Smoking and Surgery Don’t Mix

Even routine operations are riskier for smokers.

Smokers who are scheduling a medical operation might want to think seriously about quitting, once they hear the results of a new review of the impact of smoking on surgical outcomes.

A scheduled operation is the perfect incentive for smokers to quit smoking. The fact that smokers have poorer post-surgical outcomes, with longer healing times and more complications, is not a new finding. But the study by researchers from the University of California in San Francisco, and Yale University School of Medicine, published in the Journal of Neurosurgery, spells out the surgicial risks for smokers in graphic detail.

Cellular Injury

The systematic effects of nicotine and carbon monoxide in the blood of cigarette smokers result in tissue hypoxia, which is a lack of adequate blood supply caused by a shortage of oxygen.  When carbon monoxide floods the bloodstream in high concentrations, as it does in smokers, it is capable of binding with hemoglobin and thus lowering the oxygen-carrying capacity of the blood. A cascade of physiological reactions then lead to the possibility of low coagulation levels, vasoconstriction, spasms, and blood clots. 

Wound Healing and Infection

If the circulatory system is dysfunctional, healing will be impaired. “In addition,” the researchers say, “tobacco may stimulate a stress response mediated by enhanced fibroblast activity, resulting in decreased cell migration and increased cell adhesion. The net consequence is inappropriate connective tissue deposition at the surgical site, delayed wound healing, and increased risks of wound infection.”

Blood Loss

 In their review of the neurosurgical literature, the researchers found higher blood loss for smokers particularly following surgery for certain kinds of tumors and for lumbar spine injuries. Smoking causes “permanent structural changes of vessels such as vessel wall thickening,” and there is evidence that smoking is linked to “larger and more vascularized tumors, which may further contribute to intraoperative blood loss during resection.”

Cardiopulmonary Effects

Even smokers who don’t have any chronic conditions associated with smoking are at increased risk during and after surgery. Oxidative damage from smoke can cause “mucosal damage, goblet cell hyperplasia, ciliary dysfunction, and impaired bronchial function,” all of which impedes the ability to expel mucus, which increases the bacterial load, which alters the respiratory immune response, and which ultimately leads to higher rates of postoperative pneumonia in smokers.

The authors of the review note that the evidence is particularly strong in certain specialties: Cranial surgery, spine surgery, plastic surgery, and orthopedic surgery. One randomized clinical trial showed that a 4-week smoking cessation program lead to a 50 relative risk reduction for postoperative complications. Another study showed significant improvement in wound healing when patients abstained from smoking for 6 to 8 weeks prior to surgery. And a third trial of smokers cited in the study showed a major decrease in complications following surgery for the repair of acute bone fractures in patients who quit before surgery.

The authors close by suggesting that the seriousness of surgery can be used to create a “teachable moment” for patients who smoke. Other studies show consistently that “patients tend to be more likely to quit smoking after hospitalization for serious illness.” All of this makes the act of scheduling surgery a perfect point of contact with smokers in medical settings. Clinicians can neutrally lay out the facts of the matter, in a way that truly brings home the health consequences of tobacco.

Lau D., Berger M.S., Khullar D. & Maa J. (2013). The impact of smoking on neurosurgical outcomes, Journal of Neurosurgery,   1-8. DOI: 10.3171/2013.5.JNS122287

Graphics Credit:  http://www.ontarioanesthesiologists.ca/

A Weak Smoker’s Vaccine Might Be Worse Than None

New PET scans show wide responses to antibodies.

One of the brightest hopes of addiction science has been the idea of a vaccine—an antibody that would scavenge for drug molecules, bind to them, and make it impossible for them to cross the blood-brain barrier and go to work. But there are dozens of good reasons why this seemingly straightforward approach to medical treatment of addiction is devilishly difficult to perform in practice.

Last January, health care company Novartis threw in the towel on NicVax, a nicotine vaccine that failed to beat placebos in Phase III clinical trials for the FDA. And back in 2010, a report in the Archives of General Psychiatry demonstrated that a vaccine intended for cocaine addicts only generated sufficient antibodies to dull the effects of the cocaine in 38 percent of the test subjects. Moreover, it proved possible to overcome immunization by upping the cocaine dose, which sounded like an invitation to overdose.

And now, neuroscientists at the Society of Nuclear Medicine and Molecular Imaging annual meeting have presented a new study, the conclusions of which might help researchers understand why the vaccine results have been so mixed. The research “represents one of the first human studies of its kind using molecular imaging to test an investigational anti-nicotine immunization,” lead author Alexey Mukhin, professor of psychiatry and behavioral science at Duke University Medical Center, said in a prepared statement.


