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  • Driving under the influence of marijuana: An explainer and research roundup

    Naseem S. Miller – The Journalist's Resource

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Update 1: On May 16, 2024, the U.S. Department of Justice sent a proposed rule to the Federal Register to downgrade marijuana from a Schedule I to a Schedule III drug. This is the first step in a lengthy approval process that starts with a 60-day comment period.

    Update 2: Two recent research studies were added to the “Studies on marijuana and driving” section of this piece on July 18, 2024.

    As marijuana use continues to rise and state-level marijuana legalization sweeps the U.S., researchers and policymakers are grappling with a growing public safety concern: marijuana-impaired driving.

    As of April 2023, 38 U.S. states had legalized medical marijuana and 23 had legalized its recreational use, according to the National Conference of State Legislatures. Recreational or medical marijuana measures are on the ballot in seven states this year.

    The issue of marijuana-impaired driving has not been an easy one to tackle because, unlike alcohol, which has well-established thresholds of impairment, the metrics for marijuana’s effects on driving remain rather elusive.

    “We don’t have that kind of deep knowledge right now and it’s not because of lack of trying,” says Dr. Guohua Li, professor of epidemiology and the founding director of the Center for Injury Science and Prevention at Columbia University.

    “Marijuana is very different from alcohol in important ways,” says Li, who has published several studies on marijuana and driving. “And one of them is that the effect of marijuana on cognitive functions and behaviors is much more unpredictable than alcohol. In general, alcohol is a depressant drug. But marijuana could act on the central nervous system as a depressant, a stimulant, and a hallucinogenic substance.”

    Efforts to create a breathalyzer to measure the level of THC, the main psychoactive compound found in the marijuana plant, have largely failed, because “the THC molecule is much bigger than ethanol and its behavior after ingestion is very different from alcohol,” Li says.

    Currently, the two most common methods used to measure THC concentration to identify impaired drivers are blood and saliva tests, although there’s ongoing debate about their reliability.

    Marijuana, a term interchangeably used with cannabis, is the most commonly used federally illegal drug in the U.S.: 48.2 million people, or about 18% of Americans reported using it at least once in 2019, according to the latest available data from the Centers for Disease Control and Prevention. Worldwide, 2.5% of the population consumes marijuana, according to the World Health Organization.

    Marijuana is legal in several countries, including Canada, where it was legalized in 2018. Despite state laws legalizing cannabis, it remains illegal at the federal level in the U.S.

    As states grapple with the contentious issue of marijuana legalization, the debate is not just about public health, potential tax revenues and economic interests. At the heart of the discussion is also the U.S. criminal justice system.

    Marijuana is shown to have medicinal qualities and, compared with substances like alcohol, tobacco, and opioids, it has relatively milder health risks. However, it’s not risk-free, a large body of research has shown.

    Marijuana consumption can lead to immediate effects such as impaired muscle coordination and paranoia, as well as longer-term effects on mental health and cognitive functions — and addiction. As its use becomes more widespread, researchers are trying to better understand the potential hazards of marijuana, particularly for younger users whose brains are in critical stages of development.

    Marijuana and driving

    The use of marijuana among drivers, passengers and pedestrians has increased steadily over the past two decades, Li says.

    Compared with the year 2000, the proportion of U.S. drivers on the road who are under the influence of marijuana has increased by several folds, between five to 10 times, based on toxicology testing of people who died in car crashes, Li says.

    A 2022 report from the National Transportation Safety Board finds alcohol and cannabis are the two most commonly detected drugs among drivers arrested for impaired driving and fatally injured drivers. Most drivers who tested positive for cannabis also tested positive for another potentially impairing drug.

    “Although cannabis and many other drugs have been shown to impair driving performance and are associated with increased crash risk, there is evidence that, relative to alcohol, awareness about the potential dangers of driving after using other drugs is lower,” according to the report.

    Indeed, many U.S. adults perceive daily marijuana use or exposure to its smoke safer than tobacco, even though research finds otherwise.

    Several studies have demonstrated marijuana’s impact on driving.

    Marijuana use can reduce the drivers’ ability to pay attention, particularly when they are performing multiple tasks, research finds. It also slows reaction time and can impair coordination.

    “The combination is that you potentially have people who are noticing hazards later, braking slower and potentially not even noticing hazards because of their inability to focus on competing things on the road,” says Dr. Daniel Myran, an assistant professor at the Department of Family Medicine and health services researcher at the University of Ottawa.

