Gone, baby, gone

It appears that opium harvests greatly exceed demand for heroin and no one seems to know where the excess heroin is.

More sentencing sense

I mentioned drug courts in a recent post. Well, the NY Times is reporting on drug courts.

Highlights:

Clearly, the courts do not help everyone. One of the most successful programs is in New York State, where about 1,600 offenders are in adult drug courts. Studies found that while 40 percent dropped out of the program along the way, those who started it, including both dropouts and graduates, had 29 percent fewer new convictions over a three-year period than a control group with similar criminal histories and no contact with drug courts, Mr. Berman said.

In other regions, half or more of those who start the program do not finish. And recidivism rates for participants are reduced by about 10 percent to 20 percent, depending upon the quality of the judges and treatment programs, said John Roman, a researcher at the Urban Institute, based on a recent study.

An earlier review of 57 “rigorous” drug court evaluations around the country, led by Steve Aos of the Washington State Institute for Public Policy, found that recidivism was reduced on average by only 8 percent, but with wide variation.

Yet even that modest reduction in crimes and prison yields cost benefits. The report this year by the Urban Institute found that, for 55,000 people in adult drug courts, the country spends about half a billion dollars a year in supervision and treatment but reaps more than $1 billion in reduced law enforcement, prison and victim costs. A large expansion would yield similar benefits, the report argued.

But some scholars, like Mark A. R. Kleiman, director of the Drug Policy Analysis Program at the University of California, Los Angeles, remain skeptical about the potential and the achievements. He suggests, for example, that success rates of some courts may be inflated because they take in offenders who are not addicted and entered this track only to avoid prison. Dr. Kleiman advocates a slimmed-down system that does not initially require costly treatment, as drug courts do, but simply demands that offenders stop using drugs, with the penalty of short stays in jail when they fail urine tests. Such an approach has shown promise with methamphetamine users in Hawaii, he said, and because it is far cheaper, it can be applied to far more offenders.

I'd like Kleiman's proposal if what he describes is a "pre-drug court" that would step addicts up into a full drug court.

There's something exciting and troubling about drug courts and health professional recovery programs in the context of the addiction treatment system. Exciting because there are important ways that they are succeeding in implementing some chronic disease management elements, namely long term monitoring and swift reintervention when relapse happens or appears imminent. Troubling because it seems that we are only implementing these strategies with involuntary involuntary clients and other systems are the ones implementing these programs for their own ends. (Not that there's anything wrong with this. In fact, it's great that these systems are approaching these problems in this way. But it should be cause for concern that these other systems are pulling us in this direction rather than us leading the way.) These programs get to be considerably more directive with these patients--they HAVE to go to treatment, they HAVE to get regular drug testing, they HAVE to attend recovery support groups, etc.

There will be a whole new set of challenges with voluntary clients. I suppose we'll face the same challenges that cardiac care and diabetes programs face every day.

Five Myths About Crack

A Washington Post Op-Ed contributor offers some guidance to the supreme court in the form of 5 myths about crack:

1. Crack is different than cocaine.
2. Crack is instantly and inevitably addicting.
3. The "plague" of crack use spread quickly into all sectors of society.
4. Crack is the direct cause of violent crime.
5. Harsh sentences for crack are necessary to deter "serious" and "major traffickers."

Technorati Tags: cocaine, crack, policy, criminalization, addiction

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More on the new Canadian drug plan

65% for prevention and treatment (including culturally specific treatment) doesn't exactly sound Draconian:

The Conservative government's new $63.8-million, two-year drug strategy could be worse, but it could be better.Fully half the money will go toward beefing up treatment for addicts. Since health and social services are mainly a provincial responsibility, however, that money will go mainly to development of national benchmarking - so that evaluations can be consistent across the country - and extra programs for aboriginals. The main burden of helping addicts remains with the provinces.Another $10 million will go to prevention - ad campaigns and brochures to remind people, especially young people, how damaging addiction is. "Drugs are dangerous and destructive," Prime Minister Stephen Harper said, unveiling the plan. "If drugs do get hold of you, there will be help to get you off them."

Based on American experience, mandatory minimum sentences don't seem like a wise move, but why not start lobbying and negotiating instead of calling them idiots.


Technorati Tags: canada, addiction, treatment, prevention, policy

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More criticism of Canadian drug policy plan

First off, I am not at all in favor a the war on drugs and I'm skeptical of this new plan. (In my limited understanding, it emphasizes criminalization.) However, I believe that these comments from Stephen Harper make a lot of sense:

Harper unveiled a $63.8-million, two-year drug strategy in Winnipeg Thursday, saying harm reduction is not a "distinct pillar" of the Conservative strategy.

Vancouver's safe injection site is "a second-best strategy at best," he said, "because if you remain a drug addict, I don't care how much harm you reduce, you're going to have a short and miserable life."
...
Harper said Thursday: "I remain a skeptic that you can tell people we won't stop the drug trade, we won't get you off drugs, we won't even send messages to discourage drug use, but somehow we will keep you addicted and yet reduce the harm just the same."

These comments have been met with accusations of ignorance:

Mark Townsend, director of the Portland Hotel Society in Vancouver, said Harper doesn't understand the scourge of drug addiction.

"It's depressing to see his [Harper's] lack of leadership on that and now he is out there trying to find a new study that will say the world is flat," Townsend said.

A columnist for the Victoria Times-Colonist rails against the plan:

The problems of ideology-based governance clearly must be more obvious from afar. Otherwise, Canadians wouldn't be able to bear the hypocrisy of railing against oppressive and backward regimes elsewhere in the world while committing ourselves anew to the folly of a war on drugs.

...

The real tragedy is that the misuse of drugs continues to cost us $40 billion a year in Canada in direct and indirect costs, and that's not even counting all the billions we've thrown away on misguided and ideologically driven attempts to do something about that.

Here's the thing: Health issues can't be resolved through ideology.

...

So why do we continue to let our elected politicians ignore the science when it comes to drug issues? Why should anybody's poorly informed position around drug use be the lens that we apply when trying to address complex health and social problems that are far too important to be left to political whim?

I respect the right of Stephen Harper and his MPs to believe that using illicit drugs is bad. It's a free country and they're welcome to their opinions, and never mind that alcohol is actually Canada's most dangerous and readily available drug by a long shot. (The social costs of alcohol use in Canada are more than double that of all illicit drugs combined and health-related costs are three times higher.)

But why would we want to base something as important as our national drug strategy on opinion and belief?

We've got six decades worth of scientific studies underlining the importance of an informed, health-based approach in reducing the harm and societal costs of drug use. Yet we're still letting vital public policy be decided by people who would rather maintain their personal fictions than take steps to fix the problems.

This complete rejection of the role of values in policy decisions can't be serious. What about torture? Is the only acceptable argument against torture and argument that it doesn't work? I don't know anything about this writer, but I suspect she believes it is wrong and would oppose any pro-torture policy on moral grounds--even if torture was scientifically proven to be effective.

Granted, there's a long distance between torture and drug policy. The point is that we base policy decisions on values and morals all the time, even in health care. Are Canada's universal health care policies and the U.S. SCHIP programs based in pragmatism? They're based on moral
convictions about providing access to health care. Furthermore, the argument that harm reduction activism is value-free and rooted only in science is folly. HR arguments are consistently value-laden. For example, common themes include:

• Drug use is not bad
• Self-determination and personal liberty trump competing concerns
• Drug experimentation is a normal developmental task for adolescents

Would it be so difficult to build a dialog on drug policy around values? For example:

• Drug use is bad for addicts
• Recovery is the ideal outcome and should never be abandoned as a goal
• No one should be incarcerated for simple personal possession or use
• If an addict refuses recovery, we should still provide assistance with basic needs
  

How much common ground could be developed? What policy initiatives might arise?

