Does cannabis availability help prevent opioid overdoses?

There’s been lots of chatter about the cannabis-opioid substitution question.

Newsweek headlines, “Can Legal Marijuana Solve the Opioid Crisis?”  while Dr. Jeff Sessions opines that cannabis is “only slightly less awful” than heroin.

People whose background is medical research tend to distrust anything that’s not a randomized controlled trial. They point to the positive correlation between cannabis use and opioid use at the individual level, and the fact that opioid deaths continue to rise even where cannabis is most freely available. Their position is, “We don’t know anything about this. Let’s due the clinical studies before taking action.”

But “not taking action” now means continuing to criminalize even the possession of cannabis. If cannabis substitutes for opioids, those laws cost lives: lives that can’t be regained ten years from now, after the clinical-trial results are in.

Moreover, the relevant clinical trials can’t actually be done in the U.S. Continue reading “Does cannabis availability help prevent opioid overdoses?”

The medical value of cannabis and the fraud of “medical marijuana”

Cannabis has medical value, but “blow some weed” is not a prescription.

Of course cannabis has medical value; the FDA has approved pure THC as a pharmaceutical, and the cannabidiol in whole cannabis has its own therapeutic applications and also protects against some side effects of THC. So denying that natural cannabis has medical value is nonsensical.

But equally of course, the variation in natural cannabis means that “marijuana” isn’t the name of a medicine; a medicine is a material of known chemical composition that has been shown in clinical trials to be safe and effective in the management of some condition in some group of patients.

Some sick people get relief from whole cannabis, but “medical marijuana” is a political fraud, and the “medical marijuana” business is mostly a sham, with most of the volume going to non-medical users – many of them with diagnosable cannabis use disorder – and resellers.

Footnote In a Twitter exchange, MPP lobbyist Dan Riffle doesn’t deny the facts, but seems to prefer that I use some euphemism for “fraud.”

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

Don’t believe me about the “medical marijuana” lobby? Ask the founder of Seattle’s oldest dispensary.

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.

****
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.

 

Lies, damned lies, and “medical” marijuana

Industry lobbyists lie.
That includes the “medical marijuana” industry.

The “medical marijuana” business – which in practice gets most of its revenues from non-medical users and from buyers intending to resell illegally, including those who resell to minors – now grosses more than $1 billion per year nationwide. Of course, every billion-dollar industry needs a lobbying group, and the green-cross crowd has one: Americans for Safe Access, which relentlessly talks about the interests of patients while single-mindedly serving the interests of the sellers.  (Like most of the rest of the “drug policy reform” movement – with the exception of MAPS (Update: and CA Norml) – ASA has yet to spend a nickel on medical research or safety studies; everything goes to campaigning, litigating, and lobbying.)

And, since no trade association is complete without dishonest 30-second political ads, ASA has decided to celebrate the passage in the House of the Rohrbacher amendment – designed to protect medical-marijuana sellers (in states where it’s legal) from federal enforcement – by grossly slandering some Congresscritters who voted against the amendment. Here’s the attack on Andy Harris of Maryland.

As the image of a four-year-old and his mother come on the screen, he voice-over says, “Why would Congressman Harris vote to send patients like this to prison?”

Why, indeed?

Continue reading “Lies, damned lies, and “medical” marijuana”

Washington State Court of Appeals bans medical marijuana stores

Never a dull moment.

I completely failed to see this one coming.

A brief history lesson:

Washington State has had a medical marijuana law since 1998. In 2011, the legislature passed a bill allowing the creation of “collective gardens” (aka stores) to grow cannabis for patients registered with the state, and regulating those outlets in various ways: all members of the collectives would have had to register with the state. The governor used her line-item veto to take out major provisions of that bill, including the part that would have created the patient registry.

Until now, the prevailing view has been that the permission to open stores was valid law even though the regulations designed to control them had been zapped, leaving Washington with a booming, and virtually unregulated and untaxed, medical cannabis industry; as everyone says, Seattle has more “medical outlets” than it does Starbucks locations. Some players in that industry were among the strongest opponents of the I-502 initiative that legalized non-medical sales.

