The Dramatic Arrival of Health-Oriented Drug Policy

Health care for addiction in the United States has been forever transformed by three new pieces of legislation

Given how often some people demand “health-oriented drug policy” from the Obama Administration it is more than a little peculiar how one of the biggest reforms in history didn’t attract more attention and draw more praise in the blogosphere. With the Administration’s declaration that treatment of mental health and substance use disorders are essential health care benefits, to be provided not only in the state health insurance exchanges but in all new individual and small-market health insurance plans, over 60 million Americans just got better insurance coverage for these disorders. The graphic below is from HHS:

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That isn’t the end of the good news. The more than 100 million Americans who receive coverage under large-group plans are also getting better coverage due to the Mental Health Parity and Addiction Equity Act. Passed in the waning days of the G.W. Bush Administration with the regulations being written by the Obama Administration, the law mandates that any offered benefits for addiction and mental health must be comparable to those offered for other conditions.

But wait there’s more: Medicare, which enrolls almost 50 million people, has long had inferior coverage for addiction and mental health outpatient care, reimbursing only 50% of costs versus 80% of those for other forms of medical care. Thanks to a provision in the 2008 Medicare Improvements for Patients and Providers Act (again, give it up for the 110th Congress and President Bush), this disparity in reimbursement is being phased out and will be entirely eliminated by January 1 of next year.

When you consider that addictions almost always evidence themselves in adolescence or early adulthood, it becomes clear that the ACA provision allowing parents to keep children on their insurance until age 26 adds yet another layer of protection for the population.

Some people of course have coverage from more than one of the above sources, but even granting that overlap, over 200 million Americans have gotten improved insurance coverage for treatment of drug and alcohol problems (and mental health disorders as well). This includes many people who were starting with nothing, as well as a large population that had a benefit of inferior quality.

This is the biggest expansion to access to care for addiction in at least 40 years and probably in American history. In financial terms, it is certainly the biggest commitment of public and private resources to the health care of people with substance use disorders in U.S. History. Congratulations are in order to countless grassroots advocates, civil servants, political appointees, members of Congress and two U.S. President for transforming the face of health care for addiction.

Cigarettes kill no one

Stupid, right? “Cannabis kills no one” isn’t much better.

There! Can you imagine a more obviously stupid claim? Cigarettes kill about 400,000 people per year in the U.S. alone, and tens of millions more worldwide.

But, so far as I know, it is not physiologically possible to absorb a fatal dose of nicotine by smoking. Nicotine can be lethal if swallowed or injected, but a cigarette contains perhaps 2% of the median lethal dose. There are no published reports of acute fatal overdose from cigarette smoking. When smoking kills, it does so through chronic disease.

Acute alcohol poisoning is the primary cause of about 400 deaths per year and a contributing cause in another 1000 (mostly overdoses of other drugs). That’s out of about 100,000 total alcohol-related deaths, the rest being from chronic disease, accident, suicide, and crime.

So if we looked at acute overdoses alone, we would miss all of the lethality of cigarettes and about 99% of the lethality of alcohol.

That’s why its so outrageous to for Andrew Sullivan to post a headline reading “Cannabis kills no one.”
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Paternalism and pot policy

Legalizing drugs tempts people into drug abuse. Banning them tempts people with drug dealing.

Andrew Sullivan points to arguments by Rod Dreher and David Frum that cannabis legalization would benefit mostly middle-class moderate users at the expense of mostly poor heavy users.

Sullivan is horrified by the frank paternalism involved, but horror isn’t a criticism, and he’s wrong to attribute to Frum and Dreher the notion that “all American adults are basically children that we have to protect from their own choices.” What Frum and Dreher are saying is that some Americans – many of them minors – are indeed in need of protection from their own bad choices. (Dreher is especially clear-minded in pointing out that the need for paternalistic protection varies not just from person to person but from choice to choice: lots of people are capable of managing their diets but not their retirement financial planning. I, for example, want paternalistic protection against being sold adulterated drugs or contaminated food.) There’s no logical flaw in the idea that more-liberal policies in a variety of domains might serve the interests of those better-placed to make good choices at the expense of those worse-placed.