One other truth that activists on both sides need to accept is that any policy that does not enjoy broad and deep public support will always be in peril. The general public will never embrace a policy focused on incarceration or a policy focused on needle exchanges, safe injection centers and drug maintenance programs.

Technorati Tags: harm_reduction, canada, addiction, policy

How many drinks is too many? | The Daily Telegraph

I've been in a couple discussions over the past few days about federal drinking guidelines and what constitutes risky drinking. It just happens that Australia is reviewing their drinking guidelines. Of special concern are pregnant women and young women. Their drinking guidelines for healthy people between 18 and 64 are as follows:

For men: No more than 4 Standard Drinks a day on average and no more than 6 Standard Drinks on any one day. One or two alcohol-free days per week.

For women: No more than 2 Standard Drinks a day on average and no more than 4 Standard Drinks on any one day. One or two alcohol-free days per week.

*These drinks should be spread over several hours. For example, men should have no more than 2 standard drinks in the first hour and 1 per hour after that. Women should have no more than 1 standard drink per hour.

Special report: Under-age drinking (U.K.)

Independent Online Edition >England is also experiencing problems with underage drinking. In England 18 year olds can purchase alcohol and 16 year olds can drink alcohol in s restaurant, if the alcohol was purchased by a parent.

Amid growing concerns over 24-hour drinking, soaring rates of liver disease and police forces unable to cope with drunken disturbances on the streets, an exclusive Independent on Sunday investigation today reveals the dramatic rise in children admitted to hospital because of alcohol-related illnesses.

The biggest increase is seen among girls under 16 years old, with a 25 per cent increase between 2002/03 and 2004/05. And the problem is getting worse: hospital admissions for under-18s are at their highest since records began, and the average amount children are drinking every week has doubled since 1990.

Professor Mark Bellis, director of the Centre for Public Health at Liverpool John Moores University and a government adviser on alcohol-related issues, said: "The numbers of underage drinkers in hospital for alcohol-related conditions are substantial but it is only the tip of the iceberg. Many more children are admitted for problems not recorded as alcohol. The admissions include everything from being involved in violence to teenage pregnancies. For every one youth admitted due to alcohol consumption there are many more whose health suffers through excessive alcohol consumption."

The ages of children admitted to hospital for alcohol-related problems are getting lower. The number of eight-year-old-boys who drink has doubled from 5 per cent in 1995 to 10 per cent in 2005. The number of 11-year-old girls who drink has increased from 15 per cent in 1995 to 25 per cent in 2005. Many experts believe country is in the grip of a hidden epidemic - one that, like alcoholics themselves, the country is in denial about.

...

Last year police introduced exclusion zones around the beaches of Polzeath and Rock after residents complained of underage drinking and fighting. Dubbed the "Costa del Sloane", the beaches are a magnet for children from public schools.

A senior policeman with Devon and Cornwall constabulary also spoke out about the underage drinking culture after a mob of 100 youths - some as young as 12 - were caught at a mass boozing session in Falmouth.

The startling rise in underage drinking is already beginning to have repercussions on public health and will continue to do so for future generations unless something is done to curb the alcohol consumption of British children, campaigners say.

Frank Soodeen of the charity Alcohol Concern said: "A recent government report on alcohol-related deaths showed that the biggest group was men and women aged 35-54 - which is far younger than ever before. Clearly it's beginning to catch up at an earlier stage, which is very worrying. Generally the highest proportion a few years ago was well above that age group."

The most serious of these health problems is liver cirrhosis. People in their 20s and 30s are now ending up with serious liver problems which, until recently, were normally seen in people twice those ages.

Professor Ian Gilmore, president of the Royal College of Physicians and a liver specialist at the Royal Liverpool Hospital, said: "Cirrhosis of the liver has increased tenfold since the 1970s. There is a big concern about the rise in deaths from cirrhosis among young people. I think we are going to see big increases in people in their 20s and 30s being diagnosed with liver cirrhosis."

David Mayer, chair of the UK Transplant Liver Advisory Group, warned that young drinkers are storing up a problem for the future and are likely to require his services in years to come. "People have more money and more opportunity to drink from an earlier age and therefore their livers are exposed to chronically high alcohol levels. We are concerned that it's becoming an epidemic. It does take many years to develop cirrhosis, but if you start drinking at an early age you are going to see problems sooner rather than later."

With such a marked increase in child drinking, campaigners are furious over the lack of provision offered to young people such as Hayley in helping to tackle their problems. There are even calls for drying-out clinics to be set up specially for young people.

But Professor Bellis argues that we need to help children long before it reaches that stage. "Waiting until children develop alcohol problems means their health, their education and ultimately their life prospects have already begun to suffer. We need a major shift in our national attitudes towards alcohol."

Caroline Flint, the public health minister, last week claimed that the Government is tackling the problem through "targeted enforcement" - reducing sales to under-18s by bars, off-licences and retailers - as well as education on substance abuse.

But campaigners blame the drinks industry for promoting alcohol as "sexy" to the young. Mr Soodeen said: "The drinks industry plays a big part in the whole issue. We really need to be cutting off the supply to young people. Unfortunately, the drinks industry has been very effective in persuading the Government that a 'voluntary health' approach is the way forward. We find it odd that so much of the packaging on alcopops seems juvenile and the alcohol industry has yet to come up with a credible explanation."

[via: Alcohol and Drugs History Society]

An Honest Conversation About Alcohol

From Inside Higher Ed:

Two months after he finished up as president of Middlebury College in 2004, John M. McCardell Jr. wrote a column for The New York Times called “What Your College President Didn’t Tell You.” In the piece, he discussed how he was “as guilty as any of my colleagues [as presidents] of failing to take bold positions on public matters that merit serious debate.” Taking advantage of his new emeritus status, he proceeded to take a few such positions. Among other things, he wrote that the 21-year-old drinking age is “bad social policy and terrible law,” and that it was having a bad impact on both students and colleges....

The current law, McCardell said in an interview Thursday, is a failure that forces college freshmen to hide their drinking — while colleges must simultaneously pretend that they have fixed students’ drinking problems and that students aren’t drinking. McCardell also argued that the law, by making it impossible for a 19-year-old to enjoy two beers over pizza in a restaurant, leads those 19-year-olds to consume instead in closed dorm rooms and fraternity basements where 2 beers are more likely to turn into 10, and no responsible person may be around to offer help or to stop someone from drinking too much.

I have a few brief reactions. First, I don't have a strong opinion on the matter, other than I'd be troubled by 18 year old high-school students being able to buy alcohol.

In principle, the general idea of a less restrictive drinking law might appeal to Libertarians, but drinking licenses? That'll lose Libertarian support fast.

He makes an argument about current law criminalizing parents who try to teach their kids to drink responsibly. First, is serving alcohol necessary to do this? Second, as we saw a few weeks ago, this isn't illegal in 31 states. Third, when is the last time you heard of parents fined or arrested for allowing their teen to have a glass of wine with dinner?

Some of his arguments are a stretch -- for example, using SAMHSA's increased attention to underage drinking as an argument against the existing policy and implying that there's a relationship between the 21 year old drinking law and younger ages of first use.

The fact that we currently have problems, isn't necessarily a good argument against the status quo. Anyone who's honest with themselves will recognize that there is no such thing as a problem-free drug and alcohol policy. As I've said before in this blog, these drug policy questions are all about trade offs and, recognizing that every policy requires living with some problems, the questions you have to wrestle with are:

• Which problems are intolerable and which are you willing to tolerate?
• How do you make these decisions? (I'd suggest that even responses that purport to be value-free are value laden.)
• Which policy (or combination of policies) best balances these values?

It seems like these discussions would generate more light if people were a little more honest in acknowledging the problems inherent in their pet theory.

