Social Affairs (Papers)

PHE publications gateway number: 2016490 December 2016

Executive summary

Alcohol is a prominent commodity in the UK marketplace. It is widely used in numerous social situations. For many, alcohol is associated with positive aspects of life; however, there are currently over 10 million people drinking at levels which increase their risk of health harm. Among those aged 15 to 49 in England, alcohol is now the leading risk factor for ill-health, early mortality and disability and the fifth leading risk factor for ill health across all age groups. Since 1980, sales of alcohol in England and Wales have increased by 42%, from roughly 400 million litres in the early 1980s, with a peak at 567 million litres in 2008, and a subsequent decline.

This growth has been driven by increased consumption among women, a shift to higher strength products, and increasing affordability of alcohol, particularly through the 1980s and 1990s. Over this period, the way in which alcohol is sold and consumed also changed. In 2016 there were 210,000 license premises in England and Wales, a 4% increase on 2010. There has been a shift in drinking location such that most alcohol is now bought from shops and drunk at home.

Although consumption has declined in recent years, levels of abstinence have also increased. Consequently, it is unclear how much of the decline is actually related to drinkers consuming less alcohol and how much to an increasing proportion of the population not drinking at all. In recent years, many indicators of alcohol-related harm have increased.

There are now over 1 million hospital admissions relating to alcohol each year, half of which occur in the lowest three socioeconomic deciles. Alcohol-related mortality has also increased, particularly for liver disease which has seen a 400% increase since 1970, and this trend is in stark contrast to much of Western Europe. In England, the average age at death of those dying from an alcohol-specific cause is 54.3 years. The average age of death from all causes is 77.6 years.

More working years of life are lost in England as a result of alcohol-related deaths than from cancer of the lung, bronchus, trachea, colon, rectum, brain, pancreas, skin, ovary, kidney, stomach, bladder and prostate, combined.

Despite this burden of harm, some positive trends have emerged over this period, particularly indicators which relate to alcohol consumption among those aged less than 18 years, and there have been steady reductions in alcohol-related road traffic crashes. The public health burden of alcohol is wide ranging, relating to health, social or economic harms. These can be tangible, direct costs (including costs to the health, criminal justice and welfare systems), or indirect costs (including the costs of lost productivity due to absenteeism, unemployment, decreased output or lost working years due to premature pension or death).

Harms can also be intangible, and difficult to cost, including those assigned to pain and suffering, poor quality of life or the emotional The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies: An evidence review 7 distress caused by living with a heavy drinker. The spectrum of harm ranges from those that are relatively mild, such as drinkers loitering near residential streets, through to those that are severe, including death or lifelong disability. Many of these harms

impact upon other people, including relationship partners, children, relatives, friends, co-workers and strangers. In sum, the economic burden of alcohol is substantial, with estimates placing the annual cost to be between 1.3% and 2.7% of annual GDP.

Few studies report costs on the magnitude of harm to people other than the drinker, so the economic burden of alcohol consumption is generally underestimated. Crucially, the financial burden which alcohol-related harm places on society is not reflected in its market price, with taxpayers picking up a larger amount of the overall cost compared to the individual drinkers. This should provide impetus for governments to implement effective policies to reduce the public health impact of alcohol, not only because it is an intrinsically desirable societal goal, but because it is an important aspect of economic growth and competitiveness. Reflecting three key influencers of alcohol consumption – price (affordability), ease of purchase (availability) and the social norms around its consumption (acceptability) – an extensive array of policies have been developed with the primary aim of reducing the public health burden of alcohol. The present review evaluates the effectiveness and cost-effectiveness of each of these policy approaches.

Source: 2016

The proliferation of retail boutiques in California did not really bother him, Evan told me, but the billboards did. Advertisements for delivery, advertisements promoting the substance for relaxation, for fun, for health. “Shop. It’s legal.” “Hello marijuana, goodbye hangover.” “It’s not a trigger,” he told me. “But it is in your face.”

When we spoke, he had been sober for a hard-fought seven weeks: seven weeks of sleepless nights, intermittent nausea, irritability, trouble focusing, and psychological turmoil. There were upsides, he said, in terms of reduced mental fog, a fatter wallet, and a growing sense of confidence that he could quit. “I don’t think it’s a ‘can’ as much as a ‘must,'” he said.

Evan, who asked that his full name not be used for fear of the professional repercussions, has a self-described cannabis-use disorder. If not necessarily because of legalization, but alongside legalization, such problems are becoming more common: The share of adults with one has doubled since the early aughts, as the share of cannabis users who consume it daily or near-daily has jumped nearly 50 percent-all “in the context of increasingly permissive cannabis legislation, attitudes, and lower risk perception,” as the National Institutes of Health put it.

Public-health experts worry about the increasingly potent options available, and the striking number of constant users. “Cannabis is potentially a real public-health problem,” said Mark A. R. Kleiman, a professor of public policy at New York University. “It wasn’t obvious to me 25 years ago, when 9 percent of self-reported cannabis users over the last month reported daily or near-daily use. I always was prepared to say, ‘No, it’s not a very abusable drug. Nine percent of anybody will do something stupid.’ But that number is now [something like] 40 percent.” They argue that state and local governments are setting up legal regimes without sufficient public-health protection, with some even warning that the country is replacing one form of reefer madness with another, careening from treating cannabis as if it were as dangerous as heroin to treating it as if it were as benign as kombucha.