    In a study published in September in JAMA Network Open, Myran and colleagues find that from 2010 to 2021 the rate of cannabis-involved traffic injuries that led to emergency department visits in Ontario, Canada, increased by 475%, from 0.18 per 1,000 traffic injury emergency department visits in 2010 to 1.01 visits in 2021.

    To be sure, cannabis-involved traffic injuries made up a small fraction of all traffic injury-related visits to hospital emergency departments. Out of 947,604 traffic injury emergency department visits, 426 had documented cannabis involvement.

    Myran cautions the increase shouldn’t be solely attributed to marijuana legalization. It captures changing societal attitudes toward marijuana and acceptance of cannabis use over time in the lead-up to legalization. In addition, it may reflect an increasing awareness among health care providers about cannabis-impaired driving, and they may be more likely to ask about cannabis use and document it in medical charts, he says.

    “When you look at the 475% increase in cannabis involvement in traffic injuries, rather than saying legalizing cannabis has caused the roads to be unsafe and is a public health disaster, it’s that cannabis use appears to be growing as a risk for road traffic injuries and that there seem to be more cannabis impaired drivers on the road,” Myran says. “Legalization may have accelerated this trend. Faced with this increase, we need to think about what are public health measures and different policy interventions to reduce harms from cannabis-impaired driving.”

    Setting a legal limit for marijuana-impaired driving

    Setting a legal limit for marijuana-impaired driving has not been easy. Countries like Canada and some U.S. states have agreed upon a certain level of THC in blood, usually between 1 to 5 nanograms per milliliter. Still, some studies have found those limits to be weak indicators of cannabis-impaired driving.

    When Canada legalized recreational marijuana in 2018, it also passed a law that made it illegal to drive with blood THC levels of more than 2 nanograms. The penalties are more severe for blood THC levels above 5 nanograms. The blood test is done at the police station for people who are pulled over and are deemed to be drug impaired.

    In the U.S., five states — Ohio, Illinois, Montana, Washington and Nevada — have “per se laws,” which set a specific amount of THC in the driver’s blood as evidence of impaired driving, according to the National Conference of State Legislatures. That limit ranges between 2 and 5 nanograms of THC per milliliter of blood.

    Colorado, meanwhile, has a “permissible inference law,” which states that it’s permissible to assume the driver was under the influence if their blood THC level is 5 nanograms per milliliter or higher, according to NCSL.

    Twelve states, most which have legalized some form of marijuana of use, have zero tolerance laws for any amount of certain drugs, including THC, in the body.

    The remaining states have “driving under the influence of drugs” laws. Among those states, Alabama and Michigan, have oral fluid roadside testing program to screen drivers for marijuana and other drugs, according to NCSL.

    In May this year, the U.S. Department of Transportation published a final rule that allows employers to use saliva testing for commercially licensed drivers, including truck drivers. The rule, which went into effect in June, sets the THC limit in saliva at 4 nanograms.

    Saliva tests can detect THC for 8 to 24 hours after use, but the tests are not perfect and can results in false positives, leading some scientists to argue against using them in randomly-selected drivers.

    In a 2021 report, the U.S. National Institute of Justice, the research and development arm of the Department of Justice, concluded that THC levels in bodily fluids, including blood and saliva “were not reliable indicators of marijuana intoxication.”

    Studies on marijuana and driving

    Over the past two decades, many studies have shown marijuana use can impair driving. However, discussions about what’s the best way to measure the level of THC in blood or saliva are ongoing. Below, we highlight and summarize several recent studies that address the issue. The studies are listed in order of publication date. We also include a list of related studies and resources to inform your audiences.

    State Driving Under the Influence of Drugs Laws
    Alexandra N. Origenes, Sarah A. White, Emma E. McGinty and Jon S. Vernick. Journal of Law, Medicine & Ethics, July 2024.

    Summary: As of January 2023, 33 states and D.C. had a driving under the influence of drugs law for at least one drug other than cannabis. Of those, 29 states and D.C. had a law specifically for driving under the influence of cannabis, in addition to a law for driving under the influence of other drugs. Four states had a driving under the influence of drug laws, excluding cannabis. Meanwhile, 17 states had no law for driving under the influence of drugs, including cannabis.  “The 17 states lacking a DUID law that names specific drugs should consider enacting such a law. These states already have expressed their concern — through legislation — with drug-impaired driving. However, failure to name specific drugs is likely to make the laws more difficult to enforce. These laws may force courts and/or law enforcement to rely on potentially subjective indicators of impairment,” the authors write.

    Associations between Adolescent Marijuana Use, Driving After Marijuana Use and Recreational Retail Sale in Colorado, USA
    Lucas M. Neuroth, et al. Substance Use & Misuse, October 2023.