Tobacco, tobacco tobacco

Three recent articles on tobacco. First, The Boston Globe reports on the effectiveness of pharmacological treatments for nicotine addiction. The article presents a pretty pharmacological treatments as an essential part of a smoking cessation plan.

Philip Quartier, a 64-year-old stockbroker from Mission Hill, had been smoking a pack of cigarettes a day for 45 years when he quit for the first time. After five clean years, an impulse led him to pick up another cigarette eight months ago, and the biking enthusiast, who has lung disease, was frustrated to be back to his old habit.

Determined to quit for good, he dug out the subliminal motivation tapes he'd used the first time around, went back on the nicotine patch, bought a self-help book, and joined a counseling group, but several months into the process, he was getting nowhere. So in November, he got a prescription for Chantix (varenicline), a six-month-old drug that is the first new quit-smoking treatment in a decade.

The pills don't work for everyone but quickly diminished Quartier's cravings. "By the eighth day I was absolutely ready" to give cigarettes up again, he said.

Though most smokers try to quit without help, nicotine-free treatments including Chantix and longtime staples like nicotine gum and patches are more effective than trying to quit "cold turkey," according to experts and research.

Next, Dr. Wes questions the federal push toward pharmacological treatments and provides some compelling arguments:

Well it seems that nicotine patches are now part of the federal guidelines regarding smoking cessation issued by the Public Health Service, a division of the Department of Health and Human Services. But an interesting twist to these guidelines was revealed yesterday (WSJ, subscription):

(Doctor) Michael Fiore is in charge of revising federal guidelines on how to get smokers to quit. He also runs an academic research center funded in part by drug companies that make quit-smoking aids, and he personally has received tens of thousands of dollars in speaking and consulting fees from those companies. ... Dr. Fiore, a University of Wisconsin professor of medicine, headed the 18-member panel that created those guidelines. He and at least eight others on it had ties to the makers of stop-smoking products.

Those opposed to urging medication on most quitters note that cold turkey is the method used by the vast majority of former smokers. They fear the federal government's campaign could discourage potential quitters who don't want to spend money on quitting aids or don't like the idea of treating their nicotine addiction with more nicotine.

"To imply that medications are the only way is inappropriate," says Lois Biener, a senior research fellow at the University of Massachusetts at Boston who has surveyed former smokers in her state. "Most people don't want them. Most of the people who do quit successfully do so without them."

What is interesting is the way the government makes these recommendations: based on clinical trials. And who is better equipped to perform clinical trials than drug companies? (Bias 1). Further, all of the individuals in clinical trials must sign consent, and therefore have to be willing to take a drug (Bias 2). So these "clinical trials" are, by their very nature, skewed toward those willing to take a drug.

But in the interest of revealing effectiveness of these smoking cessation drugs in the real world, another type of study, an observational population trial that looks at all comers to the smoking cessation party, found this:

Studies of quitters outside clinical trials have shown no consistent advantage for medicine over cold turkey, the pharmaceutical industry's primary competitor. An unpublished National Cancer Institute survey of 8,200 people who tried quitting found that at three months, users of the nicotine patch and users of bupropion (Wellbutrin) remained abstinent at higher rates than did users of no medication. But at nine months, the no-medication group held an advantage over every category of stop-smoking medicine. The study was presented at a world tobacco conference last summer.

Finally, a recent Biological Psychiatry commentary addresses the links between alcohol and nicotine addiction, including the genetic links, shared neurobiological mechanisms, shared behaviors and treatment.

Epidemiologic data confirm that: (1) heavy drinking may stimulate smoking; (2) cessation of smoking may enhance abstinence from alcohol; and (3) combined treatment for dual addiction may achieve the most beneficial treatment outcome.

Teen drinking laws update

A couple of weeks ago I posted about laws that allow teens to drink with their parents and asked for info on Michigan law. Brian, a student of mine who is also a juvenile probation officer sent this:

I checked into the laws governing underage drinking related to parents here at the courthouse. There are no laws that allow for parents to let their kids drink in any circumstance. However, there are limited exceptions. One is allowed for religious purposes in a religious setting. Another is for educational purposes like in a culinary class for cooking. If a parent provides or allows a kid to drink they can be charged with contributing to the delinquency of a minor or furnishing alcohol to a minor.

Thanks Brian!

Pseudophedrine restrictions a boon to Mexican cartels

Recent efforts may have been successful at reducing American meth production, but it appears Mexican cartels may be picking up the slack.

The Combat Methamphetamine Act of 2005, which trumps laws that had already been passed in many states, made stores move their cold medicines containing the decongestant pseudoephedrine - which can be extracted and used to make methamphetamine - behind the counter, limit the amount that consumers can purchase and require purchasers to present photo identification. Stores must also keep personal information about these customers in a logbook for two years.
The regulations lend an illicit air to a legitimate attempt to banish a stuffy nose. Many cold meds now include phenylephrine, which doesn't carry the same restrictions - or efficacy....

But if consumers view this new counter ritual as a small sacrifice to keep meth off the streets, they may be disappointed to see that tough restrictions at the drugstore have failed to dent availability of the illegal drug. Restricting pseudoephedrine may have shut down small-time neighborhood meth cookeries, but Mexican cartels have seized the opportunity to swoop into unconquered territory and make those meth customers their own.

According to the National Drug Intelligence Center's 2007 National Drug Threat Assessment, "Marked success in decreasing domestic methamphetamine production through law enforcement pressure and strong precursor chemical sales restrictions has enabled Mexican (drug trafficking organizations) to rapidly expand their control over methamphetamine distribution - even in eastern states - as users and distributors who previously produced the drug have sought new, consistent sources."
Additionally, the flow of "ice" - highly concentrated meth that is usually smoked - from Mexico has increased sharply, most likely creating more addicts because of the better high it creates, states the report.

So while lawmakers have focused on regulating sniffling customers at drugstore counters, Mexican cartels have monopolized the gaps left in the meth market, bringing their goods - and guns - across a porous border. "Now, approximately 80 percent of all meth purchased in the U.S. originates from Mexican labs,"

This has gotten some attention on some blogs, but feels like they're trying to have it both ways: "Look! The boneheaded drug warriors have created a crisis. They've given a gift to those vicious Mexican drug cartels, who are invading thanks to our porous borders."; and "Look! The boneheaded drug warriors are hyping meth use. There's no crisis and there never was!"

This particular columnist is politically conservative and has previously written at least a few articles on immigration. Is this just an opportunity to raise alarm at illegal immigration?

No Child Left Untested?

The ONDCP is starting a new push for random drug testing of athletes in schools. A truly awful idea. This article includes Q & A with representatives from the Drug Policy Alliance and ONDCP. It's a shame that the fringes get the spotlight.

The Michigan High School Athletic Association has weighed in against drug testing.

Dopey, Boozy, Smoky—and Stupid

The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren't all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policy should be to minimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.

That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

• Don’t fill prisons with ordinary dealers.
• Lock up dealers based on nastiness, not on volume.
• Pressure drug-using offenders to stop.
• Break up flagrant drug markets using low-arrest crackdowns.
• Deny alcohol to problem drinkers.
• Raise the tax on alcohol, especially beer.
• Eliminate the minimum drinking age.
• Prevent drug dealing among kids.
• Say more than “No.”
• Don’t rely on DARE.
• Encourage less risky forms of nicotine use.
• Let pot-smokers grow their own.
• Encourage problem drug users to quit without formal treatment.
• Expand opiate maintenance.
• Work on immunotherapies.
• Get drug enforcement out of the way of pain relief.
• Create a regulatory framework for performance-enhancing chemicals.
• Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
• Stop sacrificing foreign policy and human rights objectives to drug control.

