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11/16/2015 12:00 AM

When we asked Greg Williams, head of Facing Addiction and organizer of the October 4 rally in Washington, D.C., why Mehmet Oz, M.D., of TV fame — someone with no past at all in the field — was a good choice to talk about addiction, his response was sharp and swift. “Perhaps our ‘field’ needs to stop talking to ourselves about how big this problem is and start talking to new audiences,” he said.

When we asked Greg Williams, head of Facing Addiction and organizer of the October 4 rally in Washington, D.C., why Mehmet Oz, M.D., of TV fame — someone with no past at all in the field — was a good choice to talk about addiction, his response was sharp and swift. “Perhaps our ‘field’ needs to stop talking to ourselves about how big this problem is and start talking to new audiences,” he said.

Williams is widely credited with bringing Oz into the addiction discussion in September with last month’s rally. But, Williams told ADAW, it wasn’t anything that Facing Addiction engineered. “We just were a big addiction story at the same time their show decided to focus on these issues,” Williams said last week. “We are thrilled he is opening up this important conversation for millions of Americans.”

And that is key: getting the addiction message to the many people who are concerned about it but not knowledgeable. Even Oz, a cardiologist, is approaching the topic “like a journalist instead of an expert,” said Williams.

Reaching the audience

Nobody would disagree that Oz is more a media personality than an academic or medical expert. But that can work to the benefit of patients, prospective patients and treatment providers. Consider this comment sent to us by the National Institute on Drug Abuse (NIDA) on Oz:

“Given the broad reach of the Dr. Oz show, the program has the potential to deliver important educational information about addiction prevention and treatment to millions of viewers nationwide and NIDA has worked with them in the past to provide scientific information on selected initiatives. For example, the Dr. Oz show has supported NIDA’s National Drug Facts Week in the past by promoting it through social media. More recently, NIDA provided input to a parent discussion guide created by the Dr. Oz show for their Night of Conversation project.”

Night of Conversation

“The Dr. Oz Show,” as the program is called, has urged all Americans to talk about drugs at dinnertime on November 19. This “National Night of Conversation” is being conducted in partnership with Facing Addiction, Drugs Over Dinner (funded by Jamison Monroe Jr., CEO of Newport Academy). The show and organizations have downloadable media materials, including the parental discussion guide developed with input from NIDA, the Substance Abuse and Mental Health Services Administration, the National Council on Behavioral Health and HealthCorps (a high school program founded by Oz).

On November 10, U.S. Surgeon General Vivek Murthy, M.D., was Oz’s guest; he talked about the forthcoming surgeon general’s report on addiction. One purpose of the report is “to bring the best possible science together about prevention, treatment and recovery,” said Murthy.

“The most important first step we can take in reducing the suffering and death from addiction is to simply talk about it,” said Oz in a November 5 statement. “By removing the fear and shame surrounding addiction, through an open dialog in families we will save lives. Parents need to educate their children about the overall risks of drugs and drinking, as well as get inside their children’s heads to assess what risks they may be facing already. Most importantly, we want to make it safe for family members to reach out for help.”

“We’re not pretending to be an expert,” said Tim Sullivan, spokesman for “The Dr. Oz Show.” “We have experts. He is a journalist and we are a show and he’s here as a doctor reporter. If anyone feels that there’s not a good upside to that…”

Unusual for a talk show, guests from the federal government — not authors of new books or other people with something to “sell” — have been featured, such as the surgeon general and Michael Botticelli, director of the Office of National Drug Control Policy.

Sullivan has worked with Oz long before the show started, in 2009. Out of the 1,100 or so shows done since then, a few have been on addiction, but never with the focus of this season, he told ADAW.

Telling the ‘happy’ story

Audience feedback was a main reason for choosing addiction as the main topic for this season, said Sullivan, a medical public relations professional who has done work with Smithers at Beth Israel, the Association of Recovery Schools, and the deservedly ill-fated Prometa (“I was a hired gun,” he explains).

“We want to tell the happy and redemptive side of the addiction story” he said. “It’s not all crisis and sadness — treatment can be successful — recovery is real.” When shows “focus on the point of crisis, it’s hard for people to watch,” said Sullivan. After meeting with former Surgeon General David Satcher, M.D., and with the National Council on Behavioral Health, Dr. Oz decided to facilitate a “national conversation” on addiction — not focusing on the need for access to treatment, but focusing on addiction and recovery.

