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The wildly popular e-cig startup Juul is valued at $15 billion, but it faces a growing backlash of lawsuits and investigations

The wildly popular e-cig startup Juul is valued at $15 billion, but it faces a growing backlash of lawsuits and investigations

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Pax Labs

For a slim device that looks like a USB stick, the Juul e-cig packs a powerful punch. Each refillable insert contains twice the nicotine as a pack of cigarettes.

American vapers have embraced the device: The Juul now represents nearly 71% of the entire e-cig market. Last month, sales of the devices surged 738%.

But despite the ballooning popularity of its vapes, Juul Labs – a Silicon Valley startup recently valued at $15 billion – is facing a growing backlash.

Several state and federal investigations and a handful of consumer lawsuits highlight concerns about the Juul’s health effects and its worrisome popularity among teens. The Massachusetts Attorney General is investigating whether Juul violated state consumer-protection laws by failing to keep minors from buying its products, and the Food and Drug Administration recently cracked down on sales of the Juul to minors.

On top of those concerns, the city of San Francisco recently banned flavored tobacco products like the Juul, a move public-health researchers and leading philanthropists like Michael Bloomberg have said they hope other cities follow.

A startup that’s booming

juul e-cigarette

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JUUL Labs

Behind the unassuming, aging brick facade of a shipping warehouse in San Francisco’s Dogpatch neighborhood, Juul Labs is growing exponentially. Its five floors are packed with employees. Staff crowd the halls, spill onto balconies for meetings, and squat on the building’s sweaty top floor.

Juul’s US staff has tripled in the last six months, and more growth is coming. Juul has plans to open offices in 19 more locations across the country, including big cities like Boston and Chicago and smaller ones like Des Moines, Iowa and Manchester, New Hampshire. The company is expanding internationally, too. After launching in London earlier this month, Juul has plans to expand to three more countries.

The company has the money to do it. After scoring a $15 billion valuation that puts Juul in the ranks of startups like Pinterest, Lyft, and Snap Inc., Juul Labs raised $650,000 within just two days.

But as Juul has grown, government groups, nonprofits, and public-health experts have started sounding alarms, calling out the Juul for being addictive and uniquely appealing to teens.

Teen ‘Juuling’ could be the ‘genie you can’t put back in the bottle’

woman vaping vape e-cig

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Shutterstock

The first signs of trouble came from high school bathrooms. In small groups, students began gathering to “Juul” (the verb the product has spawned) under clouds of creme-brulee-scented vapor. Some carried the devices into class, where they’d sneak pulls from Juuls hidden inside the bodies of emptied Sharpie pens.

Worried teachers brought their concerns to principals, who called on public-health researchers to visit campuses and discuss the risks of nicotine.

Then some of those teachers looked at YouTube, and found the platform was full of videos made by teens showing themselves sneaking Juuls into class and vaping on the sly – sometimes even in front of teachers.

Using hashtags like #JuulGang and #VapeNation, teens boasted on social media about the number of devices they could use at once. Some appeared to be linked to viral hashtags that Juul Labs had used in a 2015 advertising campaign when its device launched.

Juul maintains that it does not want teens to use its devices and claims its products are designed solely for adult smokers looking to transition to less harmful devices. The company has also said that sales of its devices did not take off until at least two years after the 2015 campaign was launched.

“Juul is a company that was started by smokers with an objective to switch smokers to non-combustible products,” Ashley Gould, Juul’s chief administrative officer, told Business Insider in March.

A Juul Labs spokesperson also told Business Insider that the company has been working with social media platforms to remove Juul-related content that involves young people, and has deleted more than 4,000 vape-related posts from Instagram and Facebook collectively.

But experts say these moves have come too late.

“This is really the genie you can’t put back in the bottle,” Matthew Myers, the president of the nonprofit Campaign for Tobacco-Free Kids, told Business Insider.

Snowballing evidence of vaping’s health risks

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Eduardo Munoz/Reuters

Alarmed by the prevalence of e-cigs, researchers have increasingly started studying the health impacts of vaping. So far, evidence suggests that although inhaling vapor is healthier than breathing in burned tobacco, e-cigs come with their own health concerns.

Chief among those issues is e-cigs’ high concentration of nicotine. This may be part of the reason why teens who vape are seven times more likely to smoke regular cigarettes than young people who never use e-cigs.

