How big a problem is heavy cannabis use?

Annie Lowrey has a well-thought-out piece about cannabis use disorder in The Atlantic. In my view, this is the most under-covered topic in the debate about whether – and, more importantly how – legalize cannabis.  I’m especially grateful to Lowrey for making me sound coherent; that doesn’t always happen.
Unfortunately, the editor who added the headline and subhead to the story misstated matters fairly significantly. (This happens so often that I now insist on having a voice in the headlines that run over my essays.)

Continue reading “How big a problem is heavy cannabis use?”

A primer on fentanyl(s)

The synthetic opioids – usually referred to both in the press and by law enforcement as “fentanyl” – have now outstripped not only the prescription opioids such as oxycodone but also heroin in terms of overdose deaths, and (as you can see below) the trend line is almost vertical.

Image result for opioid overdose deaths

Keith Humphreys warns of “fentanyl’s potential to permanently alter illegal drug markets.”

Kevin Drum asks about the causes of the change:   “Fentanyl has been around for a long time, and only recently has its use become widespread. Why?”

Why, I thought you’d never ask. Settle back; this is a complicated story, and it’s going to take a while to tell. But Keith is right: this is a BFD. So it’s worth understanding. Continue reading “A primer on fentanyl(s)”

Another Day, Another Misinformed Article on Obama’s Addiction Treatment Record

Writing about President Obama’s record on drug addiction treatment without mentioning the passage of the Affordable Care Act and the development of the regulations for the Mental Health Parity and Addiction Equity Act (MHPAEA) is analogous to writing about LBJ’s record on health care without mentioning Medicare and Medicaid. But alas, Christopher Ingraham of the Washington Post is the latest journalist to do so. The transformative impact of the ACA and MHPAEA on addiction treatment is not a hard-to-uncover secret. It has been written about extensively in the scholarly literature (see for example here and here) and in the mass media (see for example here and here). But like a number of other journalists, Ingraham critiqued the Obama Administration’s alleged lack of commitment to drug treatment without even mentioning either landmark piece of legislation.

To Ingraham’s credit, he did at least look at some data, which was the budget for federal drug control spending across agencies:

So on the one hand, yes – it’s true that more federal dollars are going toward drug treatment. On the other hand, treatment and prevention account for less than half of federal drug spending, most of which still goes toward law enforcement efforts.

This conclusion rest on the false assumption that an administration’s financial commitment to addiction treatment is equal to federal spending on addiction treatment. But the ACA and MHPAEA are major federal actions that drive private dollars into addiction treatment by improving coverage for over 100 million people with private insurance. Analyzing what an administration has done in any health care policy area without looking at its laws and regulations for private insurance is generally misleading, and is certainly so in this case where none of the private investment is captured in federal drug control budget data.

Health care policy analysts generally see the Obama Administration’s addiction treatment record as the most praiseworthy in at least 40 years, and some journalists (e.g., Jesse Singal) have done a fine job reporting that fact. That does not however make it less disappointing to see yet another misinformed article written as if the ACA and MHPAEA never happened.

Legalizing pot carries risks. So does prohibition.

My letter to the WSJ about Bill Bennett’s “16.2 million marijuana addicts.”

As predicted, the Wall Street Journal refused to correct the Bennett/White op-ed that strongly implied (without quite stating explicitly) that I believe cannabis legalization would sextuple the rate of cannabis dependence to 16.2 million. (My previous whining about that here.) However, the Journal did publish my letter, with only helpful edits and an accurate headline that’s a pretty good haiku-length statement of the case.

Like the original article, the letter is behind a paywall, so – on the off chance that some RBC readers don’t pay tribute to the Murdoch empire – I’ve pasted it in below.

 

Legalizing Pot Carries Risks, but So Does Prohibition

To the Editor:

William Bennett and Robert White (“Legal Pot Is a Public Health Menace,” op-ed, Aug. 14) cite my research as support for their claim that the legalization of cannabis would mean creating 16.2 million “marijuana addicts.”

Not only is the attribution false; the claim it purports to buttress is absurd. I made no such prediction, and the idea that legal cannabis could create more addicts than legal alcohol doesn’t pass the giggle test. It would be astounding if the actual number were one-third as high as Messrs. Bennett and White project

Cannabis legalization on the current alcohol model—low taxes and loose regulations—would indeed risk a large increase in the extent of cannabis abuse. That is why some of us are working hard for high taxes and sensible regulations on cannabis, as well as stronger controls on alcohol, which is after all a much more personally and socially dangerous drug.

Cannabis legalization in any form will create some harm; every drug policy has disadvantages. But against that must be set the enormous harms from cannabis prohibition: $40 billion a year in illicit revenue, some of it going to violent criminal organizations in Mexico; tens of thousands of people in prison; and more than half a million users arrested each year.

Our goal should be to eliminate as much as possible of the damage from prohibition while minimizing the harms that would result from a badly designed legalization.