How kids can drink at home, legally

It was news to me that 31 states permit underage drinking with a parent:

"You can be 10 years old and drink in Virginia," said Beth Straeten, a spokeswoman for the state's Department of Alcoholic Beverage Control.

Surprised?

...Eleven states, Virginia among them, say providing alcohol to an underage son or daughter can only occur in the home. Twenty other states say parents can provide alcohol to their children anywhere.

The Virginia exception was passed during the 2006 legislature. It drew only two negative votes and won the signature of Gov. Timothy M. Kaine.

I was unable to find out what Michigan's law is. I'll post an update if anyone fills me in.

[Update: Jess found what appears to be the relevant Michigan law and there does not seem to be any language that would permit a minor to drink with a parent.]

Scientology Treatment Program for Prisoners Funded by Feds

Scientologists have scored a victory in New Mexico:

Federal tax dollars are helping to pay for a controversial addiction-treatment program for prisoners in New Mexico based on Scientology precepts...

The Second Chance program is billed as an alternative treatment program for nonviolent offenders and uses the principals of Scientology -- such as using saunas, diet, massage and vitamins to purge the body of toxins -- to fight addiction. In New Mexico, 24 of the state's 84 district judges have referred a total of 50 clients to the program since it opened last September.

Second Chance is the only Scientology-based treatment center for inmates in the U.S. A former chief district judge from Albuquerque, W. John Brennan, is a paid consultant hired to promote the program to his former colleagues. But the current chief district judge, William Lang, doesn't want judges to make referrals to the program, saying he is suspicious of its relationship with the Church of Scientology even though program officials say there is no link.

..."There's a lot of use of sauna with the idea that you sweat out toxins in the system," said addiction expert Bill Miller, who reviewed the program at the request of the city of Albuquerque. "I don't know of any scientific basis for that. It wasn't clear to me what sort of scientific basis there was even for the conception of the program to begin with."

The most troubling thing about Narconon and other Scientology-based programs is their consistent denials of any connection to the Church of Scientology. Offering a faith-based program is one thing, but misrepresenting themselves is another.

Stats.org weighed in on the WSJ's over-tentative reporting on matter. Unfortunately the author (Maia Szalavitz) appears to have forgotten to include Twelve Step Facilitation when mentioning evidence-based treatment strategies.

Why is it so hard to help drug-addicted criminals?

Here's a column about a rejected proposal (Hamilton, Ontario) to house an addiction counselor in the police department to intervene at the time of arrest throughout the judicial process. The goal is to capitalize on the crisis of being arrested and charged with a crime as an opportunity for active linkage to help rather than a passive referral.

It was shot down because they wanted prevention programs. It's an interesting idea that could be effective.

What's more interesting is what this (and programs like drug courts) says about systemic ownership of the problem of addiction. Over the last decade or so the criminal justice system has been realizing that the drug problem is not a simple criminal matter and they they are not equipped to respond in an effective and humane manner. The response has been to incrementally develop therapeutic responses within the criminal justice system, many with decent results. However, it seems that the real issue is what system(s) should "own" the problem.

There's a push right now to move ownership from the criminal justice system to the public health system (not necessarily the treatment system). If this movement was successful, I suspect that within a generation there would be renewed calls for ownership to be transferred back to the criminal justice system.

Right now I'm thinking that it doesn't have to be and either/or decision. It seems that there could be shared ownership to some extent--maintaining some reduced measure of prohibition (I know that the work prohibition freaks people out, but we prohibit everything from speeding to murder. Pretty broad continuum of enforcement approaches, no?) and rebuilding access to a treatment system with continuous recovery management.

Alternative treatments give addicts a chance

An opinion piece on Sam Sullivan's (Vancouver's Mayor) proposal for stimulant maintenance programs. (Previous post here.) Grrrr.

Vancouver mayor proposes 'revolutionary' plan for addicts

Vancouver's Mayor is promoting his plan for stimulant maintenance again and calling it treatment. This is the same guy who suggested that addicts and the public need to get real and accept addiction as a permanent disability, like his experience of having to accept his spinal cord injury and life in a wheel chair.

Vancouver Mayor Sam Sullivan is lobbying the federal government for an exemption from Canada's narcotics laws that would allow what he calls a "revolutionary" alternative drug-treatment plan to give substitute drugs to at least 700 cocaine and crystal-meth addicts.

If he is successful, Vancouver would be a global pioneer in running such a large-scale program of drug maintenance for stimulant-drug users.

Sullivan said the drug plan, along with three other key elements that have to come from Ottawa or Victoria, will eliminate most of Vancouver's problems with homelessness, panhandling and drug-dealing. Those are the three social problems he promised to reduce by half in time for 2010 in the Project Civil City initiative that he launched in November.

U.S.-Style Rehabs Take Root in China As Addiction Grows

A shift in problem ownership of addiction from criminal justice to specialty treatment providers:

Half an hour outside this capital city in southwest China's Yunnan province, amid 100 acres of fruit trees and vineyards, three dozen recovering drug addicts stand every morning in a loose circle, their arms around each other's shoulders.

The voices that ring out do not recite the forced slogans and denouncements often heard in China's state facilities for drug users. Instead, the group reads aloud a mission statement that has been adopted from a New York-based drug treatment center:

"I am here because there is no refuge," the participants said in unison on a recent Saturday morning. ". . . Until I confront myself in the eyes and hearts of others, I am running."

That focus on individual responsibility and peer interaction is atypical for a drug treatment facility in China. Much more common are techniques used at the nearly 600 compulsory detoxification centers run by the police, or the even tougher techniques used by the Justice Department at reeducation campuses for repeat offenders. Both are military-like institutions that emphasize manual labor as part of their regimen.

Ending an Opium War: Poppies and Afghan Recovery Can Both Bloom

Washington Post columnist Anne Applebaum argues for the U.S. to start purchasing opium poppies from Afghanistan. She frames it through a lens of Afghan national stability and U.S. foreign policy interests. Her arguments are persuasive, unfortunately a couple toss away lines suggest a bias:

Of course it isn't fashionable right now to argue for any legal form of opiate cultivation.

...

The only good arguments against doing so -- as opposed to the silly, politically correct "just say no" arguments --...

What are the "just say no" arguments anyway? Am I silly for feeling queasy about the idea of further institutionalizing poppy farming and wondering if has the potential to increase international production?

I'd also challenge the "politically correct" and "unfashionable" feels spurious., she's hardly in the wilderness. Certainly, the White House is staunchly pro-war-on-drugs, but the media, academics, public health activists, and growing numbers of politicians and political thinkers on both ends of the spectrum are increasingly calling for radical changes in drug policy--including legalization

Public support for parity

Mental Health American (formerly the National Mental Health Association) released a poll on mental health and substance abuse parity this week. They are an advocacy group, so they have a clear bias, but the results they report are overwhelming:

Americans Think Health Coverage Should Include Mental Health and Substance Abuse... A large majority (74%) believe that insurance plans should cover substance abuse treatments at the same levels as treatments for general health issues. 23% feel that they should not be covered equitably. * The public demand for mental health equity is bipartisan -- 83% of Republicans and 92% of Democrats want equitable health insurance.

The other losing war

Commentary on the impact of the war on drugs in this hemisphere.

Big score holy grail for drug officers

A peak inside some of the culture problems in the narcotics unit in Atlanta. This article paints a picture of a unit that wants to make big busts but has so much pressure to generate arrests that they spend all their time arresting people with small quantities and sometimes cutting corners to get them. This is presented as the context for a shootout with a 92 year old woman that ended in her death.

Kennedy, Ramstad hit the road to tout mental health measure

Substance abuse and mental health parity bills have been introduced several times in the last decade. Supporters reportedly have all the votes they need to pass it and President Bush has indicated that he would sign it, but Republican house leadership consistently blocked it from going to the floor for a vote. Hopefully this will be an opportunity to enact it.