But cannabis is not benign, even if it is relatively benign, compared with alcohol, opiates, and cigarettes, among other substances. Thousands of Americans are finding their own use problematic-in a climate where pot products are getting more potent, more socially acceptable to use, and yet easier to come by, not that it was particularly hard before.

For Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University, the most compelling evidence of the deleterious effects comes from users themselves. “In large national surveys, about one in 10 people who smoke it say they have a lot of problems. They say things like, ‘I have trouble quitting. I think a lot about quitting and I can’t do it. I smoked more than I intended to. I neglect responsibilities.’ There are plenty of people who have problems with it, in terms of things like concentration, short-term memory, and motivation,” he said. “People will say, ‘Oh, that’s just you fuddy-duddy doctors.’ Actually, no. It’s millions of people who use the drug who say that it causes problems.”

Users or former users I spoke with described lost jobs, lost marriages, lost houses, lost money, lost time. Foreclosures and divorces. Weight gain and mental-health problems. And one other thing: the problem of convincing other people that what they were experiencing was real. A few mentioned jokes about Doritos, and comments implying that the real issue was that they were lazy stoners. Others mentioned the common belief that you can be “psychologically” addicted to pot, but not “physically” or “really” addicted. The condition remains misunderstood, discounted, and strangely invisible, even as legalization and white-marketization pitches ahead.

The country is in the midst of a volte-face on marijuana. The federal government still classifies cannabis as Schedule I drug, with no accepted medical use. (Meth and PCP, among other drugs, are Schedule II.) Politicians still argue it is a gateway to the use of things like heroin and cocaine. The country still spends billions of dollars fighting it in a bloody and futile drug war, and still arrests more people for offenses related to cannabis than it does for all violent crimes combined.

Yet dozens of states have pushed ahead with legalization for medical or recreational purposes, given that for decades physicians have argued that marijuana’s health risks have been overstated and its medical uses overlooked; activists have stressed prohibition’s tremendous fiscal cost and far worse human cost; and researchers have convincingly argued that cannabis is far less dangerous than alcohol. A solid majority of Americans support legalization nowadays.

Academics and public-health officials, though, have raised the concern that cannabis’s real risks have been overlooked or underplayed-perhaps as part of a counter-reaction to federal prohibition, and perhaps because millions and millions cannabis users have no problems controlling their use. “Part of how legalization was sold was with this assumption that there was no harm, in reaction to the message that everyone has smoked marijuana was going to ruin their whole life,” Humphreys told me. It was a point Kleiman agreed with. “I do think that not legalization, but the legalization movement, does have a lot on its conscience now,” he said. “The mantra about how this is a harmless, natural, and non-addictive substance-it’s now known by everybody. And it’s a lie.”

Thousands of businesses, as well as local governments earning tax money off of sales, are now literally invested in that lie. “The liquor companies are salivating,” Matt Karnes of GreenWave Advisors told me. “They can’t wait to come in full force.” He added that Big Pharma was targeting the medical market, with Wall Street, Silicon Valley, food businesses, and tobacco companies aiming at the recreational market.

Sellers are targeting broad swaths of the consumer market-soccer moms, recent retirees, folks looking to replace their nightly glass of chardonnay with a precisely dosed, low-calorie, and hangover-free mint. Many have consciously played up cannabis as a lifestyle product, a gift to give yourself, like a nice crystal or an antioxidant face cream. “This is not about marijuana,” one executive at the California retailer MedMen recently argued. “This is about the people who use cannabis for all the reasons people have used cannabis for hundreds of years. Yes for recreation, just like alcohol, but also for wellness.”

Evan started off smoking with his friends when they were playing sports or video games, lighting up to chill out after his nine-to-five as a paralegal at a law office. But that soon became couch-lock, and he lost interest in working out, going out, doing anything with his roommates. Then came a lack of motivation and the slow erosion of ambition, and law school moving further out of reach. He started smoking before work and after work. Eventually, he realized it was impossible to get through the day without it. “I was smoking anytime I had to do anything boring, and it took a long time before I realized that I wasn’t doing anything without getting stoned,” he said.

His first attempts to reduce his use went miserably, as the consequences on his health and his life piled up. He gained nearly 40 pounds, he said, when he stopped working out and cooking his own food at home. He recognized that he was just barely getting by at work, and was continually worried about getting fired. Worse, his friends were unsympathetic to the idea that he was struggling and needed help. “[You have to] try to convince someone that something that is hurting you is hurting you,” he said.

Other people who found their use problematic or had managed to quit, none of whom wanted to use their names, described similar struggles and consequences. “I was running two companies at the time, and fitting smoking in between running those companies. Then, we sold those companies and I had a whole lot of time on my hands,” one other former cannabis user told me. “I just started sitting around smoking all the time. And things just came to a halt. I was in terrible shape. I was depressed.”

Lax regulatory standards and aggressive commercialization in some states have compounded some existing public-health risks, raised new ones, and failed to tamp down on others, experts argue. In terms of compounding risks, many cite the availability of hyper-potent marijuana products. “We’re seeing these increases in the strength of cannabis, as we are also seeing an emergence of new types of products,” such as edibles, tinctures, vape pens, sublingual sprays, and concentrates, Ziva Cooper, an associate professor of clinical neurobiology in the Department of Psychiatry at Columbia University Medical Center, told me. “A lot of these concentrates can have up to 90 percent THC,” she said, whereas the kind of flower you could get 30 years ago was far, far weaker. Scientists are not sure how such high-octane products affect people’s bodies, she said, but worry that they might have more potential for raising tolerance, introducing brain damage, and inculcating dependence.

