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Peer drug users essential to success of needle exchanges
10/27/2014 12:00 AM

Shilo Murphy, a former homeless person who heads the Seattle-based People’s Harm Reduction Alliance, was one of the more than 1,000 people at the Harm Reduction Coalition meeting in Baltimore last week. We talked to him about his work with needle exchanges.

Shilo Murphy, a former homeless person who heads the Seattle-based People’s Harm Reduction Alliance (PHRA), was one of the more than 1,000 people at the Harm Reduction Coalition meeting in Baltimore last week. We talked to him about his work with needle exchanges.

A longtime resident of the Seattle University District, Murphy has worked at the University District needle exchange program for the past 18 years. Co-founder and executive director of the PHRA, he is also national president of the San Francisco–based Urban Survivors Union, which also runs harm reduction programs. He is a self-acclaimed “proud drug user.”

The PHRA was founded by Bob Quinn, who worked in hospice care for HIV patients. He died two years ago, and Murphy, who considers himself Quinn’s son, is now in charge.

One of the largest organizations of its kind in the country, the PHRA gives away almost 4 million syringes a year throughout four counties in Washington state. Murphy, the only paid employee of the PHRA, said the organization uses peer distribution models. “Our real success is keeping it dirt cheap, having no overhead and getting the supplies to people when they need them,” he said.

Drug users are on the board and the staff of the PHRA, said Murphy. “We can’t afford not to include drug users,” he said. “We give everyone 300 syringes” to pass out, he said. In addition, crack pipes are given out, because when people share crack pipes, they can transmit HIV as well. In addition, people burn their lips on crack pipes, making transmission via kissing or sharing pipes increasingly likely.

“You can’t focus on one single behavior” when trying to prevent HIV transmission, said Murphy. “If you only focus on sex, that won’t be helpful,” he said. “You need to deal with the full gamut” of risks, he said..

The PHRA also gives out naloxone to reverse overdoses. “So many people were dying,” said Murphy. The group uses the injectable intramuscular naloxone, as drug users know how to use needles.

No problems with Seattle police

The group has no problems with the police in Seattle, said Murphy. “The most progressive organization in Seattle is the police department,” he said. “We have had only minor conflicts in Olympia.” Murphy describes the group’s relationship with law enforcement this way: “The police want to have drug users be as disease-free as possible, because they may have to put their hands on them,” he said. “They want people to be clean.” The police suggest that drug users take their used needles and syringes to the needle exchange, he said. “The police get it,” he said.

But in some counties in the state, if someone overdoses, witnesses are charged with manslaughter, said Murphy. “Let’s be clear: people still go to jail,” he said. “We are still working toward a better tomorrow.”

While the PHRA peers and volunteers do refer drug users to opioid treatment programs, the group “doesn’t have an agenda,” said Murphy. “Our message has always been, ‘If you’re going to be a drug user, be the best drug user you can be.’”

The treatment field isn’t seen as welcoming by many drug users, Murphy pointed out. “Let’s be honest: the term ‘clean and sober’ applies to someone who has been dirty,” he said. “They still use those terms in the treatment field on a daily basis.” As a result of this stigma, there are people “who have been too ashamed to tell their lover or their parent that they’re drug users, and they have died alone of an overdose,” he said. “Every day I talk to drug users who tell me how worthless they are — it’s because everyone around them tells them they are worthless.”

We asked Murphy what he thinks the chances are that the federal government — Congress and the administration — will make it easier for drug users to engage in harm reduction programs such as needle exchanges. His response was bitter and hopeful at the same time. “Do I think the federal government is going to care about a minority population that is dying in the street? No,” he said. “Do I think they will care about folks who need help? No. I’m trying to be realistic. I hope that they care.” At the Harm Reduction Coalition conference, Murphy planned to “go to panels, speak on panels, talk to old friends, talk to people I meet, and create a larger community,” he said. “With that, we can defeat anything.”

10/20/2014 12:00 AM

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) is issuing practice guidance to adolescent substance use disorder (SUD) treatment services. Based on an advance copy received by ADAW, guidance provides comprehensive information on the essential elements of treatment and recovery systems for adolescents.

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) is issuing practice guidance to adolescent substance use disorder (SUD) treatment services. Based on an advance copy received by ADAW, guidance provides comprehensive information on the essential elements of treatment and recovery systems for adolescents.