Reps. Patrick Kennedy (D-R.I.) and Jim Ramstad (R-Minn.) will embark on a six-city tour today to tout legislation that would require insurance companies to treat mental illness and addiction just as they would any physical illness. The tour will kick off in Providence, R.I., then head to Ramstad’s district in Minnetonka, Minn., and continue on to Rockville, Md., Los Angeles and Vancouver, Wash.

Radical Recovery

For MLK day, here's an article by Bill White on "radical recovery." He describes a convergence of social activism and addiction recovery.

The article offers a model that goes well beyond the the interests of recovering people themselves and encourages advocacy in larger community contexts:

A radical recovery movement is now rising in America. That movement is flowing from the realization that addiction and its progeny of problems are visible everywhere, while recovery from addiction lies hidden. It is rising in the recognition that the stigma attached to AOD problems has increased in recent decades and has fueled the demedicalization and recriminalization of these problems. What started out as “zero tolerance” for drugs rapidly evolved into zero tolerance for people with AOD problems. It is in this regressive climate that a style of recovery is emerging that is radical in its scope (focus on environmental as well as personal transformation), radical in its inclusiveness (celebration of multiple pathways and styles of recovery), and radical in its synthesis of social responsibility and personal accountability. People in recovery are looking beyond their own addiction and recovery experiences to the broader social conditions within which AOD problems arise and are sustained. A radicalized vanguard of people in recovery is using personal transformation as a fulcrum for social change. They are living Gandhi’s challenge to become the change they wish to see in the world. Those who were once part of the problem are becoming part of the solution.

My Adventures in Psychopharmacology

A 23 year old women tells of her nightmarish experience with the psychiatric and addiction treatment system. She was prescribed 15 different drugs over a period of 5 years and, surprise, surprise, when treatment failed, she was blamed. The story ends with her being presumably correctly diagnosed and treated, but it's hard not to wonder if she has a chronic mentally illness at all.

Aside from the iatrogenic harm that professional hubris can cause, this story illustrates the hazards of a system that encourages rapid diagnosis.

Medication Nation

The Washington Post published a review of the recently published book, The Cult of Pharmacology by Richard DeGrandpre. DeGrandpre presents a pretty provocative premise:

Why isn't Nicorette gum a street drug? The Food and Drug Administration considers nicotine highly addictive. Tobacco companies seem to share this view when they manipulate the level of nicotine in cigarettes. But the gum, which packs a goodly dose of nicotine, appeals to almost no one. While we're at it, if nicotine dependence is what stands in the way of quitting, why do patched smokers -- their brains well-supplied with the substance -- still crave the next drag?

If these questions have an answer, it is that addiction is not a simple matter of chemical and receptor. Habit, ritual, social context and the means of delivery all affect how the brain processes a drug and how we experience it. As a result, drug research is replete with paradox.

...

Psychoactive compounds, he writes, function "as mere stimuli, with more or less the same, potentially great, powers as other stimuli one experiences and gives meaning to." DeGrandpre derides a set of beliefs that he groups under the infelicitous name "pharmacologicalism." This false ideology, he writes, holds that "drugs contain potentialities that lie within the drug's chemical structure . . . and when taken into the body, these potentialities take hold of and transform both brain and behavior." According to DeGrandpre, drugs do not work in any consistent, predictable way -- and we've been brainwashed if we think that they do.

The prevailing ideology, DeGrandpre argues, has another, equally insidious side. It causes us to attribute different powers to substances that are effectively identical. We demonize cocaine, a natural stimulant, but sanctify its synthetic counterpart, Ritalin. This benefits the "medicopharmaceutical industrial complex," which favors what can be patented and profited from. Ultimately, our confused beliefs lead to forms of social control, causing us to drug our children with stimulants while imprisoning consenting adults for taking nearly identical substances such as crystal meth.

The reviewer writes a thoughtful and effective critique of DeGrandpre's arguments:

The problem with DeGrandpre's argument is that he, more than his imagined opponents, ignores context. The findings of behavioral pharmacology are not unique; in medicine, environment often modifies physiology. Interferon, a medication used to treat certain cancers, causes depression, but it does so less in people who have social supports and more in patients who have had past depressive episodes. To show that the response is multifactorial hardly invalidates the claim that the drug triggers mood disorders.

Expectancy is powerful. Acupuncture is effective in pain relief. But so is sham acupuncture -- using shallow needles inserted at random points. Pain responds to placebos. It does not follow that pain lacks anatomical roots or that the use of aspirin for pain management amounts to a conspiracy.

Our drug policies, arising from puritanical moralizing as much as from the needs of corporations, are often irrational. Still, not every choice is without foundation. Like cocaine, Ritalin modulates dopamine transport in the brain. But schoolchildren who take Ritalin by mouth generally experience no high and develop no craving, while snorting cocaine famously does cause a rush. And crystal meth's minor chemical distinction -- it is water soluble and therefore easy to inject -- makes a major practical, and addictive, difference. That we allow Ritalin to be prescribed suggests that, as a nation, we pay attention both to drugs' chemical properties and to their customary usage -- hardly a sign of ideological rigidity.

It's too bad he throws in the drug policy statement. The suggestion that the motivations for U.S. drug policy are two-faceted and wholly insidious reveals his own ideology.

The needle and the damage done

This 2 year old article about the disciplinary of some British methadone maintenance physicians has been making the rounds today. It has a pretty clear bias for maintenance, but it offers quite a bit of history about the British opiate addiction treatment. It also illustrates how committed the British system has been to methadone. The whole debate is between methadone detox and methadone maintenance.

As the story of these doctors progresses, it includes drugs (obviously), Madonna, Hollywood and martial arts--what more could you want?

Three of the doctors involved were found guilty of misconduct and one was stripped of his license.

Tobacco report cards

The American Lung Association issued report cards for all 50 states on their tobacco policies. Michigan didn't fare too well:

REPORT CARD

STATE OF TOBACCO CONTROL 2006 MICHIGAN

Grades:
Smokefree Air - F
Youth Access - F
Tobacco Prevention and Control Spending - F
Cigarette Tax - A

Advocates Renew Push for Mental Health 'Parity' Bill

This NPR story suggests that there is a good opportunity right now for passing parity legislation. The story never mentions addiction treatment. In the past, every time they get close to passing comprehensive parity (mental health and addiction), they drop addiction. We'll see what happens with this go-round.

Drug Wars in the blogosphere

Matthew Yglesias offers an interesting deconstruction of an all or nothing agrument against the war on drugs:

I guess this is something liberals and libertarians are supposed to agree about, but I consistently find it bizarre that there are some people who seem to think it would be a good idea if you could just walk into your local convenience store and pick up some heroin or crack along with your Fritos and Diet Coke. At times, people taking this line seem to argue that drug prohibition couldn't possibly be having any beneficial effects because, after all, you can still find heroin. Naturally enough, you don't see anyone proposing that the "war on mugging" be ended simply because mugging-prohibition has failed to actually eliminate the proscribed activity. That said, like any reasonable person I think many aspects of current crime-control and drug-control policy in the United States don't make sense. So I have a hard time knowing what to make of things like this from Jerry Taylor:

While it should be obvious to any fair-minded observer that our increasingly brutal war on drugs is a losing proposition on all counts, few of us seem to be fair minded observers. So allow me to pose a question to those of you still clinging to this benighted enterprise: Exactly what would it take to convince you that the drug war was causing more harm than good? Is there any bit of data, any hypothetical fact, or anything at all that would cause you to give up the policy ghost? Because if there is not, then we are in the realm of religious belief — and that’s about all that I can find to support this cruel, costly, and counterproductive jihad.