As for new risks: In many stores, budtenders are providing medical advice with no licensing or training whatsoever. “I’m most scared of the advice to smoke marijuana during pregnancy for cramps,” said Humphreys, arguing that sellers were providing recommendations with no scientific backing, good or bad, at all.

In terms of long-standing risks, the lack of federal involvement in legalization has meant that marijuana products are not being safety-tested like pharmaceuticals; measured and dosed like food products; subjected to agricultural-safety and pesticide standards like crops; and held to labelling standards like alcohol. (Different states have different rules and testing regimes, complicating things further.)

Health experts also cited an uncomfortable truth about allowing a vice product to be widely available, loosely regulated, and fully commercialized: Heavy users will make up a huge share of sales, with businesses wanting them to buy more and spend more and use more, despite any health consequences.

“The reckless way that we are legalizing marijuana so far is mind-boggling from a public-health perspective,” Kevin Sabet, an Obama administration official and a founder of the non-profit Smart Approaches to Marijuana, told me. “The issue now is that we have lobbyists, special interests, and people whose motivation is to make money that are writing all of these laws and taking control of the conversation.”

This is not to say that prohibition is a more attractive policy, or that legalization has proven a public-health disaster. “The big-picture view is that the vast majority of people who use cannabis are not going to be problematic users,” said Jolene Forman, an attorney at the Drug Policy Alliance. “They’re not going to have a cannabis-use disorder. They’re going to have a healthy relationship with it. And criminalization actually increases the harms related to cannabis, and so having like a strictly regulated market where there can be limits on advertising, where only adults can purchase cannabis, and where you’re going to get a wide variety of products makes sense.”

Still, strictly regulated might mean more strictly regulated than today, at least in some places, drug-policy experts argue. “Here, what we’ve done is we’ve copied the alcohol industry fully formed, and then on steroids with very minimal regulation,” Humphreys said. “The oversight boards of a number of states are the industry themselves. We’ve learned enough about capitalism to know that’s very dangerous.”

A number of policy reforms might tamp down on problem use and protect consumers, without quashing the legal market or pivoting back to prohibition and all its harms. One extreme option would be to require markets to be non-commercial: The District of Columbia, for instance, does not allow recreational sales, but does allow home cultivation and the gifting of marijuana products among adults. “If I got to pick a policy, that would probably be it,” Kleiman told me. “That would be a fine place to be if we were starting from prohibition, but we are starting from patchwork legalization. As the Vermont farmer says, I don’t think you can get there from here. I fear its time has passed. It’s generally true that the drug warriors have never missed an opportunity to miss an opportunity.”

There’s no shortage of other reasonable proposals, many already in place or under consideration in some states. The government could run marijuana stores, as in Canada. States could require budtenders to have some training or to refrain from making medical claims. They could ask users to set a monthly THC purchase cap and remain under it. They could cap the amount of THC in products, and bar producers from making edibles that are attractive to kids, like candies. A ban or limits on marijuana advertising are also options, as is requiring cannabis dispensaries to post public-health information.

Then, there are THC taxes, designed to hit heavy users the hardest. Some drug-policy experts argue that such levies would just push people from marijuana to alcohol, with dangerous health consequences. “It would be like saying, ‘Let’s let the beef and pork industries market and do whatever they wish, but let’s have much tougher restrictions on tofu and seitan,'” said Mason Tvert of the Marijuana Policy Project. “In light of the current system, where alcohol is so prevalent and is a more harmful substance, it is bad policy to steer people toward that.” Yet reducing the commercial appeal of all vice products-cigarettes, alcohol, marijuana-is an option, if not necessarily a popular one.

Perhaps most important might be reintroducing some reasonable skepticism about cannabis, especially until scientists have a better sense of the health effects of high-potency products, used frequently. Until then, listening to and believing the hundreds of thousands of users who argue marijuana is not always benign might be a good start.

Source:   20th August 2018

In 2016, Gov. Greg Abbott announced a $9.75 million grant to McKesson Corporation. Now, Texas is among the states investigating the giant drug distributor’s role in a growing opioid crisis

In the early months of 2016, as U.S. overdose deaths were on track to break records and the number of Texas infants born addicted to opioid painkillers climbed steadily higher, Gov. Greg Abbott was courting a massive pharmaceutical company, McKesson, with a multimillion-dollar offer.

At the time, the two stories — Texas public health officials grappling with an overdose epidemic while the governor’s office worked on economic development — seemed unrelated. When Abbott announced he would give McKesson a $9.75 million grant from the state’s Enterprise Fund to woo the pharmaceutical distributor into expanding its operations in North Texas, he mostly received favorable news coverage for promising nearly 1,000 jobs to the local Irving economy.

But as the state and nation’s focus on the opioid crisis has sharpened in recent months, McKesson and other drug companies have come under legal scrutiny and the deal has put Abbott in an uncomfortable position.