Over the course of the next several months, NASADAD will hold webinars for state youth coordinators that will provide more information to the SSAs (single state authorities) — the state directors with authority over the Substance Abuse Prevention and Treatment (SAPT) block grant. The guidance, however, is not restricted to the use of block grant funds and has no mandates. It could be used for Medicaid or other payers as well, according to NASADAD. The purpose is to better inform SUD services for adolescents across the states.

Language in the document can be incorporated into contracts with treatment providers to ensure that evidence-based, high-quality treatment is delivered to adolescents ages 12 to 18, according to NASADAD.

The project, which was funded under a subcontract to JBS International, under a Substance Abuse and Mental Health Services Administration (SAMHSA) contract, originated in the states themselves, said Henrick Harwood, NASADAD’s director of research and program applications, in an interview with ADAW last week. “Many of the states had been putting together their own documents,” he said. “Other states had been struggling with [adolescent SUD services], and when they heard about this, they wanted to know more.” SAMHSA’s Center for Substance Abuse Treatment funded the development of the project, because they wanted to collect the best state methods being used to manage adolescent treatment systems, added Harwood, who is also NASADAD’s deputy executive director.

“Each state was inventing their own guidelines, their own practices, on how to manage and purchase youth services,” he said. “SAMHSA said, ‘We can help to resource this,’ and gave us a grant to work with the states.”

At least 24 states (Arizona, California, Colorado, Delaware, Georgia, Illinois, Indiana, Kansas, Louisiana, Massachusetts, Minnesota, Mississippi, Missouri, Montana, New York, North Carolina, Oklahoma, Oregon, South Carolina, Texas, Utah, Washington, Wisconsin and Wyoming) have existing documentation on adolescent treatment standards and/or guidelines for the treatment of adolescents with SUDs.

The 56-page document, called the State Adolescent Substance Use Disorder Treatment and Recovery Practice Guide, encompasses best practices derived from the State Youth Substance Abuse Coordinators Committee, a component of NASADAD’s National Treatment Network’s Adolescent Treatment Committee. SAMHSA gave “input and suggestions,” but the document is a result of a “consensus-building process that involved the expertise of the state youth coordinators,” said Harwood.

Three broad sections

The document is divided into three broad sections: principles of care, service elements and administrative considerations. While the language could be used in regulations and contracts, the document is not meant to dictate specific services or practices, but to give states options to consider.

The principles of care section includes guidance on integrated care, trauma-informed care, family-centered care, and evidence-based practices, including medication-assisted treatment.


The guidance is for patients ages 12 to 18; while the majority of adolescent patients in treatment are 16 to 18, some, especially those in the “experimenting” phase, are younger. But the problem is that the SUD treatment system, in particular for opioids, has been geared toward older males, said NASADAD Executive Director Rob Morrison. “Now we’re seeing incremental steps to change on the adolescent side,” he said.

While medication-assisted treatment is considered the first-line therapy for adults with serious opioid addiction, with either methadone or buprenorphine, there has been less consensus on the appropriateness of medication-assisted treatment for adolescents. This guidance notes that buprenorphine is appropriate for adolescents age 16 and older. “The effectiveness of buprenorphine products for adolescents under the age of 16 has not been established,” notes the guidance, citing SAMHSA’s Center for Substance Abuse Treatment. “However, medication-assisted treatment with buprenorphine should be considered part of the menu of treatment options for adolescents over 16.”

Providers who are treating adolescents who have been using opioids “need to be aware of the options,” said Harwood. “They need to consider whether or not using medications might be useful, and buprenorphine has been tested with teens.”

In addition to medication-assisted treatment, the service elements section includes screening, assessment, planning, physical health, case management/care coordination, medication-assisted withdrawal, treatment levels of care, individual and group counseling, co-occurring mental health disorders, and recovery services (transportation, continuing care, education, youth vocational and employment services, housing assistance, pregnant and parenting youth, mutual aid groups, peer-to-peer coaching, and recovery coaching and mentoring).

The administration section includes a focus on designated authority — who (the SSA, state or county) has the authority to procure and oversee adolescent SUD services. There is also information on documentation of treatment records, including compliance with regulations such as 42 CFR Part 2 (confidentiality), monitoring and quality improvement, workforce, and patient rights.

Best practice

The guidance “is meant to be a best practices document,” said Harwood. “We recognize that states are in different positions, but this is a set of guidelines, things to work towards, ideals.”