I mean, I'm not even clear on what question's being asked here. Do I think the status quo is preferable to total deregulation of currently prohibited drugs? I would say so. But considering how heavily regulated the use of alcohol and tobacco is, one hardly imagines that a heroin free-for-all (ads after school cartoons, for sale out of ice cream trucks) is a likely alternative policy. So, I don't know. What is the "war on drugs" exactly? Does it do more harm than good compared to what?

Recovery: The bridge to integration?

Bill White and Larry Davidson suggest that shifts toward recovery orientation models in mental health and addiction services could serve as a bridge toward integration:

“Recovery-oriented system transformation” is becoming an umbrella concept for integrating behavioral healthcare and creating systems of care that are culturally competent, trauma-informed, evidence-based, inclusive of families, based on strengths, and connected to communities (as indigenous sources of recovery support). Leading the call for such system transformation are new recovery advocacy movements in both the addictions and mental health fields. These movements, led by people in recovery, their families, and visionary professionals, are demanding that care be focused on the processes of long-term recovery and anchored within natural supports and local communities.

Theoretically, I don't disagree at all. My fear is that this process will not be a merger between equals, my experience (admittedly limited to southeastern Michigan) is of watching mental health systems devour addiction treatment systems. This fear is compounded by the fact that, at least in our region, mental health agencies are well-organized and well-connected governmental behemoths while addiction treatment programs are small, unstable and diffused.

Consider these historical reflections from some of Bill's other works:

The Segregation/Integration Pendulum
American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them. When the 21^st century once again gives birth to specialized addiction treatment, perhaps this “new” institution will be given a colorful name fitted to its form and function – perhaps something like inebriate asylum.

Diffusion and Diversion
Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.

The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.

A Panicked Field In Search of Its Soul and Its Future
In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.

This Is Your Brain on Drugs, Dad

In an Op-Ed in the New York Times, Mike Males calls for an end to "the obsession with hyping teenage drug use." I have the same reaction every time I read something from him. He always does a good job arguing that we while our attention is on drugs, sex and violence among youth, the biggest problems in these area are adults.

Among Americans in their 40s and 50s, deaths from illicit-drug overdoses have risen by 800 percent since 1980, including 300 percent in the last decade. In 2004, American hospital emergency rooms treated 400,000 patients between the ages 35 and 64 for abusing heroin, cocaine, methamphetamine, marijuana, hallucinogens and “club drugs” like ecstasy.

Equally surprising, graying baby boomers have become America’s fastest-growing crime scourge. The F.B.I. reports that last year the number of Americans over the age of 40 arrested for violent and property felonies rose to 420,000, up from 170,000 in 1980. Arrests for drug offenses among those over 40 rose to 360,000 last year, up from 22,000 in 1980. The Bureau of Justice Statistics found that 440,000 Americans ages 40 and older were incarcerated in 2005, triple the number in 1990.

...

In 1972, the University of Michigan researchers who carry out Monitoring the Future found that just 22 percent of high school seniors had ever used illegal drugs, compared to 48 percent of the class of 2005. Yet as that generation has aged, it has been afflicted by drug abuse and its related ills — overdoses, hospitalizations, drug-related crime — at far higher rates than those experienced by later generations at the same ages.

However, I get the sense that his intention is for the reader to be more alarmed about adult behavior and less alarmed about youth behaviors. I tend to be more alarmed about both young people and adults. He also (unintentionally?) makes the case that the problem is worse than we realize:

When releasing last week’s Monitoring the Future survey on drug use, John P. Walters, the director of the Office of National Drug Control Policy, boasted that “broad” declines in teenage drug use promise “enormous beneficial consequences not only for our children now, but for the rest of their lives.” Actually, anybody who has looked carefully at the report and other recent federal studies would see a dramatically different picture: skyrocketing illicit drug abuse and related deaths among teenagers and adults alike.

While Monitoring the Future, an annual study that depends on teenagers to self-report on their behavior, showed that drug use dropped sharply in the last decade, the National Center for Health Statistics has reported that teenage deaths from illicit drug abuse have tripled over the same period [emphasis added]. This reverses 25 years of declining overdose fatalities among youths, suggesting that teenagers are now joining older generations in increased drug use.

Everything I've read by Males is thought provoking and worth reading. I just always feel that he's successful in making his case about adults but fails to persuade me that we're overly concerned about young people.

Alcoholics forced into hospital treatment

Australia is piloting a program that commits their most severe addicts and alcoholics for 28 days. Interesting in light of Australia's embrace of harm reduction:

HEAVILY-addicted drug users and alcoholics will be forced to have treatment in hospital under a two-year pilot proposed by the New South Wales Government.

The trial, with up to 28 days of involuntary care at Nepean Hospital, would be a "circuit breaker" for the most severely addicted, state Health Minister John Hatzistergos said today.

"The four-bed service at Nepean Hospital will aim to break the addiction cycle for alcoholics and long-term entrenched drug users, before they are referred to longer-term treatment and rehabilitation with community support and follow-up," he said.

"We expect up to 50 patients a year from western Sydney will be treated in the four-bed secure unit."

The Government is drafting changes to the Inebriates Act 1912 to enable the trial to take place.

The changes would allow medical practitioners to seek a court order referring a severely drug- or alcohol-dependent person to compulsory treatment.

Marijuana Policy

This morning's post on the evolving sentiment toward marijuana policy reminded me of this interview with Bill White from Bill Moyer's Close to Home PBS series. I always thought that medical marijuana advocacy was a joke was an ineffective way to promote policy change, but I now think that they're having success in changing who we associate with marijuana.

White: ...you would be hard-pressed to build the case why in certain cultures opiates are celebrated and in other cultures alcohol is celebrated. I would suggest that it has little to do with science or pharmacology in either culture. It has much more to do with the historical niche that a drug fills within that culture. Most importantly, drug policy depends on whom we associate with that drug [emphasis added]. We almost always confuse our feelings about drugs with our feelings about the people we believe to use those drugs.

...

Moyers: How, then, were our drug laws developed?

White: They grew out of racial and class struggles, particularly on the West Coast and in the South. The first state laws were based on this sort of "dope fiend" caricature -- showing somebody of a different race and a different culture. In California, it was Chinese railway workers smoking opium; in the South, it was black men using cocaine. The reality is that the vast majority of people addicted to narcotics in the late 19th century were white affluent women, who were primarily addicted through traditional medicine or over-the-counter "patent" medicines. The caricature which drove the prohibition campaigns in the late 19th century bore little resemblance to reality. And, to give you a modern version of that, in the mid-1980s, when cocaine was overwhelmingly a white phenomenon in America, the images which began to appear on television were overwhelmingly of African-Americans, particularly young African-Americans enjoying crack cocaine on a street corner. If you look at all the exposes of drug exposed infants, we see young African-American infants, trembling in neonatal intensive care units. But that image was not the reality of cocaine addiction in the United States in 1985.

Moyers: Why?

White: At that exact point in time, those who were addicted to this drug were overwhelmingly white and affluent. The best predictors of cocaine use at that point were education and income. As years of education went up and annual income went up, the probable use of cocaine went up. Yet the image was and still is that we have poor inner-city African-Americans involved in all of these criminal illegal markets. Much of the anti-coke rhetoric and the changing of laws it generated was based on that early image. But in 1985, it had little relationship with reality.

Weed, weed, weed.

The LA Times reports on the DEA's efforts to target California's large, higher profile "medical" marijuana businesses.

The conservative Washington Times runs a UPI story that these larger business are claiming that they are unfairly targeted.

The conservative Pittsburgh Tribune-Review ran a scathing anti-drug war editorial and a letter to the editor on the recent NORML report about marijuana as the U.S.'s largest cash crop.

Finally, a DEA press release from earlier this year on some dealer's creative packaging of marijuana. Includes photos.