    Summary: Researchers use data from four waves (2013, 2015, 2017 and 2019) of the Healthy Kids Colorado Survey, including 47,518 students 15 and older who indicated that they drove. They find 20.3% of students said that they had used marijuana in the past month and 10.5% said they had driven under the influence of marijuana. They find that the availability of recreational marijuana in stores was associated with an increased prevalence of using marijuana one to two times in the past month and driving under the influence of marijuana at least once. “Over the study period, one in ten high school age drivers engaged in [driving after marijuana use], which is concerning given the high risk of motor vehicle-related injury and death arising from impaired driving among adolescents,” the authors write.

    Are Blood and Oral Fluid Δ9-tetrahydrocannabinol (THC) and Metabolite Concentrations Related to Impairment? A Meta-Regression Analysis
    Danielle McCartney, et al. Neuroscience & Biobehavioral Reviews, March 2022.

    Summary: Commonly used THC measurements may not be strong indicators of driving impairment. While there is a relationship between certain biomarkers like blood THC concentrations and impaired driving, this correlation is often weak. The study underscores the need for more nuanced and comprehensive research on this topic, especially as cannabis usage becomes more widespread and legally accepted.

    The Effects of Cannabis and Alcohol on Driving Performance and Driver Behaviour: A Systematic Review and Meta-Analysis
    Sarah M. Simmons, Jeff K. Caird, Frances Sterzer and Mark Asbridge. Addiction, January 2022.

    Summary: This meta-analysis of experimental driving studies, including driving simulations, confirms that cannabis impairs driving performance, contrary to some beliefs that it might enhance driving abilities. Cannabis affects lateral control and speed — typically increasing lane excursions while reducing speed. The combination of alcohol and marijuana appears worse than either alone, challenging the idea that they cancel each other out.

    Cannabis Legalization and Detection of Tetrahydrocannabinol in Injured Drivers
    Jeffrey R. Brubacher, et al. The New England Journal of Medicine, January 2022.

    Summary: Following the legalization of recreational marijuana in Canada, there was a notable increase in injured drivers testing positive for THC, especially among those 50 years of age or older. This rise in cannabis-related driving incidents occurred even with new traffic laws aiming to deter cannabis-impaired driving. This uptick began before legalization became official, possibly due to perceptions that cannabis use was soon-to-be legal or illegal but not enforced. The data suggests that while legalization has broad societal impacts, more comprehensive strategies are needed to deter driving under the influence of cannabis and raise public awareness about its risks.

    Cannabis and Driving
    Godfrey D. Pearlson, Michael C. Stevens and Deepak Cyril D’Souza. Frontiers in Psychiatry, September 2021.

    Summary: Cannabis-impaired driving is a growing public health concern, and studies show that such drivers are more likely to be involved in car crashes, according to this review paper. Drivers are less affected by cannabis than they are by alcohol or cocaine, but the problem is expected to escalate with increasing cannabis legalization and use. Unlike alcohol, THC’s properties make it challenging to determine direct impairment levels from testing results. Current roadside tests lack precision in detecting genuine cannabis-impaired drivers, leading to potential wrongful convictions. Moreover, there is a pressing need for research on the combined effects of alcohol and cannabis on driving, as well as the impact of emerging popular forms of cannabis, like concentrates and edibles. The authors recommend public awareness campaigns about the dangers of driving under the influence of cannabis, similar to those against drunk driving, to address misconceptions. Policymakers should prioritize science-based decisions and encourage further research in this domain.

    Demographic And Policy-Based Differences in Behaviors And Attitudes Towards Driving After Marijuana Use: An Analysis of the 2013–2017 Traffic Safety Culture Index
    Marco H. Benedetti, et al. BMC Research Notes, June 2021.

    Summary: The study, based on a U.S. survey, finds younger, low-income, low-education and male participants were more tolerant of driving after marijuana consumption. Notably, those in states that legalized medical marijuana reported driving after use more frequently, aligning with studies indicating a higher prevalence of THC detection in drivers from these states. Overall, while the majority perceive driving after marijuana use as dangerous, not all research agrees on its impairment effects. Existing studies highlight that marijuana impacts motor skills and executive functions, yet its direct correlation with crash risk remains debated, given the variations in individual tolerance and how long THC remains in the system.

    Driving Under the Influence of Cannabis: A Framework for Future Policy
    Robert M. Chow, et al.Anesthesia & Analgesia, June 2019.