Once I-502 had passed, its proponents and administrators started to worry about how a regulated and taxed commercial market could compete with a wide-open, but untaxed and unregulated, quasi-medical system. There were efforts in the legislature this year to rein in the “gardens,” but the industry (speaking, of course, in the name of “the patients”) and a partisan split in the legislature made it impossible to pass anything. Battle was expected to be joined again in January, with the threat of federal intervention lurking in the background.

In the meantime, the town of Kent had passed a local ordinance banning medical outlets. Various industry players sued, citing what was left of the 2011 law. But now the Washington State Court of Appeals (the second-tier court) has ruled that the governor’s partial veto makes all the collective gardens illegal, because a legal collective garden must serve registered patients and there is no patient registry. Therefore, Kent is at liberty to ban what was – according to the court – an illegal activity in the first place. All that’s left of the medical marijuana law is permission for individuals with medical recommendations to grow their own: if charged with a violation of state law for production or possession (but not, apparently, sale), a medical recommendation creates an affirmative defense.

Presumably most of the localities that have collective gardens, including Seattle, will continue to let them operate, especially since the commercial outlets won’t even start to open until sometime around the end of June or early July.

There may be an additional layer of complexity: the Liquor Board planned to allow newly-licensed growers to bring some of their existing cannabis plants into the legal system, since otherwise there would be nothing for the new stores to sell. If newly-licensed growers have to grow new product from seed starting late this spring, the shelves will be bare until fall at the earliest.  Whether the new ruling puts a monkey-wrench in that machinery remains to be seen, as does the effect of the ruling on the bargaining over a new law next year. (Or will the governor call the legislature into special session to give it another try this year?)

Never a dull moment.

 

Cannabis law and policy

No, Holder is not acting “lawlessly” by accomodating legal pot in CO and WA, or by keeping pot in Schedule I.

Bloomberg just posted my essay about  the federal response to cannabis legalization in Colorado and Washington State and about the “rescheduling” issue, both of which have been the subject of rather confused debate.

Short version: No, the law doesn’t require the feds to shut down the Colorado and Washington State initiatives, and “rescheduling” cannabis would be a mostly pointless exercise; it’s much more important to remove bureaucratic barriers to medical research.

That essay doesn’t include one item on which the discussion has been especially confused: the claim that the President, by himself, has the power to reschedule. In fact, the Controlled Substances Act gives that power to the Attorney General, and requires that the AG get medical advice from the Secretary of HHS and take that advice as authoritative.  The AG has delegated his responsibility to the DEA Administrator, and the HHS secretary has delegated hers to the Assitant Secretary for Health.

Those powers are not arbitrary:  the law says that rescheduling requires an “accepted medical use,” and the courts have held that to mean the satisfaction of each of five criteria:

                        a.    the drug’s chemistry is known and reproducible;

                        b.    there are adequate safety studies;

                        c.    there are adequate and well-controlled studies proving efficacy;

                        d.    the drug is accepted by qualified experts; and

                        e.    the scientific evidence is widely available.

[Alliance for Cannabis Therapeutics v. DEA, 15 F.3d 1131, 1135 (D.C. Cir. 1994)]

Arguably, the AG and HHS Secretary could decide to change that legal standard; the courts, having deferred to administrative discretion in the earlier case, might do so again. But it’s not as simple as someone saying, “Gee, I’d like to reschedule cannabis this morning.” And though the President appoints the officials in question and can fire them, the power under the law does not belong to the President.

Moreover, the law explicitly requires that any substance covered by the international drug conventions – which marijuana is – be controlled, regardless of any other factors. Thus the Executive Branch as a whole lacks the power to remove cannabis from the CSA entirely.

Since Jacob Sullum and his friends get their feelings terribly hurt when I point out that he’s talking through his hat, and since I purely hate hurting people’s feelings, I won’t mention him here. That will save him the effort of once again misrepresenting not only the law but what I said about the law, and about his misunderstanding of it.   But the next time he decides to accuse the President – who in real life was a law professor – of not having read the law, perhaps Sullum will consider … reading the law.