“Our job as a show is to shed light where there’s darkness,” said Sullivan. “Dr. Oz is a heart surgeon, so this is not his area of medicine, and his life experience in it is fairly limited.” The show is adept at topics like diabetes and blood pressure, said Sullivan.

And the show needs groups who are in the treatment field. “I think the National Council offers more to us than we offer to them, because they are in the business of aggregating best practices and bringing a coalition together,” said Sullivan.

The show probably won’t get very deep into treatment itself, said Sullivan. “You have to remember that people who are not connected to this field are still debating the disease model,” he said. “With a general audience, you have to start at the beginning, in a very gentle way.”

The Greg Williams connection

“It’s partially true that Greg was the one who brought Dr. Oz to the table,” said Sullivan. He had high praise for Williams’ film, “The Anonymous People.” Williams called him last spring and asked if the show would be interested in helping with advocacy for the September rally. “It seemed like it would be an opportunity — a way to shine a light on the 20 million people who are in recovery,” said Sullivan. “Greg is dealing with an important question, which is ‘Why anonymity?’ He has made the sensible argument that it is time for people in recovery to step forward — to show recovery as a happy ending. That story hasn’t been told.”

Improving treatment supply?

But will telling that story improve access to treatment now for people on waiting lists or people who can’t afford it?

“Your audience is the treatment field,” responded Sullivan. “That’s a completely different audience than ours. Our audience is the average person who may or may not want to know about this.”

And Williams said that by driving demand for treatment, publicity about addiction will lead to increased access. “Finding platforms that reach millions about the need for increased addiction health services will drive demand-side increases for those services,” he said. “It’s up to health care providers, payers and policymakers to figure out how to meet the increased demand,” he told ADAW. “But I am convinced by increasing demand in health care services for addiction, we will put pressure on the various systems to increase access and supply.”

“Dr. Oz is using his programming and influence to raise awareness of addiction in general and the opioid crisis specifically,” said Becky Vaughn, vice president for addictions of the National Council. “He is able to reach an audience where our own efforts often fail. As a field, we should take advantage of this opportunity. Our school- and community-based prevention and treatment providers should certainly capitalize on the messages that are being picked up by media, push the idea in their communities and provide talking points for parents.”

The National Council has been promoting initiatives that would strengthen community behavioral health centers; this is something that Oz could discuss on the show, as well as the need for medication-assisted treatment and other services. But Sullivan made it clear that the show has more basic aims.

“What we’re asking our audience to do is to just talk to their kids about drugs,” said Sullivan. “We’re not in the middle of a huge policy fight, we’re not pointing to money allocations — we’re asking people to have dinner.”

Bottom Line…

Dr. Oz sheds light on addiction by bringing top experts to his show and suggests increased demand for treatment will lead to increased access.

11/16/2015 12:00 AM

Gov. Charlie Baker of Massachusetts is proposing legislation that would add civil commitments — no court involvement unless the patient requests it — to a route to treatment for people with substance use disorders (SUDs). Modeled after the state’s civil commitment law for people with mental illness, the proposal would allow a mental health professional to commit someone to a mandatory 72-hour hold in a medical facility. The measure is supported by treatment providers, although there are questions about the details. But there are important questions about the ethical and medical implications of coerced treatment.

Gov. Charlie Baker of Massachusetts is proposing legislation that would add civil commitments — no court involvement unless the patient requests it — to a route to treatment for people with substance use disorders (SUDs). Modeled after the state’s civil commitment law for people with mental illness, the proposal would allow a mental health professional to commit someone to a mandatory 72-hour hold in a medical facility. The measure is supported by treatment providers, although there are questions about the details. But there are important questions about the ethical and medical implications of coerced treatment.

Treatment providers in the state applaud the governor for taking steps to deal with the opioid epidemic. But they are concerned about two basic issues: (1) there is already a 20-day wait for what is called a “recovery bed” and (2) what happens to the person after the three days are up.