Ana Rule, a professor of environmental health and engineering at Johns Hopkins University, said the makers of these devices fail to address “the increased risk to this huge market they are creating among teenagers and young adults that never have smoked, and would have never even considered smoking” had they not vaped.

Researchers are also not convinced that e-cigs actually help adult smokers quit. So far, the evidence suggests they don’t. In January, a study in the journal The Lancet found that e-cigs were linked with “significantly less quitting” among smokers. Several months later, a study in the Annals of Internal Medicine found that e-cig users were less likely than non-vapers to abstain from tobacco use over six months. And a study published in the journal PLOS One this month found no evidence that vaping helped adult smokers quit.

“E-cigarettes are widely promoted as a smoking cessation aid but for some, they actually make it harder to quit, so most people end up doing both,” Stanton Glantz, a professor of medicine and the director of the Center for Tobacco Control Research and Education at UCSF, told Business Insider.

Nicholas Chadi, a clinical pediatrics fellow at Boston Children’s Hospital, spoke about the Juul at the American Society of Addiction Medicine’s annual conference in April.

“After only a few months of using nicotine, [these teens] describe cravings, sometimes intense ones. Sometimes they also lose their hopes of being able to quit,” Chadi said.

For these reasons, several nonprofit anti-tobacco agencies have come out in recent months in strong opposition to the Juul, including the nonprofit Campaign for Tobacco-Free Kids and the California Department of Public Health.

Mounting legal and ethical challenges

juul e-cig vape pen california prop e poster

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California Department of Public Health

These scientific findings are being used in a snowballing number of legal and regulatory challenges against Juul.

In April, the FDA launched an investigation into Juul’s marketing practices to see if the company targeted teens.

In a letter to the company, the agency wrote: “Widespread reports of youth use of Juul products are of great public health concern and no child or teenager should ever use any tobacco product. Juul products may have features that make them more appealing to kids and easier to use, thus causing increased initiation and/or use among youth.”

Since April, Juul consumers have also filed several lawsuits against the company – most of them on behalf of teens – for what they allege are deceptive marketing practices that didn’t clearly outline how addictive nicotine is.

Then in June, voters in San Francisco approved a ban on flavored tobacco products that includes Juul cartridges, called Juul Pods.

“Most scientists believe flavorings are used to target teenagers into becoming users,” Rule told Business Insider. “There are of course many other factors such as marketing and peer-pressure, but when you look at the flavoring names, one has to wonder.”

San Francisco has led the nation with similar types of initiatives in the past, such as its 2007 ban on plastic bags, which went statewide in 2014 and has since been copied in 13 other US cities.

Finally, just this week, Massachusetts Attorney General Maura Healey launched a probe to find out whether Juul had marketed its products directly to young people in a way that could violate consumer protections in the state.

“Just when teen cigarette use has hit a record low, Juuling and vaping have become an epidemic in our schools with products that seem targeted to get young people hooked on nicotine,” Healey said in a statement. “I am investigating Juul … to keep these highly addictive products out of the hands of children.”

Juul’s rapid fundraising suggests that many investors aren’t deterred by these challenges, but others have said they’re leery for ethical reasons.

“Selling drug addiction with unknown causes isn’t something I want to be associated with,” Villi Iltchev, a partner with San Francisco-based investment firm August Capital, told Business Insider.

Villi said he used to smoke, but quit five years ago.

“Would I have switched from smoking to the Juul? Hell yes,” he said. “But in terms of kids, they’re starting from scratch. Being addicted as a teen, your probability of quitting is so low. It’s part of you.”

If you’re a Juul or Pax employee with a story to share, email this reporter at ebrodwin@businessinsider.com.

A facility giving marijuana to people with addiction has had a major shakeup after it felt ‘like walking into a cloud of smoke’

A facility giving marijuana to people with addiction has had a major shakeup after it felt ‘like walking into a cloud of smoke’

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Shutterstock

The treatment was unconventional. People addicted to everything from alcohol to opioids were given the option of using marijuana to help deal with withdrawal symptoms from their former drugs of choice. But nearly a year after the facility, a Los Angeles-based rehab center known as High Sobriety, opened its doors, a consultant to the operation started to notice problems.

“It was like walking into a cloud of smoke,” Sherry Yafai, the facility’s new clinical director, told Business Insider. That’s no longer the case, according to Yafai, who took on a leadership role at the facility roughly a year after it opened and made some major changes to its treatment protocol.