    Summary: The study presents a conceptual framework focusing on four main domains: legalization, driving under the influence of cannabis, driver impairment, and motor vehicle accidents. With the growing legalization of cannabis, there’s an anticipated rise in cannabis-impaired driving cases. The authors group marijuana users into infrequent users who show significant impairment with increased THC blood levels, chronic users with minimal impairment despite high THC levels, and those with consistent psychomotor deficits. Current challenges lie in the lack of standardized regulation for drivers influenced by cannabis, primarily because of state-to-state variability and the absence of a federal statutory limit for blood THC levels. European nations, however, have established thresholds for blood THC levels, ranging from 0.5 to 50.0 micrograms per liter depending on whether blood or blood serum are tested. The authors suggest the combined use of alcohol and THC blood tests with a psychomotor evaluation by a trained professional to determine impairment levels. The paper stresses the importance of creating a structured policy framework, given the rising acceptance and use of marijuana in society.

    Additional research

    Cannabis-Involved Traffic Injury Emergency Department Visits After Cannabis Legalization and Commercialization
    Daniel T. Myran, et al. JAMA Network Open, September 2023.

    Driving Performance and Cannabis Users’ Perception of Safety: A Randomized Clinical Trial
    Thomas D. Marcotte, et al. JAMA Psychiatry, January 2022.

    Medicinal Cannabis and Driving: The Intersection of Health and Road Safety Policy
    Daniel Perkins, et al. International Journal of Drug Policy, November 2021.

    Prevalence of Marijuana Use Among Trauma Patients Before and After Legalization of Medical Marijuana: The Arizona Experience
    Michael Levine, et al. Substance Abuse, July 2021.

    Self-Reported Driving After Marijuana Use in Association With Medical And Recreational Marijuana Policies
    Marco H. Benedetti, et al. International Journal of Drug Policy, June 2021.

    Cannabis and Driving Ability
    Eric L. Sevigny. Current Opinion in Psychology, April 2021.

    The Failings of per se Limits to Detect Cannabis-Induced Driving Impairment: Results from a Simulated Driving Study
    Thomas R. Arkell, et al. Traffic Injury Prevention, February 2021.

    Risky Driving Behaviors of Drivers Who Use Alcohol and Cannabis
    Tara Kelley-Baker, et al. Transportation Research Record, January 2021.

    Direct and Indirect Effects of Marijuana Use on the Risk of Fatal 2-Vehicle Crash Initiation
    Stanford Chihuri and Guohua Li. Injury Epidemiology, September 2020

    Cannabis-Impaired Driving: Evidence and the Role of Toxicology Testing
    Edward C. Wood and Robert L. Dupont. Cannabis in Medicine, July 2020.

    Association of Recreational Cannabis Laws in Colorado and Washington State With Changes in Traffic Fatalities, 2005-2017
    Julian Santaella-Tenorio, et al. JAMA Internal Medicine, June 2020.

    Marijuana Decriminalization, Medical Marijuana Laws, and Fatal Traffic Crashes in US Cities, 2010–2017
    Amanda Cook, Gregory Leung and Rhet A. Smith. American Journal of Public Health, February 2020.

    Cannabis Use in Older Drivers in Colorado: The LongROAD Study
    Carolyn G. DiGuiseppi, et al. Accident Analysis & Prevention, November 2019.

    Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado
    Jayson D. Aydelotte, et al. American Journal of Public Health, August 2017.

    Marijuana-Impaired Driving: A Report to Congress
    National Highway Traffic Safety Administration, July 2017

    Interaction of Marijuana And Alcohol on Fatal Motor Vehicle Crash Risk: A Case–Control Study
    Stanford Chihuri, Guohua Li and Qixuan Chen. Injury Epidemiology, March 2017.

    US Traffic Fatalities, 1985–2014, and Their Relationship to Medical Marijuana Laws
    Julian Santaella-Tenorio, et al. American Journal of Public Health, February 2017.

    Delays in DUI Blood Testing: Impact on Cannabis DUI Assessments
    Ed Wood, Ashley Brooks-Russell and Phillip Drum. Traffic Injury Prevention, June 2015.

    Establishing Legal Limits for Driving Under the Influence of Marijuana
    Kristin Wong, Joanne E. Brady and Guohua Li. Injury Epidemiology, October 2014.

    Cannabis Effects on Driving Skills
    Rebecca L. Hartman and Marilyn A. Huestis. Clinical Chemistry, March 2014.

    Acute Cannabis Consumption And Motor Vehicle Collision Risk: Systematic Review of Observational Studies and Meta-Analysis
    Mark Asbridge, Jill A. Hayden and Jennifer L. Cartwright. The BMJ, February 2012.

