Cannabis legalization: not whether, but how

The New York Times comes out for cannabis legalization.

David Frum is still against it.

Neither deals seriously with the balance of advantage and disadvantage; the Times simply blows off the question of substance use disorder and pretends that passing a law forbidding sales to minors takes care of the problem of increased use by minors, while Frum never mentions the damage done by the $40-billion-per-year illicit market created by cannabis prohibition and proposes nothing that would shrink that market.

And neither the Times editorial board nor David Frum seems interested in the question of how to legalize, as opposed to whether to legalize. The Times doesn’t notice that commercialization is only one approach to legal availability, and arguably not the best; Frum simply dismisses a temperate approach to legalization as politically unworkable, without explaining how to make his kinder, gentler prohibition a political winner.

Alas, I sometimes suspect they’re both right. As a matter of practical politics, our only choices may be a badly-implemented prohibition or a badly-implemented legalization.  (If so, I’m inclined to try the Devil I don’t know.)  So far, my attempts to put political and organizational muscle behind the idea of smart legalization have merely illustrated the wisdom of Ralph Yarborough’s maxim, “They ain’t nuthin’ in the middle of the road but yaller lines and dead admadillas.”  I don’t find life as political roadkill especially uncomfortable, but it does get frustrating. It’s not just that continued prohibition and commercial legalization are both bad ideas; it’s that the arguments for those two bad ideas leave no media space, or mindspace, for discussion of the good ideas that might lie between them.

Footnote Ann Althouse does a good demolition job on the Times editorial, though to the best of my knowledge there’s no evidence of intoxication or health damage from second-hand cannabis smoke or vapor.

The Enduring Myth of “Killer Heroin”

I was at a meeting with the Australian drug addiction researcher Shane Darke last week, which gave me the chance to congratulate him for publically predicting correctly that Philip Seymour Hoffman’s autopsy would show that the actor’s tragic overdose death was due to a combination of drugs and not an unusually strong or contaminated batch of heroin.

I talked with Harold Pollack recently about how careful research on overdoses destroyed my prior belief in “killer heroin” hype:

There’s a very nice paper just out by Professors Shane Darke and Michael Farrell, who are two of the world’s leading experts on the topic…toxicology studies of overdosed people very rarely find that impurities played an important role…victims didn’t particularly receive high doses, either. Such findings surprised me. The fact that we’ve got 16,000 people a year dying from pure, legally-manufactured opiate analgesics shows you that it’s really not about the unpredictability of illegal markets, it’s about the drugs per se.

The killer heroin/impure heroin narrative sounds plausible on its face, but the data completely undermine it. Data notwithstanding, here it is again from Isaac Campos in a recent article by German Lopez.

The most dangerous thing about taking heroin right now is you don’t know what you’re really taking. You don’t know how pure it is, which makes it very easy to overdose,” Campos says

I can’t be judgmental of Campos as I would have said the same thing, with confidence, at one point (particularly before the nation was flooded with pure, consistent, labeled opioids like Oxycodone and the result was…an overdose epidemic). But I would respectfully ask him and everyone else to look at the data on overdoses and have a rethink. Successfully tackling the overdose crisis — which is now causing almost as many deaths in the U.S. a year as AIDS did at its peak — will not be facilitated by incorrect assumptions about the nature of the problem.

Three Ways of Looking at Marijuana Consumption Data

Here’s a nice chart from Andrew Sullivan on marijuana consumption in Colorado. It illustrates a point that has been made many times by drug policy analysts such as Mark Kleiman and Beau Kilmer: The total volume of pot consumption is accounted for almost entirely by users who smoke every day or nearly every day. Envisioning how different stakeholders would respond to this evidence can be helpful both for appreciating the impossibility of value-free evidence-based policy and for understanding one of the basic dilemmas of legal marijuana regulation.

colorado

AT THE PUBLIC HEALTH CONFERENCE: “Colleagues, you can see from this chart that not all marijuana users are of equal concern to us. Some people use the drug rarely, and we know that such users tend to be high social capital individuals who could set their lives right in the unlikely event that they did develop a drug problem. So we should focus instead on these heavy users in the bottom two bars of the chart, who tend not incidentally to be people with less education, less income and poorer access to health care. The evidence we have shows that the primary risks of this drug, for example marijuana dependence, mental health problems and poor school and work performance, are concentrated in the subset of people who use every day or almost every day. Let us therefore resolve to keep the size of this group as small as possible through high taxes that discourage heavy consumption, caps on THC content that reduce the ability of the drug to promote dependence and limits on advertising and points of sale in vulnerable communities.”

AT THE CORPORATE BOARD MEETING: “Well friends, you can see from this chart that not all of our customers are of equal concern to us. We can’t make much money from the people in the top few bars of the chart, so we should focus mainly on the heavy users who provide us the bulk of our revenue. We need to move as much of the population as possible into this high-revenue bracket. So let’s all agree to press for lower taxes, higher THC content and as much advertising and as many retail locations as possible in the communities where our best customers tend to live.”