Asked whether this document is something that an SSA could take to a governor to advocate for treatment services, Morrison responded, “To the extent that governors are going to get into this detailed level, it could be used to show what state experts regarded as the categories that should be considered.” However, he added that “this is mainly for the state agency, to look at what options other states are taking."

However, most of the recommendations in the guidance document would not require legislative or executive changes, said Harwood. “This is more for the purchasing authorities,” he said. “Most of these options are doable within statutory authority.”

By providing language that can be put into contracts with service providers, the document can help the SSAs make sure that treatment for adolescents is evidence-based, said Morrison. “So often we talk about issues and platitudes, but not about the nuts and bolts of how to get there,” he said. “This is about the actual issues that states have to consider.”

The guidance document is not directed at drug courts or juvenile courts, but at treatment, said Harwood. “We are fully aware that many of the kids who go into treatment are involved with drug courts or juvenile courts,” he said, adding that about 40 percent of the people including adults who receive treatment through public dollars are involved with some kind of court. He conceded that the adequacy of treatment services for people in the court system is a “running concern” that goes back decades.


Starting next month, NASADAD will have one webinar a month for youth coordinators, devoted to each of the three main sections, said Shalini Wickramatilake-Templeman, research analyst with NASADAD. “The goal will be to train the youth coordinators,” she said.

There are 48 youth coordinators — almost one in every state — said Wickramatilake-Templeman. “They have the general oversight of SUD programs for youth in their respective states,” she said.

The states will in turn reach out to providers. NASADAD on its own doesn’t have the ability to train the hundreds of providers in the system, said Harwood.

States are “interested in getting the training.” Like any new policy or innovation, it will take several years to move ahead, he said, noting that purchasing cycles take time to change. “This is a process,” he said. “But states are moving ahead with this.”

For the guidance, go to

Bottom Line…

NASADAD has issued a guidance document that purchasers of adolescent substance use disorder treatment can incorporate into contracts to improve the quality of services.

10/6/2014 12:00 AM

The short story is the sudden retirement, effective October 3, of H. Westley Clark, M.D., who for the past 16 years has been the director of the Center for Substance Abuse Treatment (CSAT) at the Substance Abuse and Mental Health Services Administration (SAMHSA). The longer story is how his departure will affect two policy decisions pending at SAMHSA: lifting the cap on the number of patients who can be treated with buprenorphine and preserving the confidentiality regulations for alcohol and drug abuse treatment, 42 CFR Part 2.

The short story is the sudden retirement, effective October 3, of H. Westley Clark, M.D., who for the past 16 years has been the director of the Center for Substance Abuse Treatment (CSAT) at the Substance Abuse and Mental Health Services Administration (SAMHSA). The longer story is how his departure will affect two policy decisions pending at SAMHSA: lifting the cap on the number of patients who can be treated with buprenorphine and preserving the confidentiality regulations for alcohol and drug abuse treatment, 42 CFR Part 2.

According to a September 30 email from SAMHSA Administrator Pam Hyde, a copy of which was obtained by ADAW, Clark and Hyde met late during the week of September 23. That was the same week of the buprenorphine summit, which was geared toward lifting the cap (see ADAW, September 29). During the discussion, “he let me know then that he was thinking about this decision,” said Hyde. “I was very sorry to hear this, but recognize that each individual’s decision and life trajectory takes its own course and timing comes when it’s right for them.”

“This was Wes’ decision,” said Hyde in the email, which was sent under the subject line “SAMHSA personnel announcement.”

We don’t know what was said between Clark and Hyde. But we do know that he has been on the wrong side, politically speaking, of the debate on 42 CFR Part 2 and on lifting the buprenorphine cap.

42 CFR Part 2

In an August 4, 2010, public meeting on 42 CFR Part 2, Hyde and Clark said 42 CFR Part 2 would not be revised (see ADAW, August 9, 2010). The regulation requires patients to give individualized consent to having their records released. However, last year, Hyde said at a workforce meeting that 42 CFR Part 2 is “getting in our way” (see ADAW, September 23, 2013). Then, there was a “listening session” on 42 CFR Part 2 on June 11 at which Clark was not even present, much less participating, where the door was clearly opened to changing the rule (see ADAW, June 16). SAMHSA told us that his schedule didn’t allow him to be present.