Texas has since joined a multistate investigation into pharmaceutical companies, including McKesson, over whether they are responsible for feeding the nation’s opioid crisis and whether they broke any laws in the process. Several Texas counties have moved to sue McKesson and other companies for economic damages, alleging that manufacturers downplayed addiction risks and their distributors failed to track suspicious orders that flooded communities with pills.

The state grant to McKesson, worth about $10,000 for each job it brought to North Texas, is the largest Abbott has doled out from the Enterprise Fund, the controversial deal-closing incentives program created in 2004 under former Gov. Rick Perry. No U.S. state or local government has publicly given McKesson a more generous grant since 2000, according to data compiled by Good Jobs First, a Washington D.C.-based group that tracks government subsidies and other economic incentives.

In statements at the time, Abbott said the company’s expansion would “serve as an invaluable contribution to the Texas economy.”

But if Texas decides to sue McKesson, as several of its counties have, lawyers for the state will likely argue the opposite has happened — at least in the context of the company’s distribution of opioids. Across the country, local and state governments have begun to argue they are bearing the financial burden associated with opioid addiction.

One state lawmaker suggested Abbott’s office should have more closely scrutinized McKesson’s record before issuing the grant — even though the grant happened more than a year before Attorney General Ken Paxton announced Texas was joining the multistate investigation.

“There needs to be better oversight here,” said state Rep. Joe Moody, an El Paso Democrat and member of the new House panel examining the opioid crisis. “You’re in the middle of the opioid crisis, and we’re issuing an enormous grant that comprises a significant amount of grants this company is getting across the country.” 

Abbott’s office did not respond to repeated requests for comment.

Faced with the lawsuits and investigations, McKesson — headquartered in San Francisco but with a sizable Texas footprint — has denied any wrongdoing and insisted it is trying to work toward halting the opioid crisis, not fuel it.

“Our partnership with the state remains strong,” said Kristin Chasen, a company spokeswoman. “We certainly agree that the opioid epidemic is a national public health crisis, and we’re cooperatively having lots of conversations with AG Paxton and the others involved in the multistate investigation.”

A nationwide emergency

Opioids are a family of drugs that include prescription painkillers like hydrocodone as well as illicit drugs like heroin. Last Thursday, President Donald Trump declared a nationwide emergency to address the surging human and financial toll of opioid addiction.

U.S. drug overdose deaths in 2015 far outnumbered deaths from auto accidents or guns, and opioids account for more than 60 percent of overdose deaths — nearly 100 each day, according to the U.S. Centers for Disease Control. That death toll has quadrupled over the past two decades. 

“Beyond the shocking death toll, the terrible measure of the opioid crisis includes the families ripped apart and, for many communities, a generation of lost potential and opportunity,” Trump said Thursday

In Texas, opioids have claimed proportionately fewer lives than in other states, and the growth of opioid-related deaths has been slower, according to U.S. mortality data. Still, the casualties in Texas — 1,107 accidental opioid poisoning deaths in 2016 — have seized the attention of state policymakers.

Last week, Texas House Speaker Joe Straus ordered lawmakers to form a select committee on opioids and substance abuse to examine an issue that he said has had a “devastating impact on many lives.” The announcement came after Paxton joined a 41-state investigation into whether a slew of drug manufacturers and distributors broke any laws in allegedly fueling the crisis.

“This is a public safety and public health issue. Opioid painkiller abuse and related overdoses are devastating families here in Texas and throughout the country,” Paxton said when he announced the probe in June.

Some Texas counties have already taken the drug companies to court.

In late September, Upshur County, population about 40,000, sued a slew of painkiller manufacturers and distributors — including McKesson. Seeking to recoup an unspecified amount in financial damages, the East Texas county argues the drug companies broadly “ignored science and consumer health for profits,” meaning the county “continues to spend large sums combatting the public health crisis created by [a] negligent and fraudulent marketing campaign.”

More specifically, the suit argues McKesson and other distributors “did nothing” to address the “alarming and suspicious” overprescription of drugs.

Bowie County, a rural slice of East Texas nudging Arkansas, has since joined the lawsuit, with other East Texas counties expected to follow. El Paso County isalso mulling legal action, and Bexar County, home to San Antonio, has announced plans to sue.

In an interview last week, Bexar County Judge Nelson Wolff said he couldn’t immediately offer a complete list of companies his county would target, but “I’m sure McKesson is one of them.”

Wolff chuckled when asked about the company’s grant from the state. “That’d give us $10 million more that we could get out of their hides in our lawsuit, if you look at it that way.”

In teaming up to probe drug companies, some experts suggest governments are following a playbook similar to one used during the 1990s to sue tobacco companies for their role in fueling a costly health crisis — an effort that resulted in a settlement yielding more than $15 billion for Texas alone.

“It’s like a polluter externalizing all his risk,” said Mike Papantonio, a Florida-based lawyer with experience in tobacco litigation. 

“He makes a lot of money because he pours the poison right into the river,” said Papantonio, who now organizes a legal conference for groups interested in suing pharmaceutical companies. “The shareholders love it, but then the taxpayers have to come back and fix it.”

“McKesson is a great company”

At the April grand opening of the new McKesson campus in Las Colinas, near Irving, local leaders gathered alongside Abbott and company executives for a ribbon-cutting at the $157 million, 525,000-square foot campus.