Subjects underwent two PET brain scan as they smoked nicotine labeled with radioactive C-11, one before the vaccine was administered, and one after. Ten subjects who developed “high-affinity antibodies” after vaccination showed a slight decrease in nicotine accumulation in the brain, as judged by the scans. However, another group of ten subjects, who showed “intermediate serum nicotine binding capacity and low affinity of antibodies” actually showed an increase in brain nicotine levels. What the PET scans showed was that “strong nicotine-antibody binding, which means high affinity, was associated with a decrease in brain nicotine accumulation. When binding was not strong, an increase in brain accumulation was observed.”

If the bond that holds the antibodies to the nicotine molecules is weak, the bond can break during passage through the blood-brain barrier, potentially allowing excess nicotine to flood in. This result, said Mukhin, tell us “we should care about not only the amount of antibody, but the quality of the antibody. We don’t want to have low-affinity antibodies because that can negate the anti-nicotine effects of the vaccination.”

Back to the drawing board? Not entirely. Another of the study authors, Yantao Zuo of Duke University Medical Center, said that “with reports of new generations of the vaccines showing potentially much higher potencies in animal studies, we are hopeful that our current findings and methodology in human research will facilitate understanding of how these work in smokers.”

Photo Credit:http://www.medgadget.com

Seven Questions About Marijuana Legalization

RAND researcher nails it neatly.

I’ve been meaning to offer up the key points from an excellent column on marijuana legalization that appeared in April in USA Today. Beau Kilmer, a senior policy researcher at the RAND Corporation, lists the “new and tricky issues” that Colorado and Washington forgot to consider in depth before passing broad legalization statutes.

Both states are works in progress. What they have passed so far will undoubtedly be revisited. Without further ado, here are Kilmer’s “Seven Ps,” as I call them:

Production. Who gets to grow it, where do they get to grow it, and how much do they get to grow? Will the business model be Starbucks, Jack Daniels, or your local organic family farm? Will it be legal on large commercial operations, indoor growing rooms, backyard gardens? All of this matters economically, since it’s likely that legalization will force down the price of marijuana, as growers will be able to operate in the open, and middlemen won’t have to worry about arrest. Implicit in this category are things like product testing and product safety.

Profit. If the history of cigarette and alcohol regulation have any bearing on the matter (and they do), it’s likely that marijuana marketers will want to concentrate promotional efforts on the heaviest smokers. States might decide to limit production to mom-and-pop home producers—or try to, at least. Or they could throw the door open to marijuana in the free market, and attempt to regulate the for-profit corporations that flock to the new opportunity. Monopolistic practices, collusion, price-fixing, bribes, payoffs to government officials—the whole panoply of corporate malpractice would be available to Big Pot if things go that way.

Promotion. The California medical marijuana movement got itself in hot water straightaway by hiring sign pointers to stand on Los Angeles street corners and advertise the cheapest Ozs in the neighborhood. Not smart. States that legalize will likely need to pursue some form of restriction on advertising for institutions or storefronts selling marijuana. However, as the cigarette industry has shown in its successful effort to block mandatory graphic warnings on packaging, companies are availing themselves of 1st Amendment defenses as a way of demolishing attempts to restrict advertising and promotional activities. Since corporations are now officially people, it looks, so far, like a winning strategy in court.

Prevention. States will obviously enact some age restrictions, which haven’t been terribly effect with cigarettes and alcohol. In addition, the decades-old message to America’s schoolchildren about staying “chemical-free,” starting with the evil weed, will have to be revisited and revised. The pioneering states have expended much time and verbiage on the subject of how much to tax marijuana sales, and a good deal less time on whether any of that tax money will go for prevention efforts, or for addiction treatment. Yes, pot is addictive for some people, and pot smokers who are lucky enough not to have this problem cannot seem to summon much sympathy for those who do. This will have to change, as marijuana addiction and withdrawal enter the public sphere with legalization.

Potency. If you count butane hash oil, or “dabbing,” the potency of modern seedless marijuana ranges from about 15 per cent to as high as 90 per cent THC. Yes, that’s quite a bit higher than the shoebox full of Mexican from the good old days. Arguments rage in the research community over the effect of strong pot, and whether it increases cognitive deficits, general anxiety, panic attacks, and even mental illnesses. Beer, wine and alcohol have mandated strength levels, printed right there on the bottle. Something similar will likely have to be crafted for marijuana.