    Resources for your audiences

    The following resources include explainers from federal agencies and national organizations. You’re free to use images and graphics from federal agencies.

    This article first appeared on The Journalist’s Resource and is republished here under a Creative Commons license.

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  • Unbroken – by Dr. MaryCatherine McDonald

    The 10almonds Team

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    We’ve reviewed books about trauma before, so what makes this one different? Mostly, it’s the different framing.

    Dr. McDonald advocates for a neurobiological understanding of trauma, which really levels the playing field when it comes to different types of trauma that are often treated very differently, when the end result in the brain is more or less the same.

    Does this mean she proposes a “one-size fits all” approach? Kind of!

    Insofar as she offers a one-size fits all approach that is then personalized by the user, but most of her advices will go for most kinds of trauma in any case. This is particularly useful for any of us who’ve ever hit a wall with therapists when they expect a person to only be carrying one major trauma.

    Instead, with Dr. McDonald’s approach, we can take her methods and use them for each one.

    After an introduction and overview, each chapter contains a different set of relevant psychological science explored through a case study, and then at the end of the chapter, tools to use and try out.

    The style is very light and readable, notwithstanding the weighty subject matter.

    Bottom line: if you’ve been trying to deal with (or avoid dealing with) some kind(s) of trauma, this book will doubtlessly contain at least a few new tools for you. It did for this reviewer, who reads a lot!

    Click here to check out Unbroken, because it’s never too late to heal!

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  • Dates vs Raisins – Which is Healthier?

    The 10almonds Team

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Our Verdict

    When comparing dates to raisins, we picked the dates.

    Why?

    There are benefits for each fruit, but we say dates come out on top. See what you think:

    In terms of macros, while they’re both dried fruits, dates contain more water (unless you leave them sitting open for a while), which will tend to mathematically lower the relative percentages of other components because they’re being held against water weight too. However, even though this is the case (i.e. dates are being mathematically disadvantaged), dates contain more than twice the fiber that raisins do (8g/100g compared to raisins’ 3.7g/100g).

    While we’re talking macros, dates are also lower in total carbs, as well as obviously net carbs, and have a much lower glycemic index than raisins (dates have a glycemic index of 42, considered low, while raisins have a glycemic index of 64, considered medium; their respective glycemic loads are even more telling: 13 for raisins and just 2 for dates!).

    About those carbs… For dates, it’s an approximately equal mix of sucrose, glucose, and fructose, while for raisins it’s 49% glucose and 49% fructose. Because sucrose is the only disaccharide here, this (as well as the fiber difference) is one of the reasons for the different glycemic indices and glycemic loads, since glucose and fructose are more quickly absorbed.

    That’s more than we usually write about macros, but in this case, both fruits are ones especially often hit with the “aren’t they full of sugar though?” question, so it was important to cover the critical distinctions between the two, because they really are very different.

    Summary of macros: dates win easily in every aspect we looked at

    In the category of vitamins, raisins get a tally in their favor. Raisins are higher in vitamins B1, B2, C, E, K, and choline, while dates are higher in vitamins A, B3, B5, and B9, giving raisins a 6:4 lead here. In dates’ defense, the difference in vitamin K is marginal, and it’d make it a 5:4 lead if we considered that within the margin of error (because all these figures are of course based on averages), and the vitamins that dates are higher in, the margins are much wider indeed, meaning that both fruits have approximately the same overall levels of vitamins when looked at in total, but still, we’ll call this category a nominal win for raisins.

    When it comes to minerals, dates have more magnesium, selenium, and zinc, while raisins have more copper, iron, phosphorus, and potassium. Nominally that’s a 4:3 lead for raisins, but if we consider that raisins also contain more sodium, it’s more like a tie here. If we have to pick one though, this is a very slight win for raisins.

    Adding up the sections, we have one huge win for dates (macros) with two very marginal wins for raisins—hence, we say that dates win out.

    Still, of course enjoy both; diversity is good for the health.

    Want to learn more?

    You might like to read:

    Which Sugars Are Healthier, And Which Are Just The Same?

    Take care!

