are that we don't have any other better treatments for. I'm all for that. It's not going to really harm you. As long as you know that you might not be getting CBD, it might not actually do anything. You might be getting something totally unrelated. You might fail a drug test because it actually has to THC in it.

But yeah, at the end of the day, I don't want to yuck anyone's yum. I don't either. But what about when those people have it, take the, substance, say it works, and now encourage others to do so. And we're living in an age where even YouTube is promoting, how do they describe it, like first person stories of illness, like they'll highlight individuals who are living with diabetes in order to help people feel connected. And it's for a good reason. But then what happens when one of those individuals, like I have diabetes and I take miracle potion why and it helps my blood sugar does that then cross the line so that's really

tough because I think a lot of times those like first person accounts of my illness what work for me can actually lead to like meaningful research or meaningful breakthroughs on the topic but a lot of times too it is someone who either is just kind of promoting something unfounded or wants to profit or it doesn't end up actually having any benefit at the end of the day so I mean, I think medicine as a whole doesn't do a good job of kind of like listening to people who are living with illness. And we do fixate on like the evidence based portion and living with kind of especially like chronic diseases and stuff. Those people have a lot of experience that is meaningful. It's just really hard to kind of toe the line of what's what's useful, what helps and what is predatory or unhelpful.

Yeah, because I don't have a good answer. No, it's a almost impossible question. question to answer. And the reason I ask it is because I even have friends and let's say one of their girlfriends is like, I love this miracle thing. I, you know, electrolyte my water or not electrolyte, I and I's my water to change the pH. And I'm like, that's beautiful that you're doing that for yourself. Like if that makes you happy, please. But then when we're sitting at a dinner and now there's people who are sick or having some symptoms and you're like, you've got to do this to your water. And I just want to be like, no, that's not what's going on with this person.

And I don't know how to do it without coming off like a dick. Yeah, it's a really hard line. I mean, like, I interact with a lot of people who have, like, chronic pain, especially. And, like, all the evidence says that, like, long-term opioids do not have benefits for chronic pain. But people will tell you, like, they can't function in their life without being on, like, their chronic lexicotin or whatever. And so it is really hard because, like, on one hand, can you tell someone that their own experience? experience with their life and their own illness is wrong or not true. But people will then like push it on other. They're like not everyone is is genuine. So I don't know. It's it's super

nuanced. Yeah. I don't have any answer. It's always on like a case by case basis. But yeah, when someone's like, oh, you're sick here, take this like herbal potion I made you. I think that that kind of crosses the line. Yeah. And that happens a lot with, um, people that are susceptible to getting tricked because they've had such a bad experience with their health care system. And you mentioned people with chronic disease. I think they get treated not just the worst by our health care system, but they get taken advantage of by the pharma companies the most. Yeah. Because pharma, they're smart. They're business people. That's what they are. They're capitalistic. So they say, okay, what illness do people have pretty bad symptoms,

but don't die? So we have them as customers. And they look at people with autoimmune conditions. with chronic diseases, and they're like, let's develop a drug that fixes those people, but they have to take forever. Yeah. It's like the best business model ever. It's almost like getting someone hooked on an addictive substance, but without having the addictive substance or negative ramifications of doing so. One of Dr. Marino's specific complaints regarding the federal regulation of prescription

drugs is the drug enforcement agency, which he says doesn't have an actual medical professional on staff. This has resulted in regulations that just don't make. make sense, leading to nationwide shortages of a substance many college students know well, Adderall. The DEA is our drug enforcement agency at the federal level. They have no one medical on their staff. But they...

No one? No one. Like they don't have a medical director? How's that possible? Prosecutors and law enforcement. They have no medical people. Wow. And so they set quotas on all controlled substances for...

production from pharmaceutical companies, who can make them, how much they can make. They said it a year in advance. That's the reason we're in an Adderall shortage right now. It's because the DEA didn't believe that the prescriptions were legitimate. And this one company that is allowed to make Adderall cannot get the precursor products because of supply chain issues. And the DEA will not allow anyone else to make more or any new companies to make it. Wow. And who's guiding those decisions for them?

Like, is it a team? Is it collaborative? Or is it just like one person? It's very opaque. Wow. So DEA's controlling limits without no, it's almost like they're trying to be predictive. Mm-hmm. And you don't know why that's happening.

Wow. And so, yeah. So, I mean, Adderall is a good kind of topic here for, like, legalization and these kind of issues, or legal issues, federal policy, that kind of thing. Like, ADHD is a real thing. Adderall. and other stimulants for treatment of ADHD is honestly one of the most evidence-based things in medicine.

The data, I mean, is like super robust, goes back many, many years has been repeated over and over. And in the pandemic, with the kind of waivers that were given for telehealth and prescribing, these companies sprung up that maybe took advantage of it. People were able to get like an app on their phone and basically like order Adderall. And that was a concern. But that was not a ton of people. like diagnosis rates for things like ADHD.

And it's not just ADHD that Adderall is used for. So I don't want to like make people think that. What else are they using it for? For narcolepsy, for end-of-life depression. It's like one of the best antidepressants. But over the pastamine decades, like diagnosis rates have gone up for things like ADHD because people have gotten better at diagnosing them. We've realized you can treat it like it makes a difference in people's life.

and I think for most people it still seems it's like a it is an invisible illness you don't see that people have ADHD but if you look at the data like people die years earlier people get in way more car accidents they have like bad things happen to them and I mean not only that but like people can't function people can't like go to school do their jobs that kind of thing which we should also care about but the DEA felt that these rising prescription rates were not legitimate they thought they were mostly like fake people ordering this through apps. So in 2021, they set their quota for 2022, which they did not take into account the rise in prescribing rates because they didn't think, they didn't believe it. But I mean, that's not, you can't judge. That's not their

place to judge. Exactly. So even though maybe I don't even fully disagree with them, but they can't judge that. It's from such a macro level. Wow. Because then you're screwing everybody. Not just the people like that yeah that and so now i mean people are without their meds there's problems from that but people are getting put on different meds and so other people who need their like riddle in vivant whatever all these things those are now having big issues too there's no end of the shortage in sight and i mean someone could literally at the DEA could snap their fingers and this today it's been nine months now and so i mean that's just like one example but that's a good example i think because it shows kind of how broken the policy is well i feel like a lot of the problems that

come from our government, happen because of the lack of collaboration. Like, even when they're making insurance policies for physicians, they never have a physician in the room deciding this. It's like a legislator, a lawyer, a finance person, no doctor. Or some like health care administrator. I'm like, but get a clinician in the room, like a person who spent a day is seeing patients. It's such a big difference. And they'll find like a family member who has a sob story about like Adderall killed my mom or something. Yeah. And that gets press and yeah. Yeah. That gets all the attention. That's very true. So after hearing a bit more of Dr. Ryan's expertise on the subject of drugs in the United States,

let's listen to President Marino's plan for America one more time. I'm making you politician and ruler of the United States, where anything you say goes. What is your new policy? Drug policy, obviously. All drugs are legal, but they will be regulated by the FDA.