Mark Kleiman

Los Angeles

Dear Bill Keller, Please Start Taking Drug Addiction Treatment Seriously

In his closing contribution to the New York Times, Bill Keller laments President Obama’s unwillingness to invest in drug addiction treatment. It’s a common jab, made by many commentators (see for example here and here).

It is also embarrassingly, verifiably, wrong.

I am sure Mr. Keller and all the other journalistic critics of Obama’s drug treatment record have heard of The Affordable Care Act. Why don’t they know that it expands access to care for over 60 million Americans by mandating that drug treatment coverage be included in every plan and be at parity with that for other disorders? How can they further not know that the Obama Administration’s regulations for the Mental Health Parity and Addiction Equity Act provide benefit parity to more than 100 million Americans with employer-provided health insurance? More generally, how can they not know that independent analysts at CMS consider the current public policy environment the most dramatic improvement in the quantity and quality of addiction treatment in U.S. history?

I submit that Keller and his fellow critics would never confidently make such data-free assertions about cardiology, oncology or indeed any other area of the health care system. But drug treatment, like drug addiction, is a target of great stigma and ignorance. So why bother to take it seriously enough to check your facts like you would with health care for any other group of patients?

I take Keller at his word that he doesn’t want drug treatment to be a third-class part of our health care system. That’s why I feel comfortable asking him to please start taking it seriously himself. Rather than use his platform to make assertions that are demonstrably inaccurate, I hope he will in the future engage in the due diligence any other area of health care would receive from a serious journalist.

Opioid Addiction is Everywhere

Many middle-class parents were appropriately rattled by Ben Cimons’ powerful account in Washington Post of being a “nice suburban kid” who became addicted to opiods and ultimately almost died of a heroin overdose. The desire of people from “good families” to believe that drug problems are confined to low-income urban communities is understandable, but also false — indeed perniciously so.

Ben and I, along with Wall Street Journal reporter Zusha Elinson and Stanford visiting fellow Markos Kounalakis were on Warren Olney’s To the Point radio program last week to discuss how heroin is making a comeback. Among the key themes of the discussion was that the origins of the recent rise of heroin can be traced directly to the recent and continuing extensive availability of prescription opioids.

p.s. I had a brain freeze when Warren asked me for the common trade names of hydrocodone-containing pain medications; I said Lortab but forgot to mention Vicodin.

A Hand Outstretched into the Cold Night

I had an long and interesting discussion yesterday with Maia Szalavitz about public health approaches to addiction (Her full article is here). One question we kicked around is why extremely troubled street drug users sometimes make dramatic positive changes in their behavior when they come into contact with a needle exchange site or a mobile methadone van or a Salvation Army treatment program.

Mark Kleiman and I have gone back and forth on this many times, with each of us leaning toward different explanations.

Mark emphasizes the role of self-command in behavior change. His hypothesis: People who feel defeated by life at every turn gain confidence when they are taught a masterable skill (e.g., how to clean a needle to prevent HIV infection). When they thereby come to understand that they are not utterly hopeless and incompetent, they feel more confident that they can engage in other positive behaviors that have previously intimidated them (e.g., finding a place to live, enrolling in a methadone maintenance program).

Mark’s theory is entirely plausible, but I tend to lean towards a different view. People are more prone to take care of themselves if they think that others care about them. If you are using drugs and sleeping rough, you can go through long periods where no one expresses any feelings toward you other than contempt, disgust or hostility. In contrast, when a stranger stretches an open hand into the cold night and offers to help you, it communicates something markedly different: You have worth. Knowing that you are not worthless after all provides a motivation to try to make changes that will improve your health and well-being.

Mark’s theory focuses on how people change (the mechanism), mine focuses on why they do (the motivation). Both explanations could be true, or more or less true for different sorts of people. They could also of course both be wrong, but that would in no way diminish my admiration for those people who, night after chilly night, extend their hand to those in dire need.

Planting the Seeds of a New Heroin Epidemic

In our recent discussion at Washington Post’s Wonkblog, Harold Pollack and I talked about the astonishing scale of prescription opioid consumption in the US, which has no parallel anywhere else in the world. Americans consume 99% of world’s supply of hydrocodone, with the rest of the human race accounting for only 1%. Each year, U.S. health care professionals write more prescriptions for opioids than there are adults in the country.

Some of this prescribing has unquestionably been a blessing to people in pain. Some of it has however been highly destructive. Sally Satel highlights one of the adverse consequences of flooding the country with prescription opioids:

According to the 2012 National Survey on Drug Abuse and Health, four out of five new heroin users had previously abused painkillers.

The recent surge in heroin use is thus fundamentally different from its 1970s precursor. Its seeds were planted not in Southeast Asia but in doctor’s offices, emergency rooms and pill mills all across the country.

As policy makers focus attention on the resurrection of heroin in American life, they should remember that it remains a small problem compared to the painkiller addiction epidemic that fomented it and is still doing so: Deaths from legal prescription opioids exceed those from heroin by a factor of five. If we want a lower prevalence of heroin addiction five years from now, we should be looking upstream at policies that will combat the mis-marketing, mis-prescribing, diversion and abuse of prescription opioids.