Her changes hint at a tough reality about the use of cannabis as medicine. Although marijuana is being increasingly recognized for its potential health benefits, using (and dispensing) it remains an inexact science that can be further complicated by stigma and misunderstandings about drug use.

Created by Joe Schrank, a trained social worker from New York, High Sobriety was founded as an alternative to the traditional abstinence-based rehab model, which Schrank says is heavy on spirituality and religion but low on science and compassion.

“Abstinence-only drug education is about as effective as abstinence-only sex education,” Schrank told Business Insider.

Schrank ran High Sobriety in Los Angeles for a little over a year before he decided to leave after an internal dispute broke out. He’s currently based in San Francisco, where he is operating a new rehab facility based on the old High Sobriety model – if you want to use marijuana, you can.

“I like to remove anything someone’s going to potentially hurt themselves with. That’s why I’m a weed advocate,” Schrank said.

Yafai also believes that cannabis has a place in addiction treatment, but she disagrees on the details of how and when it is dispensed to patients.

‘When you’re dealing with life and death, you can’t get that concept across when they’re high’

marijuana weed pot cannabis smoke smoker

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iStock

Since Schrank’s departure, Yafai has made major changes to High Sobriety.

Smokeable marijuana is no longer allowed on the premises. Instead, patients may be given cannabis oils, creams, or edibles – but they are not allowed to carry them or take them home.

Cannabis products are dispensed “just like any other medication,” said Yafai, citing the examples of methadone and buprenorphine, which are generally given to patients addicted to opioids at a specific time of day. Also, all High Sobriety patients must go through 30 days of detox without cannabis.

“The way we try and medicate patients is so they’re not high all day,” Yafai said. “I want people to function.”

After 30 days of sobriety, patients meet with Yafai, who decides what type and dose of cannabis-based product could help them. She might recommend using a cream made with CBD (the non-psychoactive component of marijuana) for pain, or she might recommend a THC-based edible at night for sleep.

These changes are designed to address some of the problems that Yafai said she saw at the facility when she was working as a consultant.

When she’d walk onto the facility grounds, for example, she’d see smoke everywhere and find patients who were “high for the majority of the day.” As a result, patients were not addressing the underlying issues that may have brought them to High Sobriety in the first place, such as depression or other forms of mental illness.

“I found a group of individuals who were not able to engage in a conversation and were just actively smoking in front of me. I don’t think that’s appropriate. When you’re dealing with life and death with a group of 20-year-olds, you can’t get that concept across or expect them to deal with anything – let alone remember anything – when they’re high.”

Now, she believes her patients are more engaged in the various components of therapy offered at High Sobriety, whether it’s mutual help meetings like those offered by Alcoholics Anonymous or individual work with a psychologist to address issues like anxiety and PTSD. Cannabis plays a complementary role in those aspects of recovery, said Yafai.

“I can teach patients how to use cannabis so that when you leave High Sobriety, you can walk into a facility where you can pick a product that helps you address your issues,” Yafai said.

From High Sobriety in LA to Remedy Recovery in SF

A room at High Sobriety in Los Angeles.

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A room at High Sobriety in Los Angeles.
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High Sobriety for Business Insider

Schrank maintains that if people want to use marijuana, they should be free to use as much as they need.

“People lead productive lives with cannabis,” Schrank said. “And the truth is this stuff is probably safer than Doritos.”

Schrank’s new facility, called Remedy Recovery, is headquartered at a loft space in San Francisco’s China Basin neighborhood, which he envisions eventually being used as a community space. Schrank and a new a team of social workers – plus a new Remedy Recovery CEO who also has his own private equity firm – currently oversee six patients in an apartment complex nearby.

He hopes the new center will operate similar to the way High Sobriety once did. But he said doctors will play a prominent role.

“If the doctor’s counsel with cannabis, whether it’s smokeable or edible or whatever, is ‘OK, take this much,’ we’ll say, ‘Thank you doctor, we’ll follow your counsel.”

Yafai, who calls herself a cannabis clinician and is a member of a nonprofit called the Society of Cannabis Clinicians, said that wasn’t happening enough at High Sobriety before.

“There wasn’t another PhD on board giving cannabis medications,” she said.

Having a physician on board to dispense marijuana and make product recommendations could be vital for recovery centers looking to incorporate cannabis into their models. Several studies suggest that marijuana could play an important role in treating pain and helping people recover from addiction to other drugs like nicotine and opioids, but none have yet tested out High Sobriety’s model.