There is already a civil commitment law on the books in the state, known as Section 35, allowing for people with SUDs to be committed for 90 days. Until 10 years ago, that commitment was to a prison — Bridgewater State Hospital for men or MCI Framingham for women. Both facilities are run by the state Department of Corrections, and neither provided treatment, said Vic DiGravio, president and CEO of the Association for Behavioral Healthcare (ABH). About 10 years ago, the state began procuring community-based Section 35 facilities: currently, there is one for men in Boston and one for women in New Bedford. Both are run by High Point Treatment Center, an ABH member.

But often the High Point facilities do not have enough beds, so that over the past seven years, men and women committed for SUDs are still sent to the prisons, said DiGravio.

“One of the good things about the governor’s bill is that this will stop,” said DiGravio of the practice of sending Section 35 people to prisons. The bill would create a separate treatment facility on the grounds of the old Taunton State Hospital, originally called the “State Lunatic Asylum” and now falling into disrepair, although some of the buildings are in the National Historic Register. These will be long-term Section 35 beds. While it’s good that there will be some kind of expansion of treatment, DiGravio said that the real problem is a lack of capacity.

SUD version of Section 12

Currently, the only commitment available for people with SUDs is the 90-day commitment, which requires a court order. However, people with mental illness who are a danger to themselves or others (suicidal or homicidal) can be committed for three days by a mental health professional, under Section 12. Under the governor’s proposal, there would be a mirror version of Section 12 for people with SUDs. There would be no court involvement unless the patient requests it. But allowing such a provision in the event of SUDs raises many questions for mental health professionals, who wonder how they can tell when someone who is a drug user is dangerous enough to themselves to be committed.

“The emergency rooms are asking this question,” said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems. “You could say everyone who comes in there because of drugs is dangerous to themselves.”

However, Matteodo, like DiGravio, is pleased with the proposal. “We think it’s bringing attention to this area, and it’s our business to take care of these people,” he said. “There are a lot of questions about capacity, insurance payments, emergency room backups and so on.”

DiGravio and Matteodo will be among those testifying at a legislative hearing on the commitment proposal November 16. “We think the legislature will provide some clarity,” said Matteodo.

Problems with coerced treatment

There is a possibility that people would not want to present for treatment if they thought they could be held involuntarily for three days. That’s not “treatment.” This is something that worries H. Westley Clark, M.D., former director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration, and a vocal supporter of the rights to privacy and civil liberties for patients with SUDs.

“The Massachusetts proposal is essentially a state’s ‘right to keep you from harming yourself’ proposal,” Clark, a lawyer, told ADAW. He noted that there are already laws on the books concerning potential harm to others.

The use of 72-hour holds for the reason of danger to self is usually thought of in connection to suicidality. But people with SUDs aren’t necessarily suicidal. “The use of the extraordinary powers of the state to keep you from harming yourself based not on a imminent threat to others in society but on one’s use of psychoactive substances, places this measure into an arena of dire consequences,” said Clark. “What about inveterate smokers? What about those who are obese? What about those who drive while intoxicated? What about those who have hypertension but who don’t get care?”

Clark said that while this “paternalism” may sound good, it isn’t. “Procedural due process not withstanding, is this a slippery slope? I suspect so,” he said. “When liberal jurisdictions and well-trained physicians are willing to sacrifice privacy rights and civil liberties in the service of a population health notion, then we are indeed in a strange time.”

Clark warned about “unintended consequences” of civil commitment. “The issue of relapse and the resulting frustrations by family members is understandable,” he said. But instead of commitment, he recommends models like that of Proschaka and DiClemente, who argue for efforts being made to engage people with SUDs.

Capacity problems

“People shouldn’t have to be civilly committed to treatment to get access to treatment,” said DiGravio, noting that the treatment system in the state, robust as it is, can’t treat everybody who is asking for it. “We have a well-thought-out continuum of care in Massachusetts, and we’re way ahead of most of the rest of the country in that regard, but we don’t have enough capacity.”

There are problems with capacity, agreed Matteodo. “But this is where I come down — I give the governor all the credit. Because what are we going to do, say indefinitely that we don’t have the room to treat people? If people need treatment, we have to build it, create it, give it to them.”

The governor filed the bill in October, and it was part of a collection of opioid initiatives he announced last week. If the legislature passes it, the civil commitment provision will take effect nine months later.

