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?”

Admirable Obama Administration statement on marijuana legalization

There’s a big gap between what the Administration said and what it should have said.

When the Obama Administration decided to invite petitions from the public, it no doubt anticipated that there would be one or more about legalizing cannabis, a proposal that now has roughly 50% public support. Of course, the Administration isn’t ready to go there, but it had a perfectly sensible response:
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[Wordless shriek of rage and frustration]

Most of the news in the new household survey on drug abuse is good: cocaine and meth use are down, meth initiations are way down. There’s an uptick in cannabis use, especially among young adults. So why is the official press release headlined “National Survey Shows a Rise in Illicit Drug Use”?

Over the past four years, the number of people self-reporting as methamphetamine users on the big household survey is down by half, and meth initiation rates – a leading indicator, and therefore the one to watch – by 60%. The number of people self-reporting cocaine use is down by a third. Middle-school rates of drinking and smoking are also down, though less dramatically. Initiation to non-medical pain relievers remains high, but off its peak in the early 2000s, reached after a decade that saw initiation rise tenfold.

Oh, yes, and cannnabis use is up some (almost 20% from the 2007 trough, from ), especially among young adults (18-25). Cannabis use among those under 18 is flat. Mean age at first use is up from 17 to 18.4: that’s the direction you want to see it going.

So the on-one-foot summary of the results is “Nothing exciting, but basically good news.”

But if you were really, really, really stupid – or had a job that required you to pretend to be that way – you might just treat all use of illicit drugs as alike and simply count the number of users. In that case, the modest rise in cannabis use would swamp all the other results, because cannabis is by far the mostly widely used illicit drug, and a report mostly full of pretty good news would come out as “National Survey Shows a Rise in Illicit Drug Use,” complete with silly viewing-with-alarm quotes from officials.

(No, dammit, we are not “at a crossroads”! Next year is mostly going to look like this year.)

Even after 30 years in the business, it’s hard to get used to how plain damned dumb the official (and journalistic) discourse on this topic is. The household survey (aptly named NS-DUH, where DUH is pronouned “duhhhhhhhhh”) doesn’t get at what’s really interesting: the number of problem users, and especially criminally-active problem users. But it does contain some useful information. Too bad the people running the show mostly ignore that information and concentrate on fluff.