In addition, ADAW has learned that the Department of Health and Human Services (HHS), in a telephone call with federal and state officials and with stakeholders earlier this year, pressed to have methadone patients’ information put into prescription drug monitoring programs (PDMPs). Apparently, the HHS officials weren’t aware of the “Dear Colleague Letter” sent three years ago by Clark to opioid treatment programs (OTPs), advising them not to send patient data to PDMPs (see ADAW, October 24, 2011). The letter advised them to access PDMPs to find out about their patients’ other prescriptions, but said that giving OTP patient information to PDMPs would violate 42 CFR Part 2.

Any effort to require OTP patient data to go to electronic health records and PDMPs would be met with a fight from patient advocates.

CSAT promulgates 42 CFR Part 2 and regulates OTPs.

Buprenorphine cap

At a June 18 forum hosted by Sen. Carl Levin (D-Michigan) on raising the buprenorphine cap — which Levin supports — Clark pointed out, “We are dealing with the issue of addiction, not simply a medication,” and discussed concerns about diversion if the cap is lifted (see ADAW, June 23). This was not a welcome question at the forum, which ultimately led to the introduction of legislation by Sen. Ed Markey (D-Massachusetts) that would allow physicians to treat an unlimited number of patients with buprenorphine (see ADAW, August 11). Finally, there was the buprenorphine summit last month, at which Clark was not present and no discussion about the pros and cons of lifting the cap was allowed — rather, the discussion was about the logistics of how to lift the cap, and Levin himself made a presentation (see ADAW, September 29).

Current law allows physicians to treat only 30 patients with buprenorphine for the first year, and up to 100 patients with additional training. OTP physicians are allowed to have a caseload of 300 patients.

Funding for recovery

Clark has also been a champion for recovery — and patients in opioid treatment programs appreciate him for understanding that they are in recovery. “He always managed to squeeze funding for recovery in, before recovery was even fashionable,” said Walter Ginter, project director of Medication-Assisted Recovery Services in New York. The early days of the Recovery Community Services Program made it possible for the groundswell of support for recovery that now exists. “People forget that this couldn’t have happened without the funding, and there was nobody but Westley Clark getting the money,” Ginter told ADAW. Clark also stood up for patients, “including those in the methadone world,” said Ginter. “He’s going to be a phenomenal loss.”

“Dr. Clark has been an unparalleled voice for patients in medication-assisted recovery throughout his tenure with CSAT,” said Zachary C. Talbott, director of the Tennessee Statewide and Northwestern Georgia chapter of the National Alliance for Medication Assisted Recovery. “We can only hope and pray that his successor will be equally experienced with a background in opioid treatment programs and equally unbiased when looking at the science and evidence base determining what’s effective and what should be priority.”

Recovery researcher Alexandre Laudet, Ph.D., said Clark has “contributed significantly to advancing the recovery-oriented systems of care model both conceptually as well as at the implementation level.” Clark is “a brilliant, dedicated and compassionate individual and I’m sorry to see him leave,” said Laudet.

Stuart Gitlow, M.D., president of the American Society of Addiction Medicine (ASAM), sent us this comment: “I first met Wes Clark in 1995 when he began serving on the ASAM board of directors. In the two decades since, he has always been an inspiration to me personally as well as an outspoken and respected voice within the broad field of addiction medicine. We at ASAM wish him well in his retirement and look forward to many more years of collaboration.”

“Dr. Clark’s departure from SAMHSA represents a giant loss for the federal government and the addiction field,” said Robert I.L. Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors. “As Director of CSAT, he provided incredible leadership on a range of issues. Further, he performed his duties with unrivaled integrity and commitment. It was great to see Dr. Clark recognized at our most recent Annual Meeting when Mark Stringer, President of our Board of Directors, chose to honor him with the 2014 President’s Award. I hope we can convince him to stay involved in these issues because of his expertise and knowledge.”

The American Association for the Treatment of Opioid Dependence (AATOD), which represents OTPs, gave Clark a “friend of the field” award at its conference last November, noted President Mark Parrino. “That was the first time AATOD recognized a SAMHSA official through such a public honor,” he said. “We gave Dr. Clark the award because of what he did to provide guidance to the field of addiction. We also recognize many of his behind-the-scenes struggles to protect patients and the integrity of the treatment system.”

Carol McDaid, principal with Capitol Decisions, offered the following: “Dr. Clark is a true pioneer in our field in so many ways. He has that rare gift of being a true expert steeped in the science of addiction and its treatments while really getting on a deep level the plight of those in or seeking recovery from addiction. He championed recovery before it was popular to do so, stuck his neck out on new medical innovations to treat addiction and always walked a bright line on being a true public servant. He will be missed at SAMHSA but we won’t let him get too far out of the fray. There’s more work to be done.”