11/16/2015 12:00 AM

The battle between advocates for pain treatment with opioids and advocates for cutting down on opioid prescribing has been brewing for months but reached a breaking point this fall when the federal Centers for Disease Control and Prevention (CDC) briefly released draft guidelines to reduce opioid abuse.

The battle between advocates for pain treatment with opioids and advocates for cutting down on opioid prescribing has been brewing for months but reached a breaking point this fall when the federal Centers for Disease Control and Prevention (CDC) briefly released draft guidelines to reduce opioid abuse.

Many pain management experts “see the guidelines as being nothing short of misguided,” Pain Medicine News reported in its November issue, published online November 5. “In their attempt to mitigate the real risks and dangers of addiction, critics allege that the new guidelines will cause real harm to a significant subset of chronic pain patients for whom opioids do not pose a threat, and who often do not have any other options to treat their pain,” the publication reported. “These perceptions are fueled by the fact that the draft guidelines were made public for only an hour and a half in mid-September, during a webinar, followed by a 48-hour window in which to send comments by email; as well as by the fact that the webinar in question was well attended by nonprofits focused on fighting addiction, insurers and pharmacies, and poorly attended by advocates of chronic pain patients.”


In particular, Physicians for Responsible Opioid Prescribing (PROP), headed by Andrew Kolodny, M.D., has drawn particular anger from the pain advocates. Kolodny, who is also medical director of Phoenix House, is passionate about preventing overprescribing of opioids. He has taken the Obama administration to task for not doing enough to prevent this. Hardly anti-medication — Kolodny is a big proponent of buprenorphine for the treatment of opioid use disorders — he nevertheless is a lightning rod for the pain community’s anger at being denied what they say are the only medications that help. He is frequently interviewed by ADAW and strongly believes in saving people from overdoses.

“The focus should not be on whether opioids should be used or not — the focus should be on what a person in pain needs,” said Lynn R. Webster, M.D., a past president of the American Academy of Pain Medicine, and a Pain Medicine News editorial board member. “There should be a risk-benefit analysis for every treatment, and that’s what should decide whether opioids are prescribed or not. You can’t paint every person with the same brush.” Webster told ADAW that he wonders how many prescription opioid overdoses are actually in patients who “couldn’t stand the pain anymore and took too much” (see ADAW, Sept. 17, 2012). Very little is known about the circumstances or characteristics of prescription overdose fatalities. However, the CDC’s Leonard J. Paulozzi, M.D., told ADAW this spring that stemming the flow of prescription opioids now will prevent future heroin overdoses (see ADAW, May 4).

Two crises: opioid addiction and pain

There are two national crises, Webster told Pain Medicine News. The CDC is addressing one: opioid addiction. But the other — people in pain — needs to be addressed as well, he said.

Webster also criticized the CDC for allowing payers to help draft the guidelines.

“That would be equivalent to having pharmaceutical companies making opioid guidelines,” he said. “I would hope the CDC would be above that, that they’d be most interested in helping patients, whether they have the disease of addiction or the disease of chronic pain.”

Jeffrey Fudin, Pharm.D., founder and chair of Professionals for Rational Opioid Monitoring and Pharmacotherapy, told Pain Medicine News that “the pain community is outraged.” However, he said, many pain patients are “indigent” and “don’t have the wherewithal to rise up against a government agency, or a group like PROP, that’s working 24/7 trying to take opioids away from patients in need.”

Fudin criticized the “secret way” in which the CDC is conducting the development of the guidelines. “One group that was on the CDC webinar was CVS — they own a huge, huge PBM [pharmacy benefit manager],” he said. “Don’t you think that’s a conflict of interest? They don’t want to pay for long-term extended-release opioids. It’d cost them a fortune.”

And giving the chronic pain community only 48 hours to respond to the guidelines was “cruel,” said Fudin. “I’m just disappointed in the CDC,” he concluded. “What they did was ethically, medically, professionally and morally wrong.”

Funding bias?