I've seen some year-end commentary on failures in efforts to change marijuana policy in 2006, but I think there's little doubt that it gained traction as a political issue. Growing numbers of conservative ideologues are joining libertarians and liberal ideologues in calling for radical reform in drug policy. The issue may be placed on the back burner as we approach a presidential election cycle, but I don't see it fading. What's interesting about this is that the conservatives involved see it as a conservative issue, liberals involved see it as a liberal issue, and libertarians see it as a libertarian issue. If these groups can form a functional coalition, they could be pretty effective in advocating greater latitude for states to experiment with drug policy and organizing support for state-level legislation and ballot initiatives.

Changing tactics: Recovery programs crucial to winning drug war

A Kentucky paper discusses an alternative to the war on drugs:

No one thinks drug abuse is OK. The question is how best to fight it.

There are signs that the answer is shifting toward fighting drug abuse one person at a time, helping users recover, preventing others from getting hooked.

It's slow, it's personal, it's expensive. But without it, history and economics say, we are doomed to failure.

Vendor's reefer sadness

The LA Times reports on municipalities wrestling with the growth of the medical marijuana trade and how this trade should be conducted:

Kevin Reed launched his medical marijuana business two years ago, armed with big dreams and an Excel spreadsheet.

Happy customers at his Green Cross cannabis club were greeted by "bud tenders" and glass jars brimming with high-quality weed at red-tag prices. They hailed the slender, gentle Southerner as a ganja good Samaritan. Though Reed set out to run it like a Walgreens, his tiny storefront shop ended up buzzing with jazzy joie de vivre. Turnover was Starbucks-style: On a good day, $30,000 in business would walk through the black, steel-gated front door.

Today, the 32-year-old cannabis capitalist is looking for a job, his business undone by its own success and unexpected opposition in one of America's most proudly tolerant places. Critics in nearby Victorian homes called Reed a neighborhood nuisance. Although four of five San Francisco voters support medical marijuana, the realities of dispensing the contentious medicine have proved far more controversial.

It has been 10 years since California approved Proposition 215 — the Compassionate Use Act — becoming the first state to define marijuana as a medicine. The 389-word act aimed to ensure seriously ill Californians the right to use marijuana. But it said nothing about how they might get the drug — and left ample regulatory ambiguity.

Today, about 200,000 Californians have a doctor's permission to use cannabis, which they can obtain through more than 250 dispensaries, delivery services and patient collectives — 120 of them in Los Angeles County alone. Medical marijuana, activists say, has become a $1-billion business.

IBM Worker Says He Was Fired For Chat Room Addiction

More details about the internet addiction lawsuit that I posted about a couple of weeks ago. Again, this is noteworthy because it looks like the court may weigh in on whether internet addiction is a disability or medical condition that employers need to accommodate.

Long before law, she was face of needle exchange

Good news in New Jersey's new needle exchange law:

The new law includes $10 million to expand drug-treatment options for needle exchange participants.

Overall Youth Drug Use Down in 2006, But Survey Sees Trouble Brewing with Inhalants, Prescription Drugs, Smoking

The latest Monitoring the Future drug use survey numbers are out and much of the news is good:

The survey of 50,000 8th-, 10th- and 12th-graders found that the overall percentage of U.S. youths using alcohol or other drugs declined modestly in 2006, continuing a decade-long trend. Since the mid-1990s, past-year use of marijuana has fallen 36 percent among 8th-graders, 28 percent among 10th-graders, and 18 percent among 12th-graders. That led Bush administration drug czar John Walters to cite a "substance-abuse sea change among American teens."

"They are getting the message that dangerous drugs damage their lives and limit their futures," said Walters, director of the Office of National Drug Control Policy (ONDCP).

...

Use of marijuana, the nation's most commonly used illicit drug, has been the main focus of the ONDCP's antidrug media campaign. Not surprisingly, federal officials this week celebrated the fact that past-month use of marijuana reported by MTF survey participants has fallen 26 percent since 2001, from 16.6 percent of teens in 2001 to 12.5 percent in 2006. NIDA Director Nora Volkow called this finding "great news."

Some of the researchers are expressing concern about some of the findings:

The University of Michigan, which produced the report, took a more nuanced view, noting that while there was little evidence of increased drug use, reported overall declines in adolescent drug use were relatively small, and that use of many drugs -- including inhalants, LSD, powder cocaine, crystal methamphetamine, heroin, and club drugs like Ketamine, Rohypnol, and GHB -- did not decline at all.

Lloyd Johnson, Ph.D., principal investigator of the study, expressed particular concern about a decline in perceived risk of using inhalants. Use of inhalants did not increase in 2006, according to the study, but inhalant use has been rising among American youth in recent years. "Perceived risk is often a leading indicator of changes in actual use," said Johnston. "So when we see a change like this, we take it as an early warning of trouble ahead."

Misuse of prescription drugs, which also has risen sharply in recent years, did not increase in 2006, but remained at "unacceptably high levels,"... About 9 percent of 2006 survey respondents said they had used prescription narcotic drugs like OxyContin and Vicodin within the past year, and between 4 and 7 percent of 8th- to 12th-graders said they had used over-the-counter cold medicines -- typically containing dextromethorphan -- to get high.
...

University of Michigan researchers also sounded an alarm about youth smoking, saying the MTF findings indicate that the trend toward lower smoking rates among children in their early and middle teens has ended. While current daily smoking has fallen by half among 12th-graders and more than half among 8th- and 10th-graders since the mid-1990s, no further declines were reported in the 2006 survey among 8th- and 10th-graders (daily smoking declined slightly among 12th-graders, from 13.6 percent in 2005 to 12.2 percent in 2006).

Perceived risk of smoking also has leveled off, which researchers said could be due to slackening public attention and publicity about the dangers of smoking. On the other hand, lifetime use of cigarettes has declined by about half among 8th-graders, by 40 percent among 10th-graders, and by 30 percent among 12th-graders since the mid-1990s. Overall smoking rates among all three grades are at an all-time low, and disapproval of smoking among teens is still rising among teens.

Dynamic Drug Policy

An editorial in the new issue of Addiction questions the static drug policy models that dominate current policy debates:

Drug researchers have long understood that there can be long-term waves of greater and lesser drug use and that upswings can involve epidemic-like spread. These and other dynamics discussed below imply that policy ought to vary over the course of a drug use cycle, but drug policy debates have not yet internalized this perspective.

...

Because drug problems vary in these complex ways, it seems plausible that drug policy should vary over time as well; yet it is rare to hear someone couch their drug policy recommendations in these terms. This is striking and more than a little troubling. It suggests that the mental models guiding policy discussions implicitly superimpose a static framework on an intrinsically dynamic phenomenon, akin to popular nostrums for get-rich-quick investing that never vary even as economic conditions change over the business cycle.

It is not clear why policy is not discussed more often in dynamic terms. Perhaps disciplinary boundaries and stove-piped bureaucracies create single-issue advocacy. Perhaps both the health and criminal justice perspectives favour individual-level analyses. Whatever the reasons for their absence to date, dynamic perspectives on drug policy are, in fact, possible.

What are the policy implications? The author discusses the stage-specific limitations and strengths of several approaches:

Preventing an initiation in the early stages of an epidemic is tremendously valuable, because it short-circuits a chain reaction that would have involved many people. (In technical terms, the reproductive rate at that point would have been large.) However, primary prevention cannot be timed to react to a burgeoning epidemic because of intrinsic lags. For example, the median age of cocaine initiation in the US is 21 years, but students in school-based prevention programmes are younger, often only 13 years old. Therefore, if school-based prevention interventions were to have any hope of affecting cocaine initiation dramatically, the ideal time to have run them would have been in the early 1970s, 8 years before the peak in initiation. However, no one knew in 1970 that there was a cocaine epidemic brewing. Conversely, the vast majority of cocaine consumed from 1985 to 2005 was consumed by people who were already older than 13 years in 1985. For instance, over 85% of people the Treatment Episode Data Set (TEDS) records as receiving treatment for cocaine between 1992 and 2003 were born before 1973. Consequently, prevention programmes initiated around the time the cocaine epidemic became salient could not possibly have had a dramatic effect on use over the next generation, regardless of how effective they were.