Price. How elastic is the price of pot? Could heavy taxation push the whole game back underground? What’s a fair market price for a quarter of Train Wreck? “Retail prices will largely be a function of consumer demand, production costs and tax rates,” writes Kilmer. “The way taxes are set will also have an effect on what’s purchased and consumed—that is, whether pot is taxed by value, total weight, THC content, or other chemical properties.”

Permanency. With legalization, we are likely to see a pioneer penalty: “The first jurisdictions to legalize pot will probably suffer growing pains and want to make changes later on,” Kilmer believes. He envisions a powerful lobbying organization putting the arm on legislators on behalf of a newly legal and seriously profitable line of business. It would be best if legislation comes with maximum flexibility to make future changes, so states can adapt their operations as the thing plays out on the ground for the first time.


I personally understand and sympathize with the drive for legalization. I also think that Colorado and Washington have jumped first, and plan to think later, sorting it all out in freefall. That seems like a possible recipe for disasters large and small. Moving a popular drug across the legal/illegal line is a bit like getting molecules through the blood-brain barrier: It can be done, but it had better be done with sufficient care and forethought.

Graphics Credit: http://thebottomline.as.ucsb.edu/

What We Talk About When We Talk About Drugs

Some number crunching at bluelight.ru.

A fantastic set of interactive graphics tracking conversational trends in drugs at the chat board bluelight.ru reveals some surprises, to the delight of data journalists everywhere. Virostatiq, a software package authored by Marko Plahuta, was put to the task of analyzing traffic at the drug discussion site. Various kinds of plots are available, with endless variables to permutate. Bear in mind that the data that got crunched dealt with the subject of messages, and cannot be directly correlated with drug use, trends, distributions, etc. But it is a fascinating glimpse at what illegal drug users are talking about, and from that, some inferences can be hazarded.

Plahuta writes:

I thought it would be nice to visualize these drug groups based on what users of harm-reduction forums say, so I analyzed around 1.2 million posts on bluelight.ru and constructed a simple diagram that tells a lot…. My whole database contains posts from 2010 until March 2013. Here’s an analytical tool to better understand what’s going on in the recreational drug community. Time is on horizontal axis, while the proportion of posts mentioning specific drug relative to all posts in that month is on the vertical axis. Play around with interactive chart to discover emerging trends, or simply to behold the wax and wane of specific chemicals as they compete for users’ neurological apparatuses, while their manufacturers are temporarily evading ever stricter analog laws.

The chart above represents a graphic created for Addiction Inbox using the visual data provided by Virostatiq. I have singled out six drugs of abuse for discussion. Bear in mind that the trend lines for common drugs like LSD, Ecstasy, marijuana, and methamphetamine all show much higher usage than the ones I have chosen to chart.

—Mephedrone, arguably the most common “bath salt” stimulant, was mentioned at bluelight.ru a lot during 2010, when it came to the U.S. in a major way. But comments have been tailing off pretty steeply ever since. This suggests that mephedrone was sampled and found wanting by those who knew what drug they were taking. Or it could simply be old news by now, and less of a topic for discussion. But if the graph is suggestive of interest levels in the drug-using community, mephedrone seems to have a PR problem.

—Surprisingly, at least to me, a hallucinogen name 2c-e was one of the most talked-about designer drugs of all. 2c-e is a research chemical similar to mescaline but with a spotty track record. Linked to deaths and hospitalizations in Oklahoma and Minnesota, it isn’t known for certain whether the medical problems were due to the pure drug or contaminants. 2c-e is one of the drugs to come out of Alexander Shulgin’s infamous laboratories, and has been around for 20 years. As Tony O’Neill wrote at The Fix: “All in all, it doesn’t sound like the best bet for a recreational Saturday night at the dance club.” As with mephedrone, 2c-e was less talked bout in the last year of the graph.

—Kratom retained a steady popularity over the full 3-year period. Kratom has always been hovering in the background of the opiate family, but seems to have undergone an unprecedented surge in underground popularity of late. From a tree native to Southeast Asia, and often used as a tea, Kratom is powered by an active ingredient called mitragynine—a substance capable of partially activating the mu- and delta-opioid receptors. Kratom serves as a weak opium, and some opiate enthusiasts swear by it for use as a withdrawal aid.