AT THE STATE LEGISLATURE: “Fellow committee members, as you know we have seen this chart twice today, once when the public health advocates visited and again when the marijuana industry lobbyists visited. Both groups agreed on the evidence but they wanted us to respond to it in opposite ways. And that’s not the end of what we have to consider. The state budget analyst’s office has calculated that almost 90% of the marijuana tax revenue we wanted from legalization comes from the people in the bottom bars of this chart. We care about public health but if we implement policies that make too many of those heavy marijuana users quit, the tax revenue hit we will take might force us to sacrifice other important priorities.”

Into Thin Air

Much has been made about the surge in the use of electronic cigarettes but what might be overlooked are the health effects that low-end electronic cigarettes have on its customers compared to that of the higher grade. With no quality assurance for any electronic smoking device, those who can only use the “economical” types of e cigarettes may be opening themselves up to additional health detriments though poor e cigarette construction.

The low end of the e cig market is filled with disposable products that costs anywhere from five to ten dollars, unsurprisingly these products are sold in lower income neighborhoods. Scientists at the University of California Riverside tested a “lower end” e cigarette model as well as a mid-range brand known as “Mistic”, both bought from a San Diego drug store. During the tests the liquid (or “juice) that is inside the e cig is heated and put inside a centrifuge and spun. The end product of the cheap brand, known as “Smoking Everywhere Platinum”, was a pellet that contained mostly tin, with trace amounts of some nickel and copper. Cheaper e cigarette devices may be prone to releasing metals during use due to the tin soldering coming off of the casing, a result of the cheap construction of the cartridge. The Mistic brand e cig had trace amounts of copper and no amounts of tin found due to no solders being used in the product, something common with higher end e cigs. Regulated manufacturing is inherently more expensive, but the switch to a standard set of rules for e cigarette production could lead to reduced instances of metal inhalation for those who cannot afford higher end e cigs.

The people being exposed to harmful e cigarettes are the same who are exposed to the lower end of actual cigarettes: poor minorities. Though the hold that cigarettes have on low income populations remains in a death grip e cigarette use is on the rise and much like cigarettes that are made on the cheap, e cigarettes made for as little money as possible carry inherently worse risks than those made with the consumer in mind. Lack of regulation in the electronic cigarette market allows bargain brands to pump out cheaply constructed disposable e cigs that open up lower income users to health problems from metal inhalation and nicotine poisoning, a greater push for regulation needs to come in order for lower income users to be as safe as their higher end e cigarette smoking counterparts.

Swift, Certain and Fair Consequences for Substance-Involved Offenders in the UK

I am grateful to Policy Exchange for arranging this recent event about how to improve community supervision of criminal offenders who have problems with alcohol and other drugs. The host, Max Chambers, has since ascended into Number 10, which is a good sign that criminal justice reform is of interest at the highest levels of the UK government.

News Chew

Any platform where a company can engage directly with potential customers is obviously a powerful tool to be harnessed; a healthy social media presence is important for the success of most businesses. When you work in regulated markets like pharmaceuticals or alcohol, engaging with a potential customer base can get a little tricky, especially where “tricky” means harmful and expensive. Let’s agree that this is also your working definition of “risk”.

It would be hard to argue that a company’s social media presence is anything besides a more dynamic outlet for advertising. For regulated markets, mitigating risk even when advertising in “traditional” platforms like print and TV gets a bit lumpy (e.g. the pretty ad with a lady enjoying a tire swing has to be that much more appealing to allay the turn-off of a full page of micro print describing risks and side effects), but the rules and implications around use of social media is fuzzier, so those risks can grow.

Enter Reg-SM, a new launch from the social-media marketing agency, Attention. Reg-SM specializes in helping businesses in those regulated markets use social and mobile media in ways that are legally compliant.

Just in time, it seems, as last week the FDA proposed new guidelines for companies who post about their drugs or medical devices on social media platforms. The guidelines would require that any tweet or post or unit of social media speech (air quotes optional) promoting a drug or medical device to include the product’s risks and adverse side effects. It’s hard for me to imagine a worthwhile tweet about a prescription drug anyway, but to jam anything but the risks of a drug into a tweet seems impossible.

Always helpful, the FDA has offered a sample tweet for a fictional drug that sounds kind of attractive to me.

NoFocus (rememberine HCl) for mild to moderate memory loss-May cause seizures in patients with a seizure disorder www.nofocus.com/risk

Sign me up, I guess. Quick aside, though: how odd for a drug to be named after not the affliction (still weird), but the cause of the affliction the drug is meant to address. When I have a headache I reach for my bottle of JawClenchesWhenSleepDeprived.