That said, it seems to me that Frum and Dreher do only half of the analysis. They consider the consumer side of the drug market (even then, ignoring the costs inflicted, mostly on poor folks, by 800,000 possession arrests per year), but not the producer side.
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Marijuana Policy and Traditional Liberalism

Former Congressman Patrick Kennedy, a long-time advocate for people with addiction and mental illness, is leading a new group calling for a different approach to marijuana policy.

Smart Approaches to Marijuana will advocate for alternatives to incarceration, expanded mental health and addiction treatment and the provision of non-smoked cannabis medicines to sick patients (without waiting for FDA approval) at taxpayer expense.

It will also oppose legalization, not wanting a Big Tobacco-like industry in the marijuana sphere.

From the viewpoint of traditional liberalism, which Patrick and his family have championed as well as anyone in my lifetime, this is the logical policy mix (see Adam Serwer in the same vein). Curbing incarceration and using the power of government to aid the sick are honorable pillars of American liberalism. Entrusting public health to corporations in contrast is both naive and much more in line with a libertarian/pro-business conservative mindset.

UPDATE: Comments are back on, thanks to Steve or whoever fixed that. I have re-titled the post to better reflect its content, our blogging interface has been chronically broken and frustrating lately but an upgrade is just around the corner.

Marijuana: The Most-Debated, Least-Important Illegal Drug

By most measures the majority of the drug problem in both the US and Mexico does not relate to marijuana, so nothing you’re going to do with marijuana is very likely to decisively change the character of the overall drug policy situation

So says Professor Jonathan Caulkins in Randolph Nogel’s unusually nuanced article on the potential impact of US marijuana policy on Mexico. What Jon is saying will surprise many people, but he’s quite correct. Marijuana gets outsized attention in US drug policy debates, yet it matters at most slightly for the security of Mexico (and not at all for Central and South America). Domestically, it does not contribute to overdose deaths nor account for even 1% of imprisonments. But its status as a culture war symbol — particularly for baby boomers — will keep it in the forefront of popular debate even as concern over cocaine, methamphetamine and heroin wanes.

Cannabis and alcohol (reprise)

Comparing pot to booze is beside the point; the question is how one influences the other.

David Frum and I agree that “But something else is even worse than X!” is not a good reason to ignore the X problem: autos kill more people than guns, but we should still try to reduce the number of people killed with guns. And the fact that alcohol is a much nastier drug than cannabis, both physiologically and behaviorally, doesn’t make cannabis abuse either rare or benign.

But Point #13 in the post Frum links to wasn’t about the comparison between cannabis and alcohol; it was about the causal connection between cannabis policy and alcohol abuse. As Frum notes, alcohol use and cannabis use are now positively correlated. But that doesn’t tell you anything conclusive about whether making cannabis legally available would increase or decrease heavy drinking.

In my view, an increase of as little as 10% in heavy drinking would wipe out any benefits from cannabis legalization, including the benefit in the form of fewer arrests because of the additional crime that would go along with the additional heavy drinking. Frum is aware of that possibility.

But he ignores the opposite possibility, equally plausible in terms of both logic and evidence. Continue reading “Cannabis and alcohol (reprise)”

Thirteen theses on cannabis policy

A few facts, and many unknowns, for Frum, Riggs, and Sullivan to chew on (or smoke).

Rather than getting into the cultural or media criticism of the FrumRiggsFrumSullivan fracas over cannabis policy, perhaps it makes more sense to try to separate out the knowns and identify the unknowns. Experts on the question see open questions where passionate amateurs are most dogmatic about the answers.

1. Cannabis dependency is rarely as bad as severe alcoholism, but it can be plenty bad enough, and it isn’t very rare, especially among those who start – as most users now do – in their middle teens. (A sixteeen-year-old who goes beyond experimentation has about one chance in six of winding up a heavy daily user for a period of months or years.)