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  • 7 Signs of Undiagnosed Autism in Adults

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    The 10almonds Team

    When it comes to adults and autism, there are two kinds of person in the popular view: those who resemble the Rain Man, and those who are making it up. But, it’s not so, as Paul Micallef explains:

    The signs

    We’ll not keep them a mystery; they are:

    1. Social interaction difficulties: such a person may struggle with understanding social cues, leading to awkwardness, isolation, or appearing eccentric.
    2. Need for structure and routine: either highly structured or disorganized, both of which stem from executive function challenges. The former, of course, is a coping mechanism, while the latter is the absence of same.
    3. Sensory sensitivities: can include sensitivities or insensitivities to light, sound, temperature, smells, tastes, and so forth.
    4. Spiky skillset: extreme strengths in certain areas, coupled with significant difficulties in others, leading to uneven abilities. May be able to dismantle and rebuild a PC, while not knowing how to arrange an Über.
    5. Emotional regulation issues: experiences of meltdowns, shutdowns, or withdrawal as coping mechanisms when overwhelmed. Not that this is “or”, not necessarily “and”. The latter goes especially unnoticed as an emotional regulation issue, because for everyone else, it’s something that’s not there to see.
    6. Unusual associations: making mental connections or associations that seem random or uncommon compared to others. The mind went to 17 places quickly and while everyone else got from idea A to idea B, this person is already at idea Q.
    7. Being “just different”: a general sense of being the odd one out, standing out in subtle or distinct ways. This is rather a catch-all, but if there’s someone who fits this, there’s a good chance, the other things apply too.

    For more on all of these, whether pertaining to yourself or a loved one (or both!), enjoy:

    Click Here If The Embedded Video Doesn’t Load Automatically!

    Want to learn more?

    You might also like to read:

    Take care!

    Don’t Forget…

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  • Undo The Sun’s Damage To Your Skin

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    The 10almonds Team

    It’s often said that our skin is our largest organ. Our brain or liver are the largest solid organs by mass (which one comes out on top will vary from person to person), our gut is the longest, and our lungs are the largest by surface area. But our skin is large, noticeable, and has a big impact on the rest of our health.

    The sun is one of the main damaging factors for our skin; assorted toxins are also a major threat for many people, and once the skin barrier gets broken, it’s a field-day for bacteria.

    So, what can we do about it?

    Tretinoin: the skin’s rejuvenator

    Tretinoin is also called retinoic acid, not to be mistaken for retinol, although they are both retinoids. Tretinoin is much stronger.

    As for what it’s stronger at:

    It’s usually prescribed for the treatment of sun-damage, acne, and wrinkles. Paradoxically, it works by inflaming the skin (and then making it better, and having done so, keeping it better).

    In few words: it encourages your skin to speed up its life cycle, which means that cells die and are replaced sooner, which means the average age of skin cells will be considerably younger at any given time.

    This is the same principle as we see at work when it comes to cellular apoptosis and autophagy in general, and specifically the same idea as we discussed when talking about senolytics, compounds that kill aging cells:

    Fisetin: The Anti-Aging Assassin

    About that paradoxical inflammation…

    ❝The topical use of tretinoin as an antiacne agent began almost a half century ago. Since that time it has been successfully used to treat comedonal and inflammatory acne.

    Over the intervening years, the beneficial effects of tretinoin have grown from an understanding of its potent cornedolytie-related properties to an evolving appreciation of its antiinflammatory actions.

    …

    The topical use of clindamycin and tretinoin as a combination treatment modality that includes antibacterial, comedolytic, and antiinflammatoiy properties has proven to be a very effective therapy for treating the various stages of acne

    …

    It is now becoming increasingly clear that there may be good reasons for these observations.❞

    ~ Drs. Schmidt & Gans, lightly edited here for brevity

    Read in full: Tretinoin: A Review of Its Anti-inflammatory Properties in the Treatment of Acne

    Against damage by the sun

    The older we get, the more likely sun damage is a problem than acne. And in the case of tretinoin,

    ❝In several well-controlled clinical trials, the proportion of patients showing improvement was significantly higher with 0.01 or 0.05% tretinoin cream than with placebo for criteria such as global assessment, fine and coarse wrinkling, pigmentation and roughness.

    Improvements in the overall severity of photodamage were also significantly greater with tretinoin than with placebo.

    …

    Several placebo-controlled clinical studies have demonstrated that topical tretinoin has significant efficacy in the treatment of photodamaged skin. Improvements in subjective global assessment scores were recorded in:

    49–100% of patients using once-daily 0.01% tretinoin,

    68–100% of patients using 0.05% tretinoin, and

    0–44% of patients using placebo.❞

    ~ Drs. Wagstaff & Noble

    …which is quite compelling.