Meanwhile, the pain advocates are being accused of being funded by pharmaceutical companies that make opioids. Longtime reporter Ed Silverman, who covers the pharmaceutical industry in his Pharmalot blog, wrote an editorial November 10 in STATS headlined “CDC is right to limit opioids. Don’t let pharma manipulate the process.” Silverman quoted David Juurlink, M.D., a clinical pharmacologist at the Sunnybrook Health Sciences Centre and a member of PROP, as saying, “The criticism is hollow and comes from people who are heavily conflicted.”

In fact, virtually all not-for-profits in the field are funded to some extent by the pharmaceutical industry: the National Council for Behavioral Health, the American Association for the Treatment of Opioid Dependence, the National Alliance on Mental Illness and Community Anti-Drug Coalitions of America. These organizations cannot raise money from people with addictions or mental illness.

Pain patients can be viewed as similar to patients with addiction in this battle: pawns in the chess game between the pharmaceutical companies and the addiction prevention and treatment field. Or they can be viewed as patients who don’t have a voice and whose only representation is the people who treat them.

The bottom line: if the people who are dependent on prescribed opioids are cut off from them, they will need treatment, or they will seek opioids on the street to avert withdrawal. In many communities, the opioid of choice is now heroin, and the vast majority of patients in treatment for heroin addiction started with prescription opioids. Whether that start came from a prescription pad or from diverted medication bought in the street or stolen from a medicine cabinet is still an unanswered question. Meanwhile, the CDC plans to release the guidelines in January.

From the Field
6/15/2015 12:00 AM

Yet when it comes to health policy, there is only one reality: funding. While rhetoric for increasing the amount of attention paid to substance abuse has been at an all-time high, the commitment to funding by Congress has not kept up. Congressional funding for the Substance Abuse and Mental Health Services Administration’s Substance Abuse Prevention and Treatment block grant has not kept up with inflation and, as a result, would need a $450 million increase just to bring its purchasing power back to where it was in 2010. There are no signs on the horizon that this negative trend will change any time soon.

I have spent a career working on the issues of crime and substance abuse, including a time as vice president and chief operating officer of the National Crime Prevention Council. It is undeniable that substance abuse treatment for the incarcerated not only reduces recidivism, but in turn it allows its participants to at least have a chance at a productive life upon release. Based on my time working with states and communities on model state statutes and local ordinances related to drug abuse and gang violence, I can say this unequivocally.

Some members of Congress are to be praised for their efforts in the fight against substance abuse, and their recognition of the importance of treatment within the criminal justice system. In the Senate, Senators Rob Portman (R-Ohio) and Sheldon Whitehouse (D-R.I.) introduced the Comprehensive Addiction and Recovery Act (CARA), in both 2014 and 2015. Rep. Jim Sensenbrenner (R-Wis.) introduced a companion bill to CARA in the House. Senator Ed Markey (D-Mass.) introduced legislation that would expand access to medication-assisted treatment. Rep. Hal Rogers (R-Ky.), chair of the appropriations committee, remains committed to funding programs at the Department of Justice that screen for prescription drug abuse.

Yet when it comes to health policy, there is only one reality: funding. While rhetoric for increasing the amount of attention paid to substance abuse has been at an all-time high, the commitment to funding by Congress has not kept up. Congressional funding for the Substance Abuse and Mental Health Services Administration’s Substance Abuse Prevention and Treatment block grant has not kept up with inflation and, as a result, would need a $450 million increase just to bring its purchasing power back to where it was in 2010. There are no signs on the horizon that this negative trend will change any time soon.

RSAT slashed

Many members of Congress have uttered the phrase, or paraphrased, “We cannot arrest our way out of this problem.” They realize the law-and-order approach is not an effective deterrent to drug use. As a result, there has been much support in the past for the treatment of those in need who end up in the criminal justice system. One such program is the Residential Substance Abuse Treatment (RSAT) program housed by the Bureau of Justice Assistance in the Department of Justice.

According to the Bureau of Justice Assistance, 68 percent of jail inmates report substance abuse dependence prior to incarceration, with 29 percent being under the influence of drugs at the time of the offense and 16 percent committing offenses in order to obtain money for drugs. Of all jail inmates, over two-thirds were found to be dependent on or abusing alcohol or drugs. RSAT exists to help address the issue of substance abuse dependence and the direct link to public safety, crime and victimization by providing comprehensive treatment and services within the institution and in the community after a prisoner is released. RSAT funds are allocated to each state, the District of Columbia and territories based upon the respective prison population in relationship to the total prison population of all states combined.