“McKesson is a great company,” Abbott said on the stage of a large meeting room at the newly renovated headquarters. 

“I am proud of the work McKesson is doing,” he went on, “and make a commitment of my own to continue to ensure Texas attracts further business and expanding enterprise.”

Beth Van Duyne, then the mayor of Irving, now a U.S. Housing and Urban Development administrator under Trump, defended the city’s decision to give the pharmaceutical company a more than $2 million incentives package on top of the state’s Enterprise Fund gift.

“Having to offer incentives is always a difficult decision to make, but as long as the return on that investment is strong, we can support it,” Van Duyne said in a video recorded from the grand opening.

Even though the promise of taxpayer funds came before Paxton launched his investigation, Moody, the Democratic lawmaker, said Abbott’s office should more carefully vet companies before granting them taxpayer money, and in McKesson’s case, it should have considered the drug company’s alleged role in the opioid crisis.

“We know there’s a problem with drug distribution. These drugs being taken out of the regular route, finding their way into other people’s hands — leading to deaths, leading to overdoses,” he said, later adding, “I don’t think it’s unrealistic to ask that to be part of the evaluation at all. Part of the conversation of growing the economy is what types of companies, businesses do you want?” 

State Rep. Kevin Roberts, a Houston Republican and fellow member of the House panel studying opioids, said he did not know what went into Abbott’s decision making, so he couldn’t comment on the wisdom of the grant. But he agreed that the state should also consider wider issues when deciding which businesses are awarded grants from the enterprise fund.

“I do believe that there is some ethical responsibility in that process as well,” he said. “Just because things look profitable doesn’t mean you do them.”

The fact that McKesson got the state grant doesn’t shield it from liability if Texas ultimately files an opioid lawsuit, Roberts added. “If General Paxton goes forward, the fact that they got a TEF grant does not excuse them.”

Pressure to act

McKesson is also facing legal challenges outside of Texas.

In a recent report to the U.S. Securities and Exchange Commission, the company noted an opioid-related lawsuit brought by the State of West Virginia and nine similar complaints filed in state and federal courts in West Virginia against McKesson and other large distributors. McKesson also listed a federal lawsuit in which the Cherokee Nation alleges the company oversupplied drugs to its population.

In January, McKesson agreed to pay $150 million and revamp its compliance procedures to settle a lawsuit brought by the U.S. Department of Justice after prosecutors alleged the company failed to detect and report “suspicious orders” of opioids.

The company paid $13.25 million to settle a similar Justice Department suit in 2008. McKesson did not admit wrongdoing in either case.

Chasen, the spokeswoman, said McKesson is “really proud of our controlled substances monitoring program today,” and the recent scrutiny addresses conduct “that was really far in the past at this point.”

Chasen added that the company reports all orders “in real time” to the U.S. Drug Enforcement Agency, flagging suspicious ones. 

Mark Kinzly, a co-founder of the Texas Overdose Naloxone Initiative, which educates police officers and the public on overdose prevention, has been critical of the state’s mixed response to the opioid epidemic. In 2015, for example, Abbott drew the ire of Kinzly and other advocates when he vetoed a “Good Samaritan” bill that would have protected someone from prosecution, even if they possessed a small amount of drugs, when they called 911 to help a friend in the throes of overdose.

Abbott said at the time that the bill had an admirable goal but did not include “adequate protections to prevent its misuse by habitual drug abusers and drug dealers.”

Kinzly said Trump’s declaration of a national opioid emergency may lead more politicians to demonstrate support for expanding drug treatment programs. “That will put some pressure on Republican governors, I would imagine,” he said.

Trump, for his part, suggested Thursday that pharmaceutical companies remained in the federal government’s crosshairs.

“What they have and what they’re doing to our people is unheard of,” he said. “We will be bringing some very major lawsuits against people and against companies that are hurting our people.” 


October 2017

By Christopher Ingraham

Drug overdose deaths surpassed 72,000 in 2017, according to provisional estimates recently released by the Centers for Disease Control and Prevention. That represents an increase of more than 6,000 deaths, or 9.5 percent, over the estimate for the previous 12-month period.

That staggering sum works out to about 200 drug overdose deaths every single day, or one every eight minutes.

The increase was driven primarily by a continued surge in deaths involving synthetic opioids, a category that includes fentanyl. There were nearly 30,000 deaths involving those drugs in 2017, according to the preliminary data, an increase of more than 9,000 over the prior year.

Deaths involving cocaine also shot up significantly, putting the stimulant on par with drugs such as heroin and the category of natural opiates that includes painkillers such as oxycodone and hydrocodone. One potential spot of good news is that deaths involving those latter two drug categories appear to have flattened out, suggesting the possibility that opiate mortality may be at or nearing its peak.

Overdose estimates for selected drug types in 2017.

The CDC cautions that these figures are early estimates based on monthly death records processed by the agency. The CDC adjusts these figures to correct for underreporting, because some recorded deaths are still pending full investigation. Final mortality figures are typically released at the end of the following calendar year.

The CDC updates these provisional numbers monthly. The recent inclusion of December 2017 means that a complete, albeit early look at 2017 overdose mortality is now available for the first time.