In contrast, thousands of rehab facilities across the US operate using abstinence-only approaches such as the ones outlined in the 12 steps of Alcoholics Anonymous with scant peer-reviewed research behind them.

Yafai said she’s been “thrilled” with the changes she’s seen in her patients at High Sobriety over the past few months. But she also worries that other facilities may try to emulate the High Sobriety model without enough scientific guidance.

“I think other places will try to do this, but without the guidance of a cannabis clinician they will fail,” Yafai said.

Doctors are calling out a new drug that helps people with addiction for costing more than $1,700 a week — while a generic costs just $1

Doctors are calling out a new drug that helps people with addiction for costing more than $1,700 a week — while a generic costs just $1

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Shutterstock

Two months after it became the first federally approved drug of its kind to treat a painful facet of addiction, doctors are calling out a new branded medication for costing thousands of times more than a similar generic drug.

The branded medication, called Lucemyra, treats withdrawal from opioids and works in a way that’s similar to the generic, known as clonidine. But the US Food and Drug Administration has given the green light for the branded drug, whose off-brand name is lofexidine, to be used specifically to treat opioid withdrawal. Clonidine, on the other hand, isn’t officially approved for that use, but the generic is frequently used off-label for patients with withdrawal symptoms..

The federal green light appears to have made all the difference when it comes to the pricing of the two drugs. While clonidine costs roughly $1 for a week’s worth of treatment, Lucemyra costs $1,738.

The price gap was pointed out in a recent blog post in The Medical Letter, a peer-reviewed medical journal published by an independent nonprofit of the same name. The post highlights that while the two drugs are different, their mechanisms of action are very similar. So to physicians, the price difference doesn’t make a whole lot of sense.

“Could one [drug of this kind] really be that much better than another?” Mark Abramowicz, the president of The Medical Letter, asked in his post.

Similar drugs, but only one with FDA approval

pill placebo pills clinical trial drugs prozac

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Darren Staples / Reuters

Both drugs work by quieting the part of the nervous system responsible for the fight-or-flight response, called the sympathetic nervous system. By subduing the sympathetic nervous system, lofexidine and clonidine both curb opioid withdrawal symptoms like nausea, vomiting, shakiness, and pervasive feelings of panic and depression.

David Juurlink, a professor of medicine at the University of Toronto, told Business Insider that clonidine is frequently used to help treat opioid withdrawal instead of lofexidine because it’s inexpensive but works similarly. He called the price gap between the two drugs “crazy.”

Studies comparing the two drugs suggest that they are equally effective for cutting withdrawal symptoms, though lofexidine appears to have a slightly lower impact on blood pressure than clonidine does.

“There are three controlled trials comparing the two,” Abramowicz wrote in The Medical Letter. “They all come to the conclusion that the two drugs are almost identical in their efficacy in reducing symptoms.”

But only lofexidine (Lucemyra) is an FDA-approved treatment for these symptoms.

Other treatments are nearly impossible to get

Still, other drugs for opioid withdrawal exist, like buprenorphine, methadone, and naltrexone. Studies suggest those drugs work better than clonidine or Lucemyra. The problem is they’re nearly impossible to get.

Only about half of private-sector treatment programs for opioid use disorder currently offer access to those drugs. And of those that offer it, only one third of patients actually receive the medication, according to a study published in the Journal of Addiction Medicine.

There are many reasons for this lack of access to medication. Some stem from a misconception about how the treatments work. The stigma surrounding drug use and addiction plays a role, too. Still other issues include federal and state laws that restrict the availability of the medications.

“It’s more of an implementation problem than a basic science problem,” Kelly J. Clark, president of the American Society of Addiction Medicine, told Business Insider in April, “because we know what works.”

Those roadblocks are part of the reason drug makers have looked for alternative drug candidates to treat various facets of addiction. The death toll from opioid use disorder continues to climb – opioids claimed roughly 42,000 lives in 2016 alone.

Mark Pirner is the medical director of clinical research for the company that makes Lucemyra, US WorldMeds. He told Business Insider that those roadblocks influenced the company’s decision to pursue lofexidine.

Pirner said he believes the slight differences between lofexidine and clonidine are substantial enough to merit the price gap.

“People who’ve used both know the benefits,” he said, adding that clonidine tends to make people feel groggy and “out of it,” whereas lofexidine does not.