Footnote Eighteen members of Congress seem to share this misundestanding, which Americans for Safe Access – the lobby for the medical-marijuana industry – is doing its best to promote.

 

 

 

Futile pursuits: chasing rainbows and rescheduling cannabis

Rescheduling cannabis wouldn’t accomplish anything: the key is to get the feds out of the way of research.

The discussion of “rescheduling” marijuana is confused because most of the people engaged in it don’t know how the law works.

Jacob Sullum, always willing to let his ignorance be the measure of other people’s knowledge, utterly unwilling to let mere facts get in the way of libertarian ideology, and eager to please his paymasters by slagging a Democratic President, illustrates my point in his response to the latest CNN Obama interview.

Rather than reviewing the bidding about who said what, let me simply lay out the actual state of affairs.

The Controlled Substances Act is a law. It cannot be changed by administrative fiat. That law provides that any substance with abuse potential be put into one of five schedules. Schedule I is for drugs without accepted medical use. Schedules II-V are for drugs with accepted medical use but with abuse potential, with less abusable drugs placed in the lower schedules. Alcohol and tobacco, both highly abusable drugs with no accepted medical use, would be Schedule I, but they are explicitly exempted in the text of the law:

The term [controlled substance] does not include distilled spirits, wine, malt beverages, or tobacco.

“Marihuana,” by contrast, is placed by name in Schedule I. That placement tracks its treatment in the international conventions governing drug policy.

Yes, authority to reschedule cannabis lies with the Administration. If the DEA Administrator decided that the drug had “accepted medical use,” that would move it to Schedule II, making cannabis legally available by prescription. Selling it without a prescription would remain the same crime it is today. (Recall that cocaine and methamphetamine are Schedule II drugs.)

But prescriptions can only be written for FDA-approved drugs. And the FDA can’t approve “marijuana,” because “marijuana” isn’t something that can be put through clinical trials. The New Drug Application would have to be for a specific cannabis preparation, to be given in a specific dosage regimen via a specific route of administration for the treatment of a specific condition. That “new drug” could be a single molecule a combination, an herbal preparation, or an extract. In any case, it would have to have a known and reproducible chemical composition and be produced using “Good Manufacturing Practice.” Producing cannabis without FDA approval would still be the illegal manufacture of a Schedule II controlled substance.

So administrative rescheduling would not make “medical marijuana,” or any other kind, legal at the federal level. Its practical effect would be identically zero.

What’s actually needed in the way of administrative action is to get the DEA and the Public Health Service out of the way of medical research, by breaking the University of Mississippi monopoly on research cannabis and eliminating the requirement that researchers using cannabis (but no other controlled drug) have the material “granted” to them by a federal agency rather than just going out and buying it. The Obama Administration can and should be criticized for not having taken those steps.

But “rescheduling” is a red herring dragged across the trail of policy reform.

Update Tom Angell’s feelings are hurt because I was mean to poor widdle Jacob Sullum. And he insists that I mention that, if marijuana were downscheduled to Schedule III rather than Schedule II (a scheduling decision that wouldn’t make much sense, given that something more than 2 million people in the U.S. meet diagnostic criteria for cannabis abuse or dependency at any one time), marijuana sellers would be able to deduct their business expenses in calculating their federal income taxes. Since that trivial impact on the cannabis problem isn’t the same as “identically zero impact,” Angell demands that I retract.

OK. Rescheduling to the appropriate schedule would have identically zero impact, but excessive downscheduling could somewhat increase the after-tax incomes of marijuana retailers and perhaps lead to slightly lower retail cannabis prices in state-legal stores.

Cannabis, alcohol, and public safety: Knowing what you don’t know

Cannabis might be a substitute for alcohol. Or they might be complements. Right now, we just don’t know.

[See update and correction below. Apologies to Adam Nagourney and Rick Lyman.]