Geographically the deaths are distributed similarly to how they’ve been in prior years, with parts of Appalachia and New England showing the highest mortality rates. Once again, the highest rates were seen in West Virginia, with 58.7 overdose deaths for every 100,000 residents. The District of Columbia (50.4), Pennsylvania (44.1), Ohio (44.0) and Maryland (37.9) rounded out the top five.

At the other end of the spectrum, states in the Great Plains had some of the lowest death rates. Nebraska had the fewest with just 8.2 deaths per 100,000, a rate less than one-seventh the rate in West Virginia.

Despite the nationwide increase, the CDC’s preliminary data also shows overdose rates fell in a number of states, including North Dakota and Wyoming, compared with the prior year. Particularly significant were the decreases in Vermont and Massachusetts, two states with relatively high rates of overdose mortality.

Beyond that, the month-to-month data brings some potentially good news: Nationwide, deaths involving opioids have plateaued and even fallen slightly in recent months, from an estimated high of 49,552 deaths in the 12-month period ending in September 2017 down to 48,612 in the period ending January of this year. While it’s too early to say whether that trend will continue through 2018, those numbers are somewhat encouraging.

Opiate death estimates through January 2018.

A chief concern among substance abuse experts is the ubiquity of fentanyl, a synthetic opioid that’s roughly 50 times more potent than heroin. Because it’s cheap and relatively easy to make, it’s often mixed with other drugs such as heroin and cocaine.

Policymakers have struggled to come up with an adequate response to the opioid crisis. Overdose deaths initially ballooned during the Obama administration, which was criticized by experts for being slow to respond to the problem. Last year, the Trump administration declared the epidemic a “public health emergency” but allocated no new funding for states to address the issue. Former congressman Patrick Kennedy (D-R.I.), a member of the task force that the administration convened to tackle the epidemic, criticized President Trump late last year for being “all talk and no follow-through” on opioids.


Report by National Families in Action Rips the Veil Off the Medical Marijuana Industry
Research Traces the Money Trail and Reveals the Motivation Behind Marijuana as Medicine

Tracking the Money That’s Legalizing Marijuana and Why It Matters documents state-by-state financial data, exposing the groups and the amount of money used either to fund or oppose ballot initiatives legalizing medical or recreational marijuana in 16 U.S. states.

• NFIA report reveals three billionaires — George Soros, Peter Lewis and John Sperling — who contributed 80 percent of the money to medicalize marijuana through state ballot initiatives during a 13-year period, with the strategy to use medical marijuana as a runway to legalized recreational pot.
• Report shows how billionaires and marijuana legalizers manipulated the ballot initiative process, outspent the people who opposed marijuana and convinced voters that marijuana is medicine, even while most of the scientific and medical communities say marijuana is not medicine and should not be legal.

• Children in Colorado treated with unregulated cannabis oil have had severe dystonic reactions, other movement disorders, developmental regression, intractable vomiting and worsening seizures.

• A medical marijuana industry has emerged to join the billionaires in financing initiatives to legalize recreational pot.

ATLANTA, March 14, 2017 (GLOBE NEWSWIRE) — A new report by National Families in Action (NFIA) uncovers and documents how three billionaires, who favor legal recreational marijuana, manipulated the ballot initiative process in 16 U.S. states for more than a decade, convincing voters to legalize medical marijuana. NFIA is an Atlanta-based non-profit organization, founded in 1977, that has been helping parents prevent children from using alcohol, tobacco, and other drugs. NFIA researched and issued the paper to mark its 40th anniversary.

The NFIA study, Tracking the Money That’s Legalizing Marijuana and Why It Matters, exposes, for the first time, the money trail behind the marijuana legalization effort during a 13-year period. The report lays bare the strategy to use medical marijuana as a runway to legalized recreational pot, describing how financier George Soros, insurance magnate Peter Lewis, and for-profit education baron John Sperling (and groups they and their families fund) systematically chipped away at resistance to marijuana while denying that full legalization was their goal.

The report documents state-by-state financial data, identifying the groups and the amount of money used either to fund or oppose ballot initiatives legalizing medical or recreational marijuana in 16 states. The paper unearths how legalizers fleeced voters and outspent — sometimes by hundreds of times — the people who opposed marijuana.

Tracking the Money That’s Legalizing Marijuana and Why It Matters illustrates that legalizers lied about the health benefits of marijuana, preyed on the hopes of sick people, flouted scientific evidence and advice from the medical community and gutted consumer protections against unsafe, ineffective drugs. And, it proves that once the billionaires achieved their goal of legalizing recreational marijuana (in Colorado and Washington in 2012), they virtually stopped financing medical pot ballot initiatives and switched to financing recreational pot. In 2014 and 2016, they donated $44 million to legalize recreational pot in Alaska, Oregon, California, Arizona, Nevada, Massachusetts and Maine. Only Arizona defeated the onslaught (for recreational marijuana).

Unravelling the Legalization Strategy: Behind the Curtain

In 1992, financier George Soros contributed an estimated $15 million to several groups he advised to stop advocating for outright legalization and start working toward what he called more winnable issues such as medical marijuana. At a press conference in 1993, Richard Cowen, then-director of the National Organization for the Reform of Marijuana Laws, said, “The key to it [full legalization] is medical access. Because, once you have hundreds of thousands of people using marijuana medically, under medical supervision, the whole scam is going to be blown. The consensus here is that medical marijuana is our strongest suit. It is our point of leverage which will move us toward the legalization of marijuana for personal use.”