2. Most users – and even many frequent users – don’t go on to diagnosable abuse or dependency. There is little evidence of lasting damage from use that isn’t both heavy and chronic. It would be a mistake to attribute all of the suffering of even the heavy, chronic users to cannabis, as opposed to the social circumstances and personal traits that lead them to acquire and maintain the habit. But it would be equally a mistake to ignore their self-reports that cannabis is a source of trouble in their lives.

3. For the non-abusing majority of users, cannabis is a fairly harmless pleasure. For some of them, cannabis use lastingly enhances their lives by broadening their range of experience, deepening their appreciation of the arts, and enhancing their creativity by teaching them a new way of thinking. Very little is known about these phenomena in any systematic way, partly because the science is hard and partly because of the constraints and incentives that influence research.
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How Substitutable are Marijuana Possession Arrests?

Many times in the history of the United States, rising prevalence of use of a drug has been responded to with increased arrests of people in possession of that drug. As Peter Reuter and Rob MacCoun pointed out some years ago, this makes the rise of marijuana possession arrests in the U.S. particularly puzzling: The rate of marijuana use was historically low and stable prior to the growth of arrests.

The trend began in the 1990s and has continued to the present day. It has been almost entirely an urban phenomenon, with the best example being New York City (For a wonderful series of charts on NYC’s arrest patterns, see this piece by Michael Keller).

No informed observer seems to believe that this rise in arrests resulted from heightened concern about marijuana use per se. Rather the explanations invoked range from the arrests being a side effect of stop-and-frisk policing, to them being a way for those police who are racially prejudiced to hassle people of colour, to them being a tactic to punish malefactors who have gotten away with something worse (e.g., someone who has repeatedly beaten a spouse who is too afraid to testify against the perpetrator). Some people are sure they know the explanation with absolute certitude, but if like me you admit the possibilities of your own ignorance and life’s complexity, please read on. Continue reading “How Substitutable are Marijuana Possession Arrests?”

Marijuana Prices in California

Following our debates here about the price of marijuana, I thought I would flag for people’s interest this piece by Michael Montgomery.

His reporting indicates that after dropping lower than $1,000 pound ($62.50/ounce), Northern California prices for the latest harvest have now rebounded to $2,000-$2,500 a pound ($125-$156/ounce).

I suspect normal market forces, bad weather and mold drove most of the change. The article suggests that law enforcement was influential as well by leading some growers to cut back on their crop. Possible, but it also led some dispensaries to close, which would have the opposite effect on prices (i.e., fewer dispensaries chasing grown crop would lower prices).

Upmarket Versus Downmarket Marijuana Prices: A Response to Andrew Sullivan et al.

I recently presented a series of DIY calculations for determining the size of the U.S. marijuana market. This post got a lot of play around the web, most notably from Andrew Sullivan, who again did me the kindness of adding his millions of regular readers to my regular readers (both of them). A number of commenters at his site, RBC and other web outlets (e.g., Washington Monthly) jumped on my estimate that the average price of marijuana was $120-$144/ounce (i.e., $120 with an upward sensitivity of 20%). Across the comments I read of those people who reported their marijuana purchasing experiences, the average price quoted was $425/ounce.

How does one account for the price estimate generated in this fashion being so much higher than, for example, reports from Oregon that indoor-grown marijuana prices are as low as $2000/pound ($125 per ounce) and prices for outdoor grown weed are as low as $700/pound ($44 per ounce)? Or the reports of law enforcement officials (who are often accused of overstating the cash value of drug seizures) from South Texas showing that marijuana prices have plummeted to $540/kilogram ($15/ounce)? Are some people fibbing or simply wildly off-base? In my view, no. All have won and all must have prizes because of the bifurcated nature of the markets for many drugs, including marijuana.

In the early 1980s, I was working with drug addicted people on the mean streets of Detroit, which were very mean indeed in those days. The mainstream media at the time and my middle class friends saw cocaine as a glamorous drug consumed by bankers and movie stars at prices upwards of $100/dose. My daily experience however was that cocaine was becoming an unglamorous drug (crack) purchased at $5/dose or less by streetwalkers, homeless people, gangbangers, and housing projects residents. Had the Internet of today existed then and I had posted that the average price of a dose of cocaine in the U.S. was very low, I would no doubt have been inundated with people saying (to paraphrase a commenter on my marijuana market post) “if Humphreys knew a place where cocaine sold for $5/dose, the world would beat a path to his door”.