And Paul Samuels, president of the Legal Action Center, said: “We are very sorry to see Westley leave, as he has been a terrific champion of addiction treatment in many aspects, including his understanding of the importance of confidentiality protections for people in substance use disorder treatment.”

Finally, Pam Hyde sent a comment as well: “Dr. H. Westley Clark has announced that he will be retiring from SAMHSA after 16 years of distinguished service with the agency and 33 years of federal service. His career has been marked by a series of extraordinary contributions to science and learning, to service and practice, and to teaching and leading. His passion for the field and his dedication to staying abreast of the latest evidence and emerging issues — domestic and international — are without equal. His commitment to the people who experience addiction and/or mental illness sets a standard to which we all can aspire. SAMHSA will deeply miss his ideas, his vast knowledge, his perspective, and many other attributes. We are profoundly grateful for his service and wish him well in all future endeavors.”

By October 2, SAMHSA had still not announced that Clark would be retiring the next day. There was no indication of who would be replacing him. Observers speculated that it would most likely be someone who would approve changing 42 CFR Part 2 and lifting the buprenorphine cap. And based on the hastiness of his departure, these changes may be taking place fairly soon.

Bottom Line…

H. Westley Clark is hastily retiring from CSAT, leaving the fate of 42 CFR Part 2 and lifting the buprenorphine cap to his still-unnamed successor.

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.

From the Field
6/30/2014 12:00 AM

Marijuana is a potent drug. My personal experiences with marijuana — occasional recreational use during graduate school — were relatively benign. A few times I had experiences I found distinctly unpleasant. Usually I found that marijuana made me feel slow, heavy, dull and sedate. And because I am a person who is predisposed to the seduction of altered states, I generally enjoyed those feelings. But I found that mixing alcohol and marijuana tended to make those unpleasant experiences more likely. And because I greatly preferred the effects produced by alcohol to those produced by marijuana — and because I was uncomfortable with the illegality of marijuana — I almost always forsook smoking for drinking.

In sobriety, I have had the opportunity to see a very different side of marijuana from the privileged, private-university world I inhabited when I indulged. In the rooms of Alcoholics Anonymous, it is very common that the stories I hear involve both drugs and alcohol. While I consider myself to be fairly exclusively an alcoholic and not a drug addict, I have no illusions about the nature of my disease: I enjoy treating discomfort with mind-altering substances. Though alcohol is my preference, I have also used marijuana and benzodiazepines. That’s not uncommon at all, nor is using cocaine, heroin, methamphetamine, or any number of prescription drugs.

The effects of chronic marijuana use that I have seen are not particularly dissimilar in their manifestations from the effects of chronic alcohol use. Not in terms of how they affect a person’s body, perhaps, but in terms of how they affect a person’s life — increasing isolation from mainstream society, ruptures in relationships and families, unemployment, legal consequences, despair, suffering and misery — problems that are routinely relieved when the abuser commits to abstinence and a program of recovery.

I also see what we in AA call “The Marijuana Maintenance Program.” Many of us come to realize that we have a problem with alcohol and need to stop imbibing. But we are unwilling or unable to face the things in ourselves that are necessary to face in order to recover. And so we turn to a drug that we believe is less harmful, or more manageable. This is no different from deciding that liquor is too dangerous so we try to switch to beer. There is occasionally a brief period of respite, but our addiction will not remit until we abandon all of our artificial anesthesias and examine the underlying causes of our affliction.

As a member of Alcoholics Anonymous — I do not, of course, speak for that organization — I take no position on the legalization of marijuana for recreational use. As a scientist, I do believe that the medical value of the cannabis plant should be studied as we study any other plant and given appropriate opportunities to relieve human morbidity and suffering as is possible. Simply because some people abuse it, we should not discard it as a source of medicines. And there is significant evidence that medicines derived from marijuana, or marijuana itself, may be beneficial for a variety of conditions. A recent article in the British Medical Journal (Farrell M et al., Should doctors prescribe cannabinoids? BMJ 2014;348:g2737) neatly capsulizes the evidence and counter-evidence for marijuana as a medical intervention for a variety of conditions.