So now, in 2015, when so many members of Congress are saying one thing, why are they doing another? Unless there is funding for programs that will benefit those in need, the words of support for treatment ring hollow. The appropriations subcommittee for Commerce, Justice, and Science (CJS) is guilty of this very hypocrisy. In their FY 2016 markup, they proposed the RSAT program be zeroed out. In layman’s terms, their recommendation was that funding for the program go from $11 million to nothing.

The CJS subcommittee slashed and burned in other places as well, and many of the programs impacted play a great role in reducing substance abuse or behavior that leads to it. Juvenile Justice programs overall are decimated, with a cut of $68 million below FY 2015 and $155.9 million below the White House request. This includes the proposed elimination of the Community-Based Violence Initiative, the National Forum on Youth Violence, the Local Delinquency Prevention Incentive grant program, the Children of Incarcerated Parents program, and a program targeting girls in the justice system.

Some politicians will recite the same tired lines. They need to prioritize. They hate to cut any programs, but in this fiscal environment, something has to go. What they are saying when they zero out a program such as RSAT is that substance abuse treatment is not a priority, especially among the incarcerated and the underserved. Such an act flies in the face of everything Congress has been telling us for the past year — that opioid abuse is the single greatest threat to our public health. If the members of the CJS subcommittee, led by Rep. John Culberson (R-Texas), truly believed this, the RSAT program would not only be fully funded, it would receive an increase. Rep. John Carter (R-Texas) is a member of the House Addiction, Treatment, and Recovery Caucus, yet he sits on the subcommittee that authored this bill. Also on the subcommittee responsible for this bill is Rep. Steven Palazzo (R-Miss.). In 2012 he joined in the celebration as a residential and workforce training center for children struggling with emotional, mental and substance abuse problems was opened in his district. Now, his committee produces legislation that will do anything but assist those with a substance abuse problem in great need of help.

It’s time for Congress to step up to the plate and fund the programs that will bring us closer to a healthier nation that fights substance abuse with every weapon in its arsenal — including appropriations.

From the Field
4/27/2015 12:00 AM

Opinion on marijuana has changed dramatically in the United States. The public increasingly perceives it as a benign substance, and there is growing interest in its potential medicinal uses. Already almost half of the states have medical marijuana laws, and congressional bills have recently been proposed that would reschedule the drug to reduce hindrances to research and facilitate marijuana’s use as medicine.

Advocates tout marijuana as a miracle drug with a wide range of potential therapeutic uses, while public health voices raise alarms about its dangers if made more widely available. The science justifying either position is often not as robust or clear as its partisans would wish. Marijuana’s impact on lung cancer remains unclear, for instance, but so does its actual range of medicinal benefits. The urgent need for more research is something all sides in the current marijuana debate can agree on. Policy changes around marijuana will need to be informed, as much as possible, by science.

There is solid evidence that the main psychoactive ingredient in marijuana, THC, is effective at controlling nausea and boosting appetite. There is also some preliminary evidence that THC or related cannabinoid compounds such as cannabidiol (CBD) may also have uses in treating autoimmune diseases, inflammation, pain, seizures and psychiatric disorders, including substance use disorders. Despite claims of marijuana’s usefulness in treating post-traumatic stress disorder, supporting data is minimal, and studies have not investigated whether symptoms may worsen after treatment is discontinued.

We do not yet know all the ways chronic treatment with marijuana or marijuana-derived compounds could affect people who are rendered vulnerable either by their illnesses or by their age. We also don’t know how medical marijuana laws will affect other aspects of public health and safety. For example, wider medical marijuana use could potentially impact driver safety, as both laboratory and epidemiological research link recent marijuana use to increased accident risk, likely reflecting marijuana’s disruptive effects on motor coordination and time perception.

Impact on teenagers

Perhaps the biggest public health concern around medical marijuana liberalization and legalization concerns the potential impact on teenagers, who could have greater access to it as a drug of abuse and who may increasingly see marijuana as a “safe, natural” medicine rather than a harmful intoxicant. Although there is still much to learn about marijuana’s impact on the developing brain, the existing science paints a picture of lasting adverse consequences when the drug is used heavily prior to the completion of brain maturation in young adulthood. In teens, marijuana appears to impair cognitive development, may lower IQ and may precipitate psychosis in individuals with a genetic vulnerability.

