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 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