Between 1996 and 2009, Soros, Lewis and Sperling contributed 80 percent of the money to medicalize marijuana through state ballot initiatives. Their financial contributions, exceeding $15.7 million (of the $19.5 million total funding), enabled their groups to lie to voters in advertising campaigns, cover up marijuana’s harmful effects, and portray pot as medicine — leading people to believe that the drug is safe and should be legal for any use.
Today, polls show how successful the billionaires and their money have been. In 28 U.S. states and the District of Columbia, voters and, later, legislators have shown they believe marijuana is medicine, even though most of the scientific and medical communities say marijuana is not medicine and should not be legal. While the most recent report, issued by the National Academies of Sciences (NAS), finds that marijuana may alleviate certain kinds of pain, it also finds there is no rigorous, medically acceptable documentation that marijuana is effective in treating any other illness. At the same time, science offers irrefutable evidence that marijuana is addictive, harmful and can hinder brain development in adolescents. At the distribution level, there are no controls on the people who sell to consumers. Budtenders (marijuana bartenders) have no medical or pharmaceutical training or qualifications.

One tactic used by legalizers was taking advantage of voter empathy for sick people, along with the confusion about science and how the FDA approves drugs. A positive finding in a test tube or petri dish is merely a first step in a long, rigorous process leading to scientific consensus about the efficacy of a drug. Scientific proof comes after randomized, controlled clinical trials, and many drugs with promising early stage results never make it through the complex sets of hurdles that prove efficacy and safety. But marijuana legalizers use early promise and thin science to persuade and manipulate empathetic legislators and voters into buying the spin that marijuana is a cure-all.

People who are sick already have access to two FDA-approved drugs, dronabinol and nabilone, that are not marijuana, but contain identical copies of some of the components of marijuana. These drugs, available as pills, effectively treat chemotherapy-induced nausea and vomiting and AIDS wasting. The NAS reviewed 10,700 abstracts of marijuana studies conducted since 1999, finding that these two oral drugs are effective in adults for the conditions described above. An extract containing two marijuana chemicals that is approved in other countries, reduces spasticity caused by multiple sclerosis. But there is no evidence that marijuana treats other diseases, including epilepsy and most of the other medical conditions the states have legalized marijuana to treat. These conditions range from Amyotrophic lateral sclerosis (ALS) and Crohn’s disease to Hepatitis-C, post-traumatic stress disorder (PTSD) and even sickle cell disease.

Not So Fast — What about the Regulations?
Legalizers also have convinced Americans that unregulated cannabidiol, a marijuana component branded as cannabis oil, CBD, or Charlotte’s Web, cures intractable seizures in children with epilepsy, and polls show some 90 percent of Americans want medical marijuana legalized, particularly for these sick children. In Colorado, the American Epilepsy Society reports that children with epilepsy are receiving unregulated, highly variable artisanal preparations of cannabis oil recommended, in most cases, by doctors with no training in paediatrics, neurology or epilepsy. Young patients have had severe dystonic reactions and other movement disorders, developmental regression, intractable vomiting and worsening seizures that can be so severe that their physicians have to put the child into a coma to get the seizures to stop. Because of these dangerous side effects, not one paediatric neurologist in Colorado, where unregulated cannabidiol is legal, recommends it for these children.

Dr. Sanjay Gupta further clouded the issue when he produced Weed in 2013, a three-part documentary series for CNN on marijuana as medicine. In all three programs, Dr. Gupta promoted CBD oil, the kind the American Epilepsy Society calls artisanal. This is because not one CBD product sold in legal states has been purified to Food and Drug Administration (FDA) standards, tested, or proven safe and effective. The U.S. Congress and the FDA developed rigid processes to review drugs and prevent medical tragedies such as birth defects caused by thalidomide. These processes have facilitated the greatest advances in medicine in history.

“By end-running the FDA, three billionaires have been willing to wreck the drug approval process that has protected Americans from unsafe, ineffective drugs for more than a century,” said Sue Rusche, president and CEO of National Families in Action and author of the report. “Unsubstantiated claims for the curative powers of marijuana abound.” No one can be sure of the purity, content, side effects or potential of medical marijuana to cause cancer or any other disease. When people get sick from medical marijuana, there are no uniform mechanisms to recall products causing the harm. Some pot medicines contain no active ingredients. Others contain contaminants. “Sick people, especially children, suffer while marijuana medicine men make money at their expense,” added Ms. Rusche.

Marijuana Industry — Taking a Page from the Tobacco Industry
The paper draws a parallel between the marijuana and tobacco industries, both built with the knowledge that a certain percentage of users will become addicted and guaranteed lifetime customers. Like tobacco, legalized marijuana will produce an unprecedented array of new health, safety and financial consequences to Americans and their children.

“Americans learned the hard way about the tragic effects of tobacco and the deceptive practices of the tobacco industry. Making another addictive drug legal unleashes a commercial business that is unable to resist the opportunity to make billions of dollars on the back of human suffering, unattained life goals, disease, and death,” said Ms. Rusche. “If people genuinely understood that marijuana can cause cognitive, safety and mental health problems, is addictive, and that addiction rates may be three times higher than reported, neither voters nor legislators would legalize pot.”
The paper and the supporting data are available at
About National Families in Action

National Families in Action is a 501 (c) (3) nonprofit organization that was founded in Atlanta, Georgia in 1977. The organization helped lead a national parent movement credited with reducing drug use among U.S. adolescents and young adults by two-thirds between 1979 and 1992. For forty years, it has provided complex scientific information in understandable language to help parents and others protect children’s health. It tracks marijuana science and the marijuana legalization movement on its Marijuana Report website and its weekly e-newsletter of the same name.