    Read in full: Tretinoin: A Review of its Pharmacological Properties and Clinical Efficacy in the Topical Treatment of Photodamaged Skin

    This is very well-established by now; here’s an old paper from when the mechanism of action was unknown (here in the current day, 17 mechanisms of action have been identified; beyond the scope of this article as we only have so much room, but it’s nice to see science building on science):

    ❝Tretinoin cream has been used extensively to reverse the changes of photoaging. It is the first topical therapy to undergo controlled clinical testing and proved to be efficacious. These results have been substantiated with photography, histopathologie examination, and skin surface replicas.

    …

    Tretinoin cream has an excellent safety record; a local cutaneous hypervitaminosis A reaction is the only common problem.❞

    ~ Dr. Goldfarb et al.

    Read in full: Topical tretinoin therapy: Its use in photoaged skin

    Is it safe?

    For most people, when used as directed*, yes. However, it’s likely to irritate your skin at first, and that’s normal. If this persists more than a few weeks, or seems unduly severe, then you might want to stop and talk to your doctor again.

    *See also: Scarring following inappropriate use of 0.05% tretinoin gel

    (in the case of a young woman who used it 4x daily instead of 1x daily)

    Want to try some?

    Tretinoin is prescription-only, so speak with your doctor/pharmacist about that. Alternatively, retinal (not retinol) is the strongest natural alternative that works on the same principles; here’s an example product on Amazon 😎

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  • He Fell Ill on a Cruise. Before He Boarded the Rescue Boat, They Handed Him the Bill.

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    The 10almonds Team

    Vincent Wasney and his fiancée, Sarah Eberlein, had never visited the ocean. They’d never even been on a plane. But when they bought their first home in Saginaw, Michigan, in 2018, their real estate agent gifted them tickets for a Royal Caribbean cruise.

    After two years of delays due to the coronavirus pandemic, they set sail in December 2022.

    The couple chose a cruise destined for the Bahamas in part because it included a trip to CocoCay, a private island accessible to Royal Caribbean passengers that featured a water park, balloon rides, and an excursion swimming with pigs.

    It was on that day on CocoCay when Wasney, 31, started feeling off, he said.

    The next morning, as the couple made plans in their cabin for the last full day of the trip, Wasney made a pained noise. Eberlein saw him having a seizure in bed, with blood coming out of his mouth from biting his tongue. She opened their door to find help and happened upon another guest, who roused his wife, an emergency room physician.

    Wasney was able to climb into a wheelchair brought by the ship’s medical crew to take him down to the medical facility, where he was given anticonvulsants and fluids and monitored before being released.

    Wasney had had seizures in the past, starting about 10 years ago, but it had been a while since his last one. Imaging back then showed no tumors, and doctors concluded he was likely epileptic, he said. He took medicine initially, but after two years without another seizure, he said, his doctors took him off the medicine to avoid liver damage.

    Wasney had a second seizure on the ship a few hours later, back in his cabin. This time he stopped breathing, and Eberlein remembered his lips being so purple, they almost looked black. Again, she ran to find help but, in her haste, locked herself out. By the time the ship’s medical team got into the cabin, Wasney was breathing again but had broken blood vessels along his chest and neck that he later said resembled tiger stripes.

    Wasney was in the ship’s medical center when he had a third seizure — a grand mal, which typically causes a loss of consciousness and violent muscle contractions. By then, the ship was close enough to port that Wasney could be evacuated by rescue boat. He was put on a stretcher to be lowered by ropes off the side of the ship, with Eberlein climbing down a rope ladder to join him.

    But before they disembarked, the bill came.

    The Patient: Vincent Wasney, 31, who was uninsured at the time.

    Medical Services: General and enhanced observation, a blood test, anticonvulsant medicine, and a fee for services performed outside the medical facility.

    Service Provider: Independence of the Seas Medical Center, the on-ship medical facility on the cruise ship operated by Royal Caribbean International.

    Total Bill: $2,500.22.

    What Gives: As part of Royal Caribbean’s guest terms, cruise passengers “agree to pay in full” all expenses incurred on board by the end of the cruise, including those related to medical care. In addition, Royal Caribbean does not accept “land-based” health insurance plans.

    Wasney said he was surprised to learn that, along with other charges like wireless internet, Royal Caribbean required he pay his medical bills before exiting the ship — even though he was being evacuated urgently.

    “Are we being held hostage at this point?” Eberlein remembered asking. “Because, obviously, if he’s had three seizures in 10 hours, it’s an issue.”

    Wasney said he has little memory of being on the ship after his first seizure — seizures often leave victims groggy and disoriented for a few hours afterward.

    But he certainly remembers being shown a bill, the bulk of which was the $2,500.22 in medical charges, while waiting for the rescue boat.