But what I was seeing in Detroit was real, namely the emergence of a “downmarket” in cocaine. The “upmarket” was also real and was mainly composed of casual users who bought high-quality product. They paid high prices and often purchased their drug with bundled services (e.g., home delivery). The “downmarket” was mainly composed of heavy users who bought low-quality product at cheap prices. The upmarket was mostly Caucasian in racial makeup, with good social capital (e.g. college education, employment). The downmarket was mainly composed of lower-income people of color. The upmarket was not just rich people; it included many middle class and some working class people. But the downmarket was overwhelmingly composed of people living in poverty (with a few cross-overs now and then).

All of what I have said about the cocaine market in the 1980s could be said about the bifurcated market in marijuana today. And that makes assessment of average marijuana prices a challenging task.

At first blush, determining the true average price of a drug across a bifurcated market might seem as simple as summing the upmarket and downmarket price and dividing by two. But this is not correct because the frequency of use and drug purchasing are much higher in the downmarket, meaning that the cheap price must be weighted much more heavily than the high-end price when determining the average national price. For marijuana, a good survey for determining average national price would require a sample in which about 80% of the marijuana purchasers live in or near poverty, and the other 20% of purchasers were financially better off.

This of course is not the sort of sample breakdown you will get on the Internet. Internet users clearly “skew upmarket“: They are more educated, have higher incomes, are more likely to be employed and are more likely to be Caucasian than is the U.S. population as whole. Although I don’t have any data on the characteristics of Internet users who read Andrew Sullivan and debate public policy with Stanford University professors, I feel safe in assuming that if anything they are even higher in education and income than is the average Internet user. Finally, to the extent that online contributions to marijuana price estimates come from websites and groups advocating marijuana legalization, this is yet another layer of upmarket bias as those sentiments are strongest among white, highly-educated and affluent people. All of the above factors combined would led us to expect that the comments about my original post would very much reflect an upmarket perspective, as indeed they do.

By and large, the various comments quote prices for an upmarket product, namely sensimilla, which is only about a fifth of the marijuana market (the rest is much cheaper commercial grade product, most of which comes from Mexico). The comments often reflect the upmarket phenomenon of service bundling, e.g., “At my dispensary in San Francisco”. If you live in a public housing project in Dallas and the local drug dealer comes to his door when you knock and hands you a half pound of marijuana in a garbage bag for $300, the price truly reflects the price of the drug. But at a dispensary, with a physical location that you enter, staff on hand and an elaborate system to reduce your perceived risk of arrest (i.e., the doctor’s recommendation), you are buying marijuana bundled with other services and the “price of weed” you pay is in fact only partly the weed.

Let me illustrate the upmarket perspective concretely using two of the many posted comments:

From one of Andrew Sullivan’s readers: I have never encountered decent quality marijuana for less than $200/ounce in the western US.

From a Washington Monthly reader: I’ve been a user since ’68 and nearly everyone I know is a user. Not abusers but users. From my experience, the avg. couple uses daily, usually after work in the evening aka a glass of wine etc. Most couples will average 1-2 oz/month, especially upper income users of which there are many.

The world these two comments describe — the upmarket — is real, but is a small part of the total marijuana market. Sullivan’s reader insists on “decent quality” which is not generally a consideration for marijuana smokers in the downmarket. And the pot smokers described by the Washington Monthly commenter are not the people who do most of the purchasing; lower income people who smoke all day almost every day complete far more transactions and thus influence average prices far more. These two comments and others like them reflect a reality as surely as did Pauline Kael’s alleged remark that she didn’t know anyone who voted for President Nixon in 1972. But Nixon won a landslide for the same reason that the average price of pot in the U.S. is far cheaper than $425/ounce: The experience of a selected part of the population can be extremely different from the experience of the whole.