—One of the popular synthetic cannabis products to come out of the Huffman labs at Clemson University, jwh-018 seems to have pretty much cratered as a topic of discussion among drug cognoscenti. Perhaps some of the news about synthetic cannabis and correlations with serious liver problems has taken the shine off that apple. Or simply the fact that, over the few years that synthetic cannabis has been available, users have learned that they prefer the real thing, drug tests notwithstanding.

—Hydrocodone, otherwise known as Vicodin, may have lost some popularity lately due to the popularity of oxycontin and other new synthetic opiate formulations. This is the drug that may have cost Rush Limbaugh his hearing. As a legitimate pain drug, it suffers in comparison with oxycontin, aka Percodan.

—Ketamine is a major topic of discussion, which makes sense. Lately it has rebounded as a party drug, and also scored highly in clinical testing of its efficacy as a short-acting treatment for depression. Unfortunately, use of the drug has been linked to bladder problems  lately.

Will Marijuana “Dabbing” Harm the Legalization Movement?

“Relax, bro—it’s just a blowtorch.”

It is called dabbing, and it is something the marijuana legalization movement would rather you didn’t know about. As crack is to powdered cocaine, so a dab is to a joint of marijuana: the same drug, in a much more concentrated form. But butane hash oil, or BHO, the end product of dabbing, is seen by many in the movement as a potential public relations disaster.

It’s easy to find instructions on the Internet for making butane hash oil. (Not to be confused with the hash oil of the 1970s produced, most commonly, using sieves, ice, naphtha, or acetone to separate the THC-rich trichomes from the rest of the plant material.) Butane hash oil, produced by “blasting”  butane through top-quality marijuana, then “purging” away the butane, looks a bit like beeswax and allegedly boosts THC content to a mind-blowing 70 to 90 per cent. The most potent of today’s varietals rarely reach or exceed 20 per cent. The result is known as wax, shatter, honey oil, and about a dozen other monikers. It is smoked using a glass tube and a red-hot piece of metal, not unlike the hippie “hot knives” method of smoking.

As Andrew Sullivan wrote at his blog, The Dish: “Going on the basis of such super high purity alone, even the funkiest colored trichome crystal encased high-grade leaf starts to look like steam punk technology in a fossil fuel world.”

Or, in the pithy phrasing favored by High Times: “A quantum leap forward in stoner evolution.”

In a High Times magazine article last year, author Bobby Black wrote about the central problem, namely that “the techniques used to make and consume BHO bear an eerie resemblance to those used for harder drugs like meth and crack.” This creates “a fear that seeing teenagers wielding blowtorches or blowing themselves up on the evening news might incite a new anti-pot paranoia that could set the legalization movement back decades.”

It happened when wine and ale became whiskey and gin, according to one school of thought. It happened again when hand dried, hand rolled tobacco became the machine rolled cigarette. And it happened when powdered cocaine became crack. Increasingly concentrated forms of plant drugs became more potent, more addictive, more expensive—and more socially disruptive. Has it happened in a high-tech way with good old friendly organic backyard marijuana?

And is BHO any more dangerous to users than regular weed? The butane technique is controversial, and the effects of ingesting marijuana that has previously been supersaturated with that particular solvent are intensely debated in the weed world. Marijuana collectives in California have been selling “butane honey oil” to qualified medical marijuana customers for some time now. There are tasting parties called “Wax Wednesdays.” But the state has made it illegal to produce BHO. David Downs, writing last month in Oakland’s East Bay Express, reported on a state appellate courting hearing in San Francisco, “in which an attorney for defendant Ryan Schultz worked to overturn the San Francisco resident’s three-year probation sentence for operating a BHO ‘drug lab.’ Meanwhile, several blocks away at permitted pot dispensaries, the fruits of such drug labs are on sale for upwards of $50 per gram.”

The defendant’s case was not helped when, in January, “two blasters blew themselves up in a San Diego motel, resulting in hospitalization, followed by drug lab charges.” And just to confuse the matter a bit more, BHO production is legal in Colorado, and other medical marijuana states are considering it.

The health verdict on all this isn’t in yet. The primary danger of BHO may be its manufacture, and in all the Richard Pryor-type explosions that lie ahead. Even High Times seems to be a bit wary of it. The magazine “strongly discourages anyone who has not been professionally trained from making BHO on their own.” Ventilation, it seems, is the key.