The main problem with journalism, in a world full of unknowns and uncertainties, is that faith is news and doubt isn’t. 

Mark Anderson of Montana State and Daniel Rees University of Colorado at Denver presented an interesting paper at this year’s meeting of the International Society for the Study of Drug Policy, using some moderately sophisticated statistics to investigate the relationship between cannabis availability, alcohol consumption, and traffic accidents. The paper moved my opinion about whether cannabis and alcohol are substitutes or complements from “Not a clue; could go either way” to “There’s a little bit of evidence for substitution” (that is, for the proposition that making pot more available or cheaper would lead to less heavy drinking).

Net substitution would be a big deal, if true, because alcohol does so much more harm than cannabis that a small reduction in the alcohol problem would, in social-cost terms, outweigh even a big increase in the cannabis problem due to legalization.

I say “a little bit of evidence” because the change in cannabis availability due to medical-marijuana laws is poorly measured; because the changes in cannabis availability due to medical marijuana laws are small compared to the changes that would result from full legalization; and because the short-term effects might not only be larger or smaller than, but might not even be in the same direction as, the long-term effects. (Remember the guy who jumped off the Emprire State Building. Being asked as he passed the fiftieth floor, how the experiment was going, he replied, “So far, so good!”)

Unfortunately, Anderson and Rees decided to build on their finding, and other findings from the literature, to make a strong claim: “We expect that the legalization of recreational marijuana in Colorado and Washington will lead to increased marijuana consumption coupled with decreased alcohol consumption. As a consequence, these states will experience a reduction in the social harms resulting from alcohol use.”

Even more unfortunately, Adam Nagourney and Rick Lyman  of the New York Times decided to take that claim at face value, ignoring the papers in the same issue of the same journal by Rosalie Pacula of RAND and Eric Sevigny of the University of South Carolina arguing that the Anderson and Rees claim is more than the current data can support.

Pacula and Sevigny didn’t make the opposite claim: that legalization will increase heavy drinking. Had they done so, normal journalistic practice would have been to cite the two conflicting opinions. But since they brought in the Scotch verdict of “Not Proven,” Nagourney and Lyman simply ignored what they had to say. That let them use the Anderson and Rees claim to support the theme of the story, well-captured by the headline “Few Problems with Cannabis for California.”

[Update and correction:

The above paragraph is inaccurate about the sequence of events. Adam Nagourney writes:

You were wrong to assume I was aware of the dissenting studies and chose to ignore them. I was not; if I was, I most certainly would have mentioned the concerns. Professor Rees  gave me an advance copy of their study; I did not have an advance copy of the journal. Again, if I had, I most certainly would have raised the fact that other people question their assertions.
As someone who has been doing this a long time, I can tell you that this: “The main problem with journalism, in a world full of unknowns and uncertainties, is that faith is news and doubt isn’t” is not true, at least for me or the place I work. One of the great things about the New York Times is that there is room for nuance and subtly. A story is stronger journalistically if it addresses both sides of an argument.

This time I have to give myself an F in Journalism 101; I should have checked with Nagourney before criticizing his work.

Very sorry, sir! Won’t happen again, sir!]

In order to know how cannabis legalization would affect heavy drinking, you’d have to know:

1. The extent of the price decline.
2. The extent of the change in other conditions of availability and use (convenience, marketing, perceived product quality and variety, stigma, legal consequences, social customs).
3. The responsiveness (“elasticity”) of demand to price changes, consisting of two components: the “participation elasticity” measuring changes in how many people use cannabis at all, and the “conditional elasticity” measuring changes in consumption-per-user.
4. Ditto for responsiveness to changes in non-price factors.
5. The “cross-elasticity” between cannabis and alcohol.
6. For all of these, you’d need estimates about the long-term effects of lasting changes, not the immediate effects of transient changes.

All Anderson and Rees can show are reasonable but not perfect estimates of the short-term effects of relatively small and poorly measured short-term changes in price and availability on various outcomes. They’re not within a million miles of being able to offer the sort of prediction on which one ought to base public policy.