Most states currently don’t allow medical marijuana for children, but they too are vulnerable. Accidental ingestion of marijuana edibles by children has increased in Colorado since marijuana was decriminalized for medicinal use in 2009. Also potentially concerning is the possibility of increased prenatal exposure if women self-treat with marijuana to control nausea associated with pregnancy. Research suggests prenatal exposure could have adverse consequences for children’s future health and brain development. There is as yet no research on the potential effects of secondhand marijuana smoke on children growing up in households where parents smoke.

Even in conditions for which THC, CBD or other cannabinoid constituents of the marijuana plant prove to be medically beneficial, consumption of the marijuana plant itself or its crude extracts via smoking, vaporizing or eating is unlikely to be the most effective, reliable or safe way for patients to obtain these benefits. Laboratory research is ongoing to better understand how cannabinoids work in the brain and body and hopefully guide development of safe, reliable therapeutic compounds that have a minimum of adverse side effects.

Existing medications

Two THC-based medications, dronabinol and nabilone, are already approved by the Food and Drug Administration to treat nausea caused by chemotherapy and to boost appetite in patients with AIDS wasting syndrome. The United Kingdom, Canada and several European countries have approved a drug called nabiximols (Sativex), containing THC and CBD, as a medication for spasticity caused by multiple sclerosis (MS) and, in Canada, for MS- and cancer-related pain. Despite its success in reducing pain and spasticity, it has not received approval in the United States, and recent evidence has found impairments in cognition in users.

CBD on its own is not psychoactive and it actually mitigates the “high” produced by THC; it has been studied as a potential antipsychotic drug, and ongoing trials are testing its efficacy as an antiseizure agent. Some parents of children with severe forms of pediatric epilepsy have claimed that high-CBD (and low-THC) marijuana extracts control their children’s seizures better than existing medicines. The maker of Sativex has recently created a CBD-based drug called Epidiolex to treat children with these conditions, and is in the process of conducting initial small-scale trials. Evidence so far shows that CBD is only effective in controlling seizures in a small subset of patients.

As public approval for medical marijuana grows, we need to ensure that our policy decisions are science-based and not swayed by the enthusiastic claims made widely in the media or on the Internet. We need to support and encourage increased research on marijuana’s potential benefits and conduct intensified research on the cannabinoid system to inform the development of safe, FDA-approvable drugs. But the existing science on marijuana’s adverse effects on youth demands we also proceed with caution in making policy changes that could result in increased use of or exposure to marijuana by young people.

From the Field
10/27/2014 12:00 AM

Last week, the Harm Reduction Coalition held its conference in Baltimore. Marijuana legalization is not one of its issues, which are mainly access to clean needles and syringes, overdose prevention with naloxone, HIV and hepatitis C, and the rights of drug users. Keynote speaker Michael Botticelli, acting director of the Office of National Drug Control Policy (ONDCP), supports naloxone and medication-assisted treatment. He is a clear harm reduction advocate, but not an advocate of marijuana legalization.

But harm reduction sometimes gets confused with marijuana legalization. I had the privilege of speaking to the “Politics” class at American University in nearby Washington, D.C. on October 20, a few days before the conference was to begin. I was invited to discuss the movement toward drug legalization. I also covered some “harm reduction” assertions as well.

Unfortunately, because the legalization movement is sweeping across America, my counterpoints were very well-received — I say “unfortunately” because we are being overcome by the tidal wave of the movement. Here is some of what I said to Assistant Professor Rick Semiatin’s “Washington Semester” class of juniors and seniors from 200 colleges and universities across the United States.

I’m a “liberal” on most things, but on the drug issue, I know the harm that is done by car crashes, DUIs, date rape and the impact of flooding already overcrowded emergency rooms — and that includes from marijuana, which most “legalizers” claim they want to separate from “harder” drugs. I was the one who wrote then-Congressman Ed Koch’s testimony on his bill in the 1970s to legalize marijuana, and sat with him at the table as he told Congress that drugs are personal and harmless, and that we should stop crowding our prisons. But both Ed and I learned and changed our positions, he as mayor of New York City and me as I learned more and more as spokesman for the House Narcotics Committee and then the White House ONDCP.