These new guidelines are going to make it very difficult for companies to tweet about their products.  The FDA’s NoFocus conveniently has only one risk to list, but even relatively safe drugs often have a number of possible side effects and risks. While I’m not sad about maybe never seeing a tweet about Viagra, these guidelines don’t seem to demonstrate a working knowledge of the platform.

Possibly more quietly impactful, the guidelines also prohibit a company from curating discussions on it’s own website by adding positive reviews and taking down negative ones.

Understanding a Global Illicit Drug Market

Iraq tobacco
In the souq of a small Iraqi town, I saw bags of tobacco leaf for sale. But the real attraction for customers was a booth stocked with well-known Western brands, of which I snapped this photo.

How did all these branded cigarettes make their way from the West to Iraq? They didn’t. They are among the more than one hundred billion fake Western brand cigarettes produced each year for the black market. What are the dynamics of the global tobacco black market, and what are its implications for public health, crime and taxation collection?

I answer these questions in my latest piece at Washington Post’s Wonkblog.

HRC talks to CNN about MJ

A CNN interviewer asked Hillary Clinton about cannabis policy.

On medical use, she replied that we need more research, including research about drug interactions, but in the meantime people with serious medical conditions where there’s “anecdotal evidence” of efficacy ought to have access.

On non-medical (“recreational”) use, she said that the states are the laboratories of democracy, that two states are trying legalization, and that we should wait and see how that goes.

Perfectly reasonable answers, as far as they went, and perhaps a little bit more pro-cannabis than I might have expected from such a cautious candidate.

But they cried out for follow-up questions:

1. As President, what would you do to promote medical research on cannabis and cannabinoids? Would you tear down the barriers to research now created by federal policy: in particular, the UMiss monopoly on cannabis for research purposes and the requirement that every study receive a “grant” of cannabis from a special committee within HHS?

2. While the states are doing their experiments, to what extent should the federal government help, or at least get out of the way? Colorado and Washington are now issuing state licenses to commit federal felonies. Current banking regulations make it difficult-to-impossible for cannabis stores to have bank accounts or to take credit cards, creating a huge all-cash business that is therefore an attractive robbery target. A state that wanted to experiment with state-monopoly retailing (arguably the best approach) would currently be barred from doing so by federal law. As President, would you propose changes in the Controlled Substances Act to make state-level experiments legal?

Instead, of course, the CNN interviewer asked her whether she intended to inhale. Arrrgggghhhhhh!

How long is it going to take for the press corps to stop giggling about cannabis policy and start reporting on it?

A dispensary operator speaks out on “medical marijuana” and Americans for Safe Access

My post about Americans for Safe Access drew the expected outraged response from its target, but it also drew an unexpected note from someone I hadn’t met before, Muraco Kyashna-tocha, who runs the Green Buddha Patient Co-Op in Seattle. With her permission, I’m posting it here.

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I am the anthropologist who runs the state of Washington’s oldest medical cannabis collective. I loved your wonderful blog post on ASA. Actually, I have really enjoyed all your writings for the last year plus. You hit the nail on the head!

I made sure to pass your recent blog to Senator Jeanne Kohl-Welles who I expect to write a bill for submission early next year which will regulate medical cannabis and align the two systems into the I502 system. I have been a strong supporter of this, as well as an open strong supporter of I502.

Odd position, you might think, for a dispensary, but we’ve been trying to hold the line and deal with only authentic patients, the ones the media sees – the ones with cancer, MS etc. They aren’t easy to find among all the riff-raff.  Half my clients are cancer patients who have found the “medical marijuana” explosion frightening, and they don’t tend to find themselves nor the products they really need in the current medical cannabis scene.Sincere patients are few and far between.

ASA has been a nightmare for my state. They rally “patients” – collecting their funds from those selling the medicine to those patients. Early this year they worked against all reasonable attempts to get mmj regulated. They spoke constantly to the media about “safe access” which is a euphemism and rallying cry for “Save the dispensaries.”

Dispensaries do not need saving in Washington State (as I have said frequently at hearings in Olympia) – even as patients’ rights do need securing – affirmative defense, arrest protection, small home grow allowance, etc.

I see ASA willing to throw out patients’ rights in order to secure legal dispensaries for the real folks they speak for. I feel like I bang my head against the wall all the time, so I loved this line:

accuses ASA of “relentlessly talk(ing) about the interests of patients while single-mindedly serving the interests of the sellers.

You are correct – this is what ASA does. Green Buddha looks forward to closing very shortly. (Gawd, please will the stores open and can we get serious about licensing producers? We’re at 50 as of last Tuesday)

Green Buddha is the last of the original collectives. We have no paid employees. We’re all volunteer. Average age of our patients is my age, 56.

I view ASA as one of the major impediments to my state rewriting its mmj laws and regulating the system – align it with I502. Stay the course and keep pounding on them.