Plus, Pirner pointed out, most patients won’t see that full cost, since it’ll be paid by insurers for the most part.

“From a cost perspective, the market will bear it out,” Pirner said.

A mysterious supplement has a viral following of people who take it for addiction — and researchers say it’s too compelling to ignore

A mysterious supplement has a viral following of people who take it for addiction — and researchers say it’s too compelling to ignore

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Shutterstock
  • The Food and Drug Administration calls kratom a dangerous opioid, but advocates say the drug is a life-saving supplement.
  • What’s missing from the debate about kratom, however, is hard science on how it works.
  • For the first time, a researcher has isolated kratom’s ingredients to see how they affect behavior in rats. The results are preliminary, but suggest the drug could hold promise for people dealing with addiction.

The Food and Drug Administration calls kratom a dangerous opioid with no medical use, but advocates say it’s a life-saving supplement.

What’s missing from the debate over whether kratom is miracle or menace, however, is hard science on how it works.

Frequently ground into a fine powder and taken as pills or tea, kratom is a psychoactive drug derived from the leaves of an Asian plant in the coffee family called Mitragyna speciosa. Kratom advocates swear by the stuff, saying it’s helped them kick devastating addictions to opioid painkillers.

But the federal regulatory bodies like the FDA and the Drug Enforcement Administration have cracked down on kratom and even tried to ban it. In February, FDA commissioner Scott Gottlieb said “there is no evidence to indicate that kratom is safe or effective for any medical use.”

A growing cluster of physicians and researchers are beginning to question the idea that kratom is useless or universally harmful, however. Some say they understand why people looking to get off opioids might find the drug helpful; others say new research suggests the plant’s compounds could have untapped potential.

“We’re at the precipice of something promising here,” Scott Hemby, a professor of pharmaceutical science at High Point University in North Carolina, told Business Insider.

Hemby is the author of a new study on kratom published in the journal Addiction Biology, and hisresults suggest that the chief compound in the plant could offer therapeutic benefits.

‘The yin and yang of kratom’

Kratom_Pills

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Psychonaught/Wikimedia Commons

The kratom plant contains multiple drug compounds, but two main ingredients seem to have the largest psychoactive effects: mitragynine (MG) and 7‐hydroxymitragynine (7‐HMG). (This is somewhat similar to the way marijuana plants have THC and CBD.)

Mitragynine, or MG, is thought to be the compound with the most therapeutic potential. It is also present in kratom in much higher concentrations than HMG. MG makes up roughly 60% of this type of compound in the plant, while HMG only makes up about 2%.

Hemby’s study is the first to use rats to investigate how each of these two compounds affects the brain.

He and his colleagues gave the animals the chance to self-administer each component of kratom by pushing a dial – first HMG, and then MG. They found that the rats quickly took advantage of the opportunity to give themselves the compound HMG, but they were completely uninterested in MG.

“We stood on our heads to get them to self-administer,” Hemby said, adding that his team tried upping the doses of MG several times. “It just wasn’t working. It was almost like it was innocuous.”

In other words, while one of kratom’s main compounds appeared to be addictive, the other wasn’t at all – in fact, it appeared to have the opposite effect.

That could be promising for people who are turning to kratom for relief from opioid addiction. The drug is known to tap into some of the same brain receptors as opioids – which spurred the FDA to officially call it an opioid in February. But some people believe those characteristics mean kratom could help treat opioid addiction by staunching cravings and reducing withdrawal and relapse.

Hemby’s findings also suggest there might be a way to process kratom to capitalize on this therapeutic potential by heightening the effects of one compound while minimizing the effects of the other. Strains of the plant, for example, can be bred to have differing concentrations of MG and HMG.

“It’s kind of the yin and yang of kratom,” Hemby said.

The results of the study are still preliminary, since the observations were in rats and not people. But this kind of research is considered the gold standard for drug studies at this early phase.

“This is just the very first step,” Hemby said.

‘I can see how someone who’s suffering could derive meaningful benefit from something like this’

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Shayanne Gal/Business Insider

Thousands of people say kratom has helped them bounce back from devastating addictions to painkillers. Some individuals have reported that they turned to the formula after trying and failing to get science-backed yet stigmatized treatments like buprenorphine and naltrexone.

Bryce Avey, a 26-year-old California native, told Business Insider that he took kratom daily as a tea to help kick the opioids he became addicted to after wrist surgery.