I told the students that the election is being overwhelmed by the issue because my own party, the Democrats, don’t want to touch it. They are afraid their candidates will lose a big chunk of the youth and liberal base who support legalization/decriminalization in the legislatures and state referenda. Like laetrile in the 1970s (which was legalized in more than 20 states and was supposed to cure cancer but turned out to be useless apricot pits that simply deferred real and needed treatment), “medical” marijuana is backed up only anecdotally and never is compared to an “n” of other treatment modalities that would be prescribed by doctors. There is truth to former drug czar Barry McCaffrey’s joke that a shot of gin also takes away your pain. Having said that, no one wants to deny a truly sick or dying patient who wants to get high the opportunity to feel better, even if it’s a placebo effect. It’s not the truly “medical” cases anyone wants to stop; it’s what law enforcement tells us are the 90-percent-plus (and as many as 99 percent) nonsick people who also come in to the clinics feigning illness with a makeshift letter just to get drugs.

Harms of marijuana

The evidence on harm in the legalizing states is rolling in. You have to scrounge for the reports, but they say, “youth marijuana use increased by nearly 11 percent since medical marijuana became legal in 2009,” “traffic fatalities involving drivers testing positive for marijuana have increased by 100 percent between 2007 and 2012” and “toxicology reports with positive marijuana results for driving under the influence have increased 16 percent from 2011 to 2013.” In addition, Colorado Public Radio reported, “Denver Emergency Room Doctor Seeing More Patients for Marijuana Edibles.” The United Nations reported, “Marijuana-related Health Problems on Rise in US,” with a 12 percent rise last year in marijuana usage by teens.

But for the most part, the legalization referenda are speeding ahead. The most-cited ones, in Oregon and D.C., show legalization 11 and 20 points up, respectively, with just days before the election, and the legalization advocates say they are counting on “young voter turnout.” Since Democrats count on that demographic as well, you can understand the silence.

Even though Maryland Governor Martin O’Malley told me personally two weeks ago that “I’m concerned about legalization” because of car crashes, emergency room upticks, the horrible message to kids (how legalization disarms parents from the moral high ground on the message), and the like, politicians in the state are silent on the issue.

Of course, the legalizers say the drug war is a “failure.” But the students I addressed did open their eyes when I said that because of the efforts of parents, teachers, coaches and religious and business leaders, and a strong foreign policy (Plan Colombia) and domestic enforcement efforts, drug use has declined almost 50 percent in the last three decades, and cocaine use — the disproportionate driver of crime — is down 70 percent. If any other social problem, such as literacy, hunger or poverty, or health problem, such as cancer, diabetes and heart attacks, improved 50–70 percent, would we call it a failure?

To these quite smart college juniors and seniors, I pointed out that medically assisted treatment — including methadone, buprenorphine and Vivitrol — is in fact harm reduction. It’s valid because people can function, work and pay taxes. But if we’re talking about heroin, cocaine and methamphetamine to addicts, that’s pure nonsense that destroys their lives. If we are talking about marijuana, I still oppose it because it jams hospital emergency rooms with car crashes and treatment centers with patients. Legalization or decriminalization would simply increase availability and use. When I debate the Ethan Nadelmanns of the world on radio or Bill Maher or Crossfire, they invariably say, “That’s true but…” I cut in and say, “You can’t say ‘but’ to more availability and use — that’s the point. Aside from that, Mrs. Lincoln, how was the play?”

I do concede we need to stop prison overcrowding but point out that’s why Attorney General Janet Reno and ONDCP Director McCaffrey supported creating drug courts, for treatment instead of prison for nonviolent drug offenders. There were eight drug courts when we started in 1996. Drug courts rose to 1,000 under Clinton-Reno-McCaffrey, and now are near 3,000.

Science, not politics, should guide U.S. drug policy.


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  • Meet the Editor

    Alison Knopf

    Alison Knopf is a professional journalist who began covering the addiction field in 1984 as founding editor of Substance Abuse Report. She has been the editor of Alcoholism & Drug Abuse Weekly since 2005.
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