    Still groggy, Wasney recalled saying he couldn’t afford that and a cruise employee responding: “How much can you pay?”

    They drained their bank accounts, including money saved for their next house payment, and maxed out Wasney’s credit card but were still about $1,000 short, he said.

    Ultimately, they were allowed to leave the ship. He later learned his card was overdrafted to cover the shortfall, he said.

    Royal Caribbean International did not respond to multiple inquiries from KFF Health News.

    Once on land, in Florida, Wasney was taken by ambulance to the emergency room at Broward Health Medical Center in Fort Lauderdale, where he incurred thousands of dollars more in medical expenses.

    He still isn’t entirely sure what caused the seizures.

    On the ship he was told it could have been extreme dehydration — and he said he does remember being extra thirsty on CocoCay. He also has mused whether trying escargot for the first time the night before could have played a role. Eberlein’s mother is convinced the episode was connected to swimming with pigs, he said. And not to be discounted, Eberlein accidentally broke a pocket mirror three days before their trip.

    Wasney, who works in a stone shop, was uninsured when they set sail. He said that one month before they embarked on their voyage, he finally felt he could afford the health plan offered through his employer and signed up, but the plan didn’t start until January 2023, after their return.

    They also lacked travel insurance. As inexperienced travelers, Wasney said, they thought it was for lost luggage and canceled trips, not unexpected medical expenses. And because the cruise was a gift, they were never prompted to buy coverage, which often happens when tickets are purchased.

    The Resolution: Wasney said the couple returned to Saginaw with essentially no money in their bank account, several thousand dollars of medical debt, and no idea how they would cover their mortgage payment. Because he was uninsured at the time of the cruise, Wasney did not try to collect reimbursement for the cruise bill from his new health plan when his coverage began weeks later.

    The couple set up payment plans to cover the medical bills for Wasney’s care after leaving the ship: one each with two doctors he saw at Broward Health, who billed separately from the hospital, and one with the ambulance company. He also made payments on a bill with Broward Health itself. Those plans do not charge interest.

    But Broward Health said Wasney missed two payments to the hospital, and that bill was ultimately sent to collections.

    In a statement, Broward Health spokesperson Nina Levine said Wasney’s bill was reduced by 73% because he was uninsured.

    “We do everything in our power to provide the best care with the least financial impact, but also cannot stress enough the importance of taking advantage of private and Affordable Care Act health insurance plans, as well as travel insurance, to lower risks associated with unplanned medical issues,” she said.

    The couple was able to make their house payment with $2,690 they raised through a GoFundMe campaign that Wasney set up. Wasney said a lot of that help came from family as well as friends he met playing disc golf, a sport he picked up during the pandemic.

    “A bunch of people came through for us,” Wasney said, still moved to tears by the generosity. “But there’s still the hospital bill.”

    The Takeaway: Billing practices differ by cruise line, but Joe Scott, chair of the cruise ship medicine section of the American College of Emergency Physicians, said medical charges are typically added to a cruise passenger’s onboard account, which must be paid before leaving the ship. Individuals can then submit receipts to their insurers for possible reimbursement.

    More from Bill of the Month

    More from the series

    He recommended that those planning to take a cruise purchase travel insurance that specifically covers their trips. “This will facilitate reimbursement if they do incur charges and potentially cover a costly medical evacuation if needed,” Scott said.

    Royal Caribbean suggests that passengers who receive onboard care submit their paid bills to their health insurer for possible reimbursement. Many health plans do not cover medical services received on cruise ships, however. Medicare will sometimes cover medically necessary health care services on cruise ships, but not if the ship is more than six hours away from a U.S. port.

    Travel insurance can be designed to address lots of out-of-town mishaps, like lost baggage or even transportation and lodging for a loved one to visit if a traveler is hospitalized.

    Travel medical insurance, as well as plans that offer “emergency evacuation and repatriation,” are two types that can specifically assist with medical emergencies. Such plans can be purchased individually. Credit cards may offer travel medical insurance among their benefits, as well.

    But travel insurance plans come with limitations. For instance, they may not cover care associated with preexisting conditions or what the plans consider “risky” activities, such as rock climbing. Some plans also require that travelers file first with their primary health insurance before seeking reimbursement from travel insurance.

    As with other insurance, be sure to read the fine print and understand how reimbursement works.

    Wasney said that’s what they plan to do before their next Royal Caribbean cruise. They’d like to go back to the Bahamas on basically the same trip, he said — there’s a lot about CocoCay they didn’t get to explore.

    Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

    Subscribe to KFF Health News’ free Morning Briefing.

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