Is cannabis addictive?

In some users, yes. Now the question is what to do about it as we make cannabis legal.

Ask this woman.

My dad will never stop smoking pot. Sometimes I wonder about the man he might have been, and the lives we all might have had, if he’d never started.

As I keep saying: the evils of prohibition do not disprove the evils of substance abuse. In the case of cannabis, it’s probable that we could get rid of the former without greatly increasing the latter. But it’s not automatic. And denying that cannabis abuse is a real problem doesn’t help.

Note how the mythology of “addiction” cultivated by the “drug-prevention” effort and the drug-treatment industry interferes with understanding. Most drug abuse is very unlike the horrible picture painted in the linked story: it’s relatively transient. And most people who use “addictive” drugs don’t get addicted to them; substance abuse happens to only a minority of users, and only a minority of abusers actually have the “chronic, relapsing disorder” touted as typical. Bad habits around drug-taking are like other bad habits: they lie along a spectrum, and not everyone who uses a drug that turns out to be habit-forming in others encounters a problem.

But if you have the problem, or your brother, or your son, or your mother, it’s a serious problem. And the risk can’t just be wished away. If you support making cannabis available from profit-seeking commercial vendors, heavily marketed, and cheap – which is the path Washington and Colorado are walking down right now – then the predictable result of your preferred policy will be more people with very bad cannabis habits. And there could be fewer such people if cannabis were kept expensive, if marketing were kept to a minimum, and if users were offered modest helps to their self-command, such as user-set periodic purchase quotas, or if we keep the commercial motive out of the business altogether with state stores or by limiting vendor licenses to consumer-owned co-ops and not-for-profit businesses with boards concerned with limiting drug abuse rather than maximizing revenue.

Of course you’re free to oppose all of that. But if you do so, you ought at least to acknowlege the inevitable human cost.

h/t Andrew Sullivan

Update Comments closed due to persistent trolling, using multipe IPAs. I may start to follow Keith’s lead. Alterantively, we could go to some sort of registered-commenter system. Sorry, folks, but I suppose if you have a picnic you have to expect some cockroaches.

Yet Another Way to Misunderstand President Obama’s Record on Addiction Treatment

President Obama has done more to expand the quantity and quality of addiction treatment than any President in at least 40 years, but you wouldn’t know it from much of the coverage his drug policy receives. In the latest critique, Rebecca McCray and Emma Andersson praise the public health rhetoric of White House drug policy director Kerlikowske but are disappointed to find only a small increase in treatment funding in the President’s FY13 federal drug control budget. I applaud McCray and Andersson’s public health advocacy, but they are misunderstanding something quite important about how health care is financed relative to other components of drug policy.

Their analytic error is not as serious as those which have plagued similar criticisms of the President: John McWhorter condemned the lack of treatment funding in the Department of Education, which doesn’t fund healthcare, while Mike Riggs completely missed the significance of (indeed, didn’t even mention) the Affordable Care Act. Nonetheless, McCray and Andersson’s mistake is worth pointing out because it supports an inaccurate and unfair conclusion about the President’s drug treatment policy.

For most categories of spending in the federal drug control budget, government dollars are 100% of total expenditures. Only the federal government has Coast Guard cutters intercepting cocaine-filled powerboats in the Caribbean. Likewise, only the federal government provides the budget of the courts in which drug traffickers are tried and convicted. Therefore, if you want to know how much is being spent on these sorts of drug policies, all you have to do is tally up what the government is spending as does the federal drug control budget.

In contrast, billions of private dollars are spent on addiction treatment each year. Federal policies that increase the amount of those dollars, for example by mandating that insurers cover addiction treatment, don’t show up in the federal drug budget. Indeed, a pro-treatment federal government policy could even reduce treatment expenditures in the federal drug control budget if the policy enabled addicted people to access privately funded care instead of publicly funded care.

For example, one of the reasons those of us who worked on the substance use disorder-related provisions of the Affordable Care Act are pleased with the legislation is that it allows parents to keep children on the family health insurance policy until the age of 26. Because the early 20s are high-risk years for the incidence of addiction, the ACA thus expands drug treatment coverage to a high-need population. How much of the spending on treatment received by young adults because of this new federal policy shows up in the federal drug control budget? None of it, because it’s private money. The President’s policy drives the increase in private sector spending but that’s irrelevant in the calculation of the federal drug control budget, which only reports public expenditures.

As the ACA is phased in, its provisions will drive much more private money into addiction treatment provision. That’s because the legislation requires the privately financed policies offered in the state health exchanges to fully cover addiction treatment at parity with treatment for other conditions.

To quote the mandarin Harold Pollack, whom everyone who writes one of these misleading articles about the President’s drug treatment policy ought to consult before going to press: Wonderfully, the Obama administration has quietly revolutionized financing of addiction services. This change is readily overlooked because it occurs outside the $15.5 billion “National Drug Control Budget”.