For example: One likely impact of legalization, as Anderson and Rees note, is increased cannabis use among minors. Even if it were known that cannabis and alcohol are, at a given point in time, substitutes for minors, that wouldn’t show that increased pot-smoking by sixteen-year-olds might not increase their risk of becoming heavy drinkers at twenty-one. And the Anderson and Rees methods don’t even look for such long-term effects.

“It’s not what you don’t know that hurts you,” said Will Rogers. “It’s what you know that ain’t so.” Knowing what you don’t know doesn’t get your name in the newspaper. But it saves you having to eat your words. Since I think that cannabis legalization of some sort (1) is probably a good idea and (2) very likely to happen in any case, I devoutly hope that Anderson and Rees turn out to be right. But it seems clear to me that Pacula and Sevigny have the stronger argument. We just don’t know.

Is Medical Malpractice Even Possible for California’s Marijuana Docs?

A physician friend who supports medical marijuana got a shock as he walked through Venice Beach. A young man in a tee shirt and gym shorts rollerbladed up to him and chirped with alacrity “Hi, I am kush doctor! Would you like to come over to my clinic and get a prescription for medical marijuana”?

We have many such skilled practitioners in California. As a cash only business without any meaningful oversight, a medical marijuana practice is a dream come true for those who graduated at the bottom of medical school. It’s also a godsend to doctors who are one jump ahead of being struck off by the licensing board.

My physician friend, who is from Rhode Island, says that his state is actually trying to regulate medical marijuana, like, well, medicine. I haven’t seen their set up so I can’t say how credible it is. But I can say with certainty that medical marijuana malpractice is virtually impossible in the Golden State.

Many Californians who voted for medical marijuana thought they were being promised a tightly run system that provided cannabis to a small number of cancer and AIDS patients. Such people feel conned today, for the very good reason that they were. But now that a deep-pocketed industry with lobbyists has been created to supply recreational users under medical cover, it probably will not become regulated in a serious fashion.

On the other hand, Arizona is known for its tough, let-God-sort-‘em-out approach to law enforcement. One of its pot docs failed to conduct a required medical history and then lied about it on the certification form. Since he did it 483 times, it is unsurprising that the steely-eyed descendants of the lawmen of Tombstone lowered the boom. They sent the miscreant the dreaded letter of reprimand.

That’ll learn ‘em.

Caulkins on (quasi) medical marijuana

How come the number of “medical” marijuana users in some states is so large compared to the total number of self-reported marijuana users? Is there an epidemic of chronic pain among otherwise healthy thirty-year-old men who have been smoking pot for years?

Jon Caulkins of Carnegie Mellon is the lead author on a book on marijuana legalization scheduled for publication next spring. The rest of the team consists of Angela Hawken of Pepperdine and me (who worked with Jon on Drugs and Drug Policy, part of the same series from Oxford University Press) plus Beau Kilmer, who heads the RAND effort studying the possible effects of legalization.

Jon and I don’t come from the same place culturally or politically, and he’s extraordinarily smart (not to mention conscientious and kind), a combination that makes working with him – as I’ve been doing off and on for twenty years – both a challenge and a pleasure. Angela and Beau bring still different personalities, views, and skills to the enterprise – along with razor-sharp minds –  but so far it’s running very smoothly.  The concluding chapter of the new book will consist of a brief statement by each author laying out a preferred option; I can’t predict any of them in detail (even my own thinking keeps shifting) but I expect the four statements to embody lots of disagreement.

Jon and I agree more about facts than we do about values or policies. For example, he’s clearly right to say that the profile of “medical” marijuana users looks like a profile of recreational drug users, not a profile of patients, and that their sheer numbers in some states suggest that most of the recreational market is now accessing its supplies through quasi-medical channels. And that doesn’t even count the people whose recreational needs are supplied by friends with medical cards. Whether he’s also right to say that the Justice Department would do well to crack down on the scam is less obvious, at least to me.