It’s unlikely, but not impossible, that the amount of residual butane inhaled could constitute a health threat. Cheap butane contains various impurities, and there has been at least one reported case of chemical epiglottitis, a condition in which inflammation caused by a chemical blocks off the windpipe. But as one marijuana backer told High Times, “you can actually get epiglottitis from hot coffee if you swallow it incorrectly.”

In February, The Federal Emergency Management Agency (FEMA) was moved to issue a formal bulletin on the matter: “Butane is highly explosive, colorless, odorless and heaver than air and therefore can travel along the floor until it encounters an ignition source…. Reported fires and explosions have blown out windows, walls, and caused numerous burn injuries.”

Bob Melamede, an associate professor of biology at the University of Colorado and the CEO of Cannabis Science Inc., told High Times: “If you have contaminants (i.e., pesticides, herbicides, fungi) on your plant, that’s going to come off into the extract. Then, when you evaporate the solvent, you’ll actually be concentrating those things—and THAT’S the real danger.”

Photo Credit: http://www.hightimes.com/

Big Tobacco Hasn't Given Up On Smoking. Have You?

World No Smoking Day.

Women, Cigarettes, and Meth

More bad news for young female addicts.

A blizzard of research findings this year continues to demonstrate that women have gender-specific issues to deal with when it comes to cigarettes and speed. None of the findings have anything to do with the old canard that women cannot “hold their liquor,” or do drugs like men do. Women hold their liquor fine, on a pound for pound basis. And women are well represented, presently, among the ranks of alcoholics. That is unfortunate, since a great deal of research has shown that alcohol causes neurological damage in women more quickly than in men. And now comes more evidence that women don’t respond metabolically to cigarettes and speed the same as men, either.

Start with cigarettes: Women who begin smoking have a great risk of heart attack than men who take up the addiction—but scientists don’t know exactly why. Cardiovascular diseases remain the leading cause of female deaths in the developed world. One theory is that smoking lowers levels of “good” cholesterol more markedly in women than in men. This is not news, but preliminary research in the Journal of Clinical Endocrinology and Metabolism now appears to show that teenaged girls in Australia were more sensitive to the effects of second-hand smoke than teenaged boys. If true, it could mean that “childhood passive smoke exposure may be a more significant cardiovascular risk factor for women than men,” lead author Chi Le-Ha said in a press release. 

And there’s more bad news: Research published in Diabetologia, the journal of the European Association for the Study of Diabetes, suggests that women who continue to smoke during pregnancy increase the risk for obesity and diabetes in their unborn daughters. Kristin Mattsson of Lund University in Sweden, along with Matthew Longnecker and members of the National Institute on Environmental Health Sciences in North Carolina, reported that data from the Medical Birth Register of Sweden showed that the risk (odds ratio) of gestational diabetes increased 52-62 per cent for women exposed to moderate or heavy smoking while in the womb. After adjusting the data for a host of outside factors, the researchers also concluded that women exposed to moderate amounts of smoking while in the womb were 36 per cent more likely to become obese, while the daughters of heavy smokers during pregnancy were 58 per cent more likely to be obese compared to non-smokers in the study.

Again, researchers are not quite sure what accounts for this effect. The researchers suggest a variety of possible answers: Alterations in appetite regulation, death of insulin-producing cells in the pancreas, gene transcription changes causing the formation of fat cells, and epigenetic changes. But it may be that other factors—undetected differences in nutrition, extent of prenatal care, neglect, abuse, and many other variables—make it difficult to determine the major difference in outcomes between smoking and non-smoking families. Nailing down these risk factors becomes all the more important as young women in countries all around the world take up daily smoking in greater numbers than ever. The authors emphasize the importance of recognizing such long-term detrimental effects on offspring.

As for methamphetamine: A study in the Journal of Adolescent Health, conducted by the UCLA Center for Behavioral and Addiction Medicine, followed a group of adolescents in treatment for methamphetamine addiction. They found that girls were more likely to continue using meth during treatment than boys. Overall, boys returned twice as many meth-free urine samples as the girls in the program. Lead author Keith Heinzerling said in a prepared statement that the findings may have significant implications for treatment: “The greater severity of methamphetamine problems in adolescent girls compared to boys, combined with results of studies in adults that also found women to be more susceptible to methamphetamine than men, suggests that the gender differences in methamphetamine addiction observed in adults may actually begin in adolescence.” The small NIDA-funded study, involving only 19 teenagers, also found that the antidepressant Wellbutrin, used effectively in many smoking cessation programs, was not effective in curbing use among the teen meth addicts.