“It’s like a cruel joke that I finally found something that works and the FDA and DEA want it banned,” Avey said.

Opioids claimed roughly 42,000 lives in the US in 2016, and 40% of all opioid-overdose deaths involved prescription painkillers like Oxycontin and Vicodin, according to the Centers for Disease Control and Prevention.

One of the most painful parts of addiction to opioids is the set of flu-like symptoms they induce in some people who stop taking them. Patients who’ve experienced these symptoms, collectively known as withdrawal, say the experience is hellish. There’s shakiness, dizziness, headaches, mood swings, and constant diarrhea – not to mention powerful cravings for opioids.

To calm those feelings, people who’ve run out of their prescriptions often turn to illegal sources of the drug, like painkillers sold on the street or even heroin.

Avey said this is what happened to him. After his surgery, he took his painkillers for a few months until his prescription ran out. Then, he said, “I started buying them illegally.”

That turned into a fast downward spiral.

“I quit going to school and working and almost became homeless,” Avey said.

When he heard about kratom from a friend, he tried it and found that it eased his symptoms.

Some physicians and pharmaceutical scientists like Hemby say they aren’t surprised by those kinds of stories, since kratom acts on some of the same brain receptors as opioids.

“It makes sense that this product would mitigate the symptoms of opioid withdrawal or allow someone to transition from a higher dose to lower dose, or help get off them off of opioids altogether,” David Juurlink, a professor of medicine at the University of Toronto, told Business Insider.

That seems to be what happened for Avey, who said he now drinks a cup of kratom tea every morning, has enrolled at a nearby community college, and is working again.

“It had enough of an effect to stop the craving for opiates but not strong enough to prevent me from living my life,” Avey said.

Hemby said his study of rats could be a step toward a better understanding this effect.

“People are saying anecdotally that this is helping them get off of opiates and if we look at rats, this may have some connection with what’s being reported in humans,” he said.

The problem with an unregulated supplement

woman taking pill vitamin supplement

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Shutterstock

Currently, there’s little to no quality oversight of kratom, which means people like Avey can’t verify what pills labeled “kratom” actually contain.

FDA commissioner Gottlieb has said this lack of oversight is what allowed bacterial contaminants like salmonella to slip into kratom batches. An outbreak sickened more than 130 people across the US earlier this year.

In April, FDA intensified its crackdown on kratom, ordering its first mandatory recall of contaminated kratom products made by a company called Triangle Pharmanatural. This summer, the agency went after three more kratom manufacturers that Gottlieb said were engaged in “health fraud scams” that “pose serious health risks.” One of those companies went so far as to claim its pills helped fight cancer – an assertion with zero scientific backing.

These examples make Juurlink wary, since any potential benefit kratom offers has to be weighed against risks due to the way the drug is processed and sold.

“Personally, I would never take this stuff,” Juurlink said. “When you go to a pharmacy, you know there’s quality control, you know precisely how much you’re getting, and you know exactly what you’re getting. With this, it’s impossible to know.”

That’s why Hemby’s new research could be so significant.

“This idea that there may be evidence of kratom’s therapeutic potential – to me, that should be enough for the government to say, ‘Hey let’s look at that more,’” Hemby said.

‘Gaming disorder’ has been classified as a mental health condition by the World Health Organization — here’s what that means

‘Gaming disorder’ has been classified as a mental health condition by the World Health Organization — here’s what that means

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Shutterstock/Lenscap
  • The World Health Organization has added “gaming disorder” to the list of mental health conditions in its next update of the International Classification of Diseases, its standardized list of diseases and other medical conditions.
  • Playing too many video games could become problematic if the behavior causes a person’s relationships or performance at school or work to suffer, according to the definition.
  • Although games can potentially become too compelling for some people, they also have some psychological benefits.

The World Health Organization has added “gaming disorder” to the list of mental health conditions.

The addition will appear in the new version the International Classification of Diseases (ICD), the WHO’s standardized list of diseases and other medical conditions used by countries around the world, which was released on Monday.

The addition is meant to help clinical professionals define the point at which a pastime or hobby of playing video games becomes problematic. That could also help individuals who feel they are struggling with gaming get treatment.

The ICD now lists gaming behavior as disordered if it meets three conditions: if a person loses control over their gaming habits, if they start to prioritize gaming over many other life interests or daily activities, and if they continue playing despite clear negative consequences. This pattern should be clear for a one-year period before a diagnosis is made, according to the definition.