Medical marijuana is, of course, also obviously a capillary-action attempt to open the door to recreational marijuana, and it has been successful in Washington and Colorado. The joke I’ve heard over and over again from such advocates is “I need medical marijuana because I get depressed when I run out of pot.” From the pragmatic perspective of someone who is primarily interested in addicts and alcoholics having a path to recovery, and the opportunity to reclaim lost lives, I am not certain that whether marijuana, or even alcohol, is legal or not matters much to me. Humans will use and abuse mind-altering substances. Some will become dependent. Of those, a few will seek recovery.

There are enormous societal investments and consequences associated with the control and enforcement of marijuana as a banned substance, and it may be worth investigating whether legalization would have a net positive or net negative impact on things like crime, poverty and social disparities. I don’t pretend to know the answer. What I know is that marijuana abuse and dependence are real and troublesome problems, but recovery from them is entirely feasible. I have seen it countless times.

From the field
12/20/2012 12:00 AM
Advocates call for mental health treatment, gun control in wake of tragedy in Newtown.

(Editor’s note: On December 14, 20 elementary school students and six school teachers and administrators were shot and killed by a troubled young man, Adam Lanza, who also killed his mother and himself.)

Now is the time for the substance use and mental health community to act together to help end the violence and self-mutilation we as a nation encourage. The victims, their families and all of our children and communities must be comforted. Substance use and mental health clinicians are often at the forefront helping in the aftermath of these too frequent massacres.

We can resolve to change this social environment of destruction. Below is a letter from the behavioral health community to President Obama, congressional leadership, members of Congress and state government officials. Will you sign on? Will you send this or your own letter to your member of Congress, governor or state legislator? Will you help recruit others — people in recovery, families caring for a loved one struggling with substance use or mental illness, counselors and leaders of behavioral health programs — to send letters and call their congressional delegations, governors and state legislators?

As people touched by the tragedies in Connecticut, Arizona, Colorado and too many other communities, as people who are touched by the destruction of untreated alcohol, drug and mental health problems, we must act together to end these killings.

We must all be part of the solution — by showing the faces, voices and resolve of people affected by mental illness and addiction to end this violence and repair our communities. Mental health and substance use are not the causes of the violence, but we can help with solutions.

Dear Mr. President, Mr. Speaker and Members of Congress:

As people who have direct, lived experience with mental illness and addiction, as family members caring for our loved ones with these illnesses, as counselors and healthcare workers and as leaders of behavioral health programs, we all call on you, the leaders of our nation, to begin with us a road to recovery from these tragedies. We grieve for the innocents murdered in Newtown. These are our children, our neighbors, our families, our friends. There can be no greater tragedy in a society than losing its young, its own future, so needlessly and so senselessly. Such actions strike at the very heart of who we are and who we hope to become.

So we must grieve. We grieve for the families who lost their children, for the families of their teachers who were killed, for the entire Newtown community and for America itself. Yet, we owe them all much, much more than just our tears. They also deserve our action to identify and implement solutions.

To begin our recovery, we recommend that you provide federal assistance to:

  • Immediately double the capacity of public mental health and substance abuse programs. Funding for community mental health and substance use treatment services has been cut dramatically. As a result, only a third of those with moderate mental illness and two-thirds of those with severe illness ever receive any care. Families simply cannot get badly needed care. The Affordable Care Act must be implemented fully, and mental health and substance use care must be fully integrated into good medical care.
  • Immediately implement school- and community-based programs to promote mental health, to prevent mental illness and substance abuse and to provide early interventions for those exhibiting these conditions. Prevention and early intervention strategies can strengthen children’s mental health and resiliency, prevent or lessen the burden of illness and help them and their families to recover from trauma. Further, teachers must be taught how to identify troubled children and to guide them into effective supports before these children get into trouble.
  • Immediately begin teaching students at all levels to recognize the signs of mental illness and addiction, and to seek help when needed. Few young people get even a single hour of education about mental illness or addiction, its signs or its treatment. We can’t expect people to step forward or to seek help for a family member when we don’t even provide them the rudimentary tools to do so. We must begin to do so.
  • Immediately ban assault rifles and large-capacity clips. Possession of these weapons is a fundamental public health problem. They are designed for the battlefield, not our closets. They are used to kill people senselessly and needlessly. In Newtown, an assault weapon was used to kill 20 young children just starting their lives and six of their heroic teachers. Enough!

Yes, we must grieve for the innocents, just as we grieved recently for those lost in Tucson, Aurora and Portland. But this time, our grieving must have a direction and purpose to galvanize action. As people who know firsthand the tragedies of mental illness and addiction, and the triumphs that are possible, we all call on you to take immediate action.

Our nation expects nothing less of all of us.


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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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