Treatment also has limited ability to stave off a burgeoning epidemic, because early in the epidemic most users do not have a treatable medical condition. Precise estimates are not available because population-level estimates of treatment need exist only for recent years, but need for treatment is correlated with average duration of use. In 2003, 39% of respondents reporting past-year cocaine use to the US Household Survey had been using for 10 or more years. In 1979, the peak year for cocaine initiation, that proportion was just 3%. For drugs that are not injected, the role of harm reduction strategies is similarly limited when most users are not experiencing significant harms with their use.

Enforcement's effectiveness at suppressing drug use declines markedly as the size of a drug market grows. However, enforcement has unique ability to focus its effects in both space and time. If a crack house opened next door, neither funding school-based prevention nor additional treatment slots would bring rapid relief. Parking a patrol car in front of the crack house would at least displace the activity. Similarly, assume treatment was five times more cost effective than incarceration at reducing drug use. Incarceration could still be twice as cost effective at reducing drug use this year—because incarceration's effects on drug use are concentrated in the present whereas treatment's effects may be spread over a decade or more. Hence, these models suggest that supply control programmes may have a unique capacity to disrupt the contagious spread of a new drug, but limited ability to eradicate established markets. (Enforcement may also be able to displace established markets into less destructive forms, such as forcing visible street dealing to convert to discreet meetings arranged by cell phone.)

Harm reduction offers particular advantages later in the epidemic cycle, when use has stabilized at high endemic levels. For injectable drugs in countries with low violence and few street markets, harm reduction may focus on syringe exchange programmes, supervised injection rooms and training ambulance crews to treat overdose. For drugs that are not injected and which are supplied through violent street markets, harm reduction may focus instead on using enforcement to target the minority of dealers who cause the greatest social harm. In either case the premise is that, with or without the harm reduction, the flow of new people into problem drug use will be modest, so reducing harmfulness of drug use has few drawbacks. That may not be a safe premise early in an epidemic, when there are feedbacks that can amplify small shocks to the system into dramatic effects on its trajectory.

I'm not sure I agree with the author's assumptions about the strengths and limitations of he various approaches, but he makes a compelling argument:

• that the static models currently being debated and advanced all have their place in policy;
• they are all inadequate by themselves;
• and, that there isn't even a correct formula because the needs, opportunities, crises, etc. are constantly changing.

Biggest U.S. Cash Crop: Marijuana

This report has gotten a ton of press this week. The report says that marijuana follows only corn and soybeans in Michigan with a value of $324 million.

I'll be interested in seeing analysis from disinterested third parties. NORML's interests are obvious and I'm suspicious of the federal estimates that this report is based on due to a history of hyping statistics to shape policy and fight for funding. If the federal estimates are correct, there is almost 1.2 ounces of weed grown for every man, woman and child in the U.S.

Alcohol Policies Really Matter

Timely commentary on alcohol policy from Join Together. It's concise, so I'm posting the whole thing.

Alcohol Policies Really Matter
December 15, 2006

Commentary
By David Rosenbloom

Today we report on the deadly results of Finland's decision to slash alcohol taxes: after two years, alcohol related illness and accidents have replaced heart disease as the leading cause of death among men aged 18 to 65.

There are other national social experiments that are getting similarly bad results. Pubs and bars in England can now stay open almost around the clock. The resulting violence in many town centers, as drunk young men and women spill into the streets, has become a national scandal.

New Zealand lowered its legal drinking age to 18 a few years ago and watched alcohol-related car crashes and deaths among teenagers increase sharply, reversing years of steady decline.

These are sobering reminders that policies about price and availability of alcohol really matter. When the United States raised the minimum drinking age to 21 between 1981 and 1984, there was an immediate drop in deaths from alcohol related accidents in young people; it has stayed near this lower level for 20 years, saving about 1,000 lives a year. The states with the highest beer taxes have significantly lower rates of teenage binge drinking and associated harms than the states with the lowest beer taxes.

Reasonable laws, effectively enforced, save lives. Poor laws -- such as the ridiculously low alcohol taxes in most U.S. states -- cost lives.

I urge all our readers to send Join Together reports about the mistakes in Finland, England and New Zealand to their state and local leaders, reminding them that they have the power to kill or save young people when they adopt new alcohol policies.

David Rosenbloom is the Director of Join Together.

Cold turkey plan for Scots addicts

The Labour Party in Scotland is rolling out a new drug policy. I've posted several times about their treatment system, which pushes methadone and successfully detoxes very few people.

The new policy has a couple of good points, including abstinence based treatment and accountability for reducing wait times:

One senior Labour figure said: "Our view is that there is a place for methadone but it should not be about people being parked on it and then left for years. There has to be an aim of getting them drug-free. Yes, we will help them but they have got a responsibility. People have just thought up till now that they have a right to methadone and that's it."

The insider added: "We feel very strongly that this agenda has been run by a fairly narrow range of people and not enough attention is being paid to people and their families. It is time to shift the balance away from them".

Justice Minister Cathy Jamieson is understood to be furious over the lengthy wait addicts are being forced to endure in order to get into rehabilitation, and is now pressing Health Minister Andy Kerr to put pressure on health boards.

It also has some points that are less recovery focused, including searching prison visitors and having addicts talk to kids about drug use.

Alcohol Ban Eyed on N.Y. Commuter Rails

I remember as a kid watching men take the train home from NYC with a Q in a brown paper bag. (I suspect that this was more powerful than any ad.) Those days may be coming to an end.

Drugs: why we should medicalise, not criminalise

This sounds so rational. When you read the whole column, it's also wrapped in the language of social justice. However, her arguments are so flawed that it's difficult to know where to begin.

Of course we should try to get drug addicts off their drugs. It is good that waiting times are now shorter for rehabilitation. But treatment doesn’t work unless users really, really want to give up. And even then, they often relapse because the cravings are so strong. So it is not surprising that enforced treatment and rehabilitation is so unsuccessful. A National Audit Office report on the Government’s Drug Treatment and Testing Order, a court-administered mandatory programme for addicts, found that 80 per cent of offenders were reconvicted within two years.

It is much more sensible to prescribe a maintenance dose for addicts, which they must take under supervision so they cannot sell it on, until they are ready to try to give up. That way, they can attempt to lead a normal life, to refrain from crime, to stay off the streets, even to hold down a job, until they can wean themselves off the drugs.

Among the flawed assumptions are that:

• addicts don't want help;
  
• treatment is only helpful if they're in the "action" or "preparation" stage of change;
  
• the failure of their lousy treatment system means treatment doesn't work;
  
• legalization would be a panacea for consuming countries and producing countries;
  
• crime should be the measuring stick for the effectiveness of drug policy;
  
• abstinence focused treatment is ineffective;
  
• doing more would be too expensive;
• we have to choose between legalization and maintenance

I'm struggling to find the words, but I also find it troubling that among some HR advocates there is something resembling a fetishizing of heroin addiction or vicarious derivation of street credibility. While speaking to some harms, they fail to grasp the pain and demoralization that addicts experience when they call it an illness but treat it like a lifestyle choice. Why such half-measures when addiction is concerned? Why is the case for treatment on demand framed as a symptom of some kind of moral panic? I suppose I am guilty of moral alarm at the "suble bigotry of low expectations." (Now, now, principles before personalities.)