This adds gaming to a list of behaviors that can become problematic if people lose control over them, including gambling and disorders related to the use of substances like alcohol, marijuana, caffeine, or nicotine.

However, defining behaviors like gaming as addictive or as mental health conditions is still controversial. Some researchers argue that problematic gaming behavior is often a symptom of mental health struggles, rather than a mental health condition by itself.

There are lots of forms of gaming, some solo, some social.

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There are lots of forms of gaming, some solo, some social.
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imtmphoto/Shutterstock

Severe enough to harm personal relationships

The term “gaming,” of course, covers a wide range of activities that can be solo or social pursuits. It includes playing a quick puzzle game on your iPhone while riding the subway, meeting up with friends to play “Minecraft,” and sitting down at a custom-built PC for a multi-hour “Destiny 2” raid session.

The WHO’s definition is not meant to imply that any one sort of gaming is addictive or to say that a specific amount of it leads to a disorder. Playing video games only would qualify as a mental health condition if the behavior is severe enough to result in “marked distress or significant impairment in personal, family, social, educational or occupational functioning,” according to the WHO.

In other words, it has to be harming personal relationships or interfering with school or work.

“Gaming disorders are uncommon, but still very important,” Dr. Shekhar Saxena, director of the WHO’s department for mental health and substance abuse, said in a YouTube video discussing changes made to the ICD. “ICD has to keep pace with evolving disorders and diseases, and this is one of them.”

witcher 3

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CD Projekt RED

The psychology of games

The psychological community has been debating whether gaming is addictive enough to be described as a disorder for some time. So far, the American Psychiatric Association has declined to classify gaming addiction as a disorder but has said it merits further research.

Before the WHO’s decision, the Society for Media Psychology and Technology Division of the American Psychology Association released a statement expressing concern about the idea of “gaming disorder,” due to insufficient research on the topic:

“[R]esearch has not provided clarity on how to define video game addiction (VGA), what symptoms best diagnose it, how prevalent it is, or whether it truly exists as an independent disorder, or, when it occurs is merely symptomatic of other, underlying mental health diagnoses.”

Part of the problem is how to distinguish between simply spending a lot of time playing games and actual addictive behavior.

Scientists need to “establish a clear-cut distinction between someone who may use games excessively but non-problematically and someone who is experiencing significant impairment in their daily lives as a consequence of their excessive gaming,” a group of researchers from Nottingham Trent University in the UK wrote in a paper published last summer in the Journal of Addictive Behavior.

There are plenty of stories about individuals whose gaming behavior has become problematic – people have gotten so caught up in online games that they’ve ruined relationships and lost jobs. Games are often designed to compel people to keep playing and in some cases, to keep spending money. Compulsive gaming and problematic substance use can also go hand in hand.

But problematic gaming may also serve as a dysfunctional coping mechanism for some, according to the Nottingham Trent researchers. Someone who is struggling with depression or anxiety may turn to gaming or abuse substances like alcohol as a way to relieve those symptoms.

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Ben Gilbert / Tech Insider

Benefits, harms, and “gaming disorder” going forward

Figuring out the degree to which playing games is harmful (or helpful) is all about context, according to Bruce Lee, an associate professor of international health at the Johns Hopkins Bloomberg School of Public Health. Lee wrote in a column for Forbes that gaming habits can also be psychologically beneficial.

On the positive side, research has shown that game playing can relieve stress, improve problem-solving abilities, and enhance traits like eye-hand coordination. Technologies that we think of as built for gaming, like virtual reality, can also be used in psychological therapy.

Yet people can struggle to find a healthy balance with gaming.

Researchers are still trying to understand the activity’s risks and effects, since it has only recently become such a common pastime – 63% of US households contain at least one “frequent gamer,” a trait that didn’t exist a couple of generations ago.

The WHO creates the ICD list so that every country can use a standardized system for classifying diseases. That allows for a unified way of identifying illnesses and keeping track of how common certain diagnoses are.

But it’ll take some time before the ICD actually gets implemented by countries around the world. Each health care system decides when to start using the updated list, which requires changing various forms of medical record-keeping. The US didn’t adopt the last version of the ICD until 2015, despite it being finished in 1992 and first adopted by some members in 1994. As member countries adopt the new system, they’ll decide how these diagnoses should be treated by healthcare systems and insurance companies.

In the meantime, research into the effects of gaming will continue.

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