The following letter was submitted to the US government Food and Drug Adminstration by Australian Professor Dr. Stuart Reece as evidence against the suggested re-scheduling of cannabinoids in the USA. This item can be found online where a full list of carefully researched references is included. Professor Reece has produced an extraordinary article which should be widely read.

We cannot recommend this article highly enough.

NDPA April 2018

This website has been created as a public service to help address the problem of the use of marijuana and other mood- and mind-altering substances in the United States and around the world. A purpose is help inform the public, the media, and those in positions of public responsibility of the challenges facing the nation as a result of the widespread use of psychoactive and mood-altering substances, particularly marijuana and designer drugs. The harmful effects of these substances have not been well understood. In fact, there is great ignorance of the harmful effects of marijuana and other drugs that are being used for experimental or recreational purposes. The implications that the harmful effects that these drugs have for the health and wellbeing of individuals, families, and society are legion. * * * * * * *

Federal Register Submission
Food and Drug Administration,
10903 New Hampshire Ave.,
Silver Spring,
MD, 20993-0002, USA.

Re: Re-Scheduling of Cannabinoids in USA – Tetrahydrocannabinol and Cannabidiol Related Arteriopathy, Genotoxicity and Teratogenesis

I am very concerned about the potential for increased cannabis availability in USA implied by full drug legalization; however, a comprehensive and authoritative submission of the evidence would take weeks and months to prepare. Knowing what we know now and indeed, what has been available in the scientific literature for a growing number of years concerning a myriad of harmful effects of marijuana, marijuana containing THC should not be reclassified.

These effects that are now well documented in the scientific literature include, alarmingly, harm involving reproductive function and birth anomalies as a result of exposure to or use of marijuana with THC. In addition to all of the usual concerns which you will have heard from many sources including the following I have further particular concerns:

1) Effect on developing brains

2) Effect on driving

3) Effect as a Gateway drug to other drug use including the opioid epidemic

4) Effect on developmental trajectory and failure to attain normal adult goals(stable relationship, work, education)

5) Effect on IQ and IQ regression

6) Effect to increase numerous psychiatric and psychological disorders

7) Effect on respiratory system

8) Effect on reproductive system

9) Effect in relation to immunity and immunosuppression

10) Effect of now very concentrated forms of cannabis, THC and CBD which are widely available

11) Outdated epidemiological studies which apply only to the era before cannabis became so potent and so concentrated

12) Cannabis is now known to have an important arteriopathic effect and cardiovascular toxic effect .

These issues are all well covered by a rich recent literature including reviews from such major international authorities as Dr Nora Volkow Director of NIDA, Professor Wayne Hall and others .

Cannabinoid Therapeutics

In my view the therapeutic effects of cannabinoids have been wildly inflated by the press. Moreover, with over 1,000 studies listed for cannabinoids on, the chance of a type I experimental error, or studies being falsely reported to be positive when in fact they are not, is at last 25/1,000 at the 0.05 level.

THC as dronabinol is actually a failed drug from USA which has such a high incidence of side effects that it was rarely used as superior agents are readily available for virtually all of its touted and alleged therapeutic applications. My American liaisons advise that dronabinol sales have climbed in recent times as patients use it as a ruse to avoid detection of cannabinoid use at work in states where it is not yet legal. So when I call it a failed therapeutic I mean in a traditional sense, not in the novel way it is now applied for flagrantly flouting the law.

In considering the alleged benefits of cannabis one has to be particularly mindful of cannabis addiction in which cannabinoids will alleviate the effect of drug withdrawal as they do in any other addiction. Moreover, the fact that cannabis itself is known to cause both pain and nausea, greatly complicates the interpretation of many studies.

I also have the following concerns which relate in sum to the arteriopathy and vasculopathy and the genotoxicity of cannabis, tetrahydrocannabinol and likely including cannabidiol and various other cannabinoids:

Cannabinoid Arteriopathy

Particularly noteworthy amongst these various reports are two reports by Dr Nora Volkow in 2014, the Director of the National Institute of Drug Abuse at NIH to the New England Journal of Medicine which together document the adverse cardiovascular and cerebrovascular effects of cannabis at the epidemiological level ; a report from our own increase cardiovascular aging to BMJ Open ; a series of reports showing a fivefold

increase in the rate of heart attack within one hour after cannabis smoking ; several reports of cannabis related arteritis ; other reports of the cerebrovascular actions of cannabis ; documentation that cannabis exposure increases arterial stiffness and cardiovascular and organismal aging ; and a recent report showing that human endothelial vascular function – vasodilation – is substantially inhibited within just one minute of cannabis exposure .

It is also relevant that a synthetic cannabinoid was recently shown to directly induce both thromboxane synthase and lipoxygenase, and so be directly vasoconstrictive, prothrombotic and proinflammatory .

Vascular aging, including both macrovascular and microvascular aging is a major pathological feature not only because most adults in western nations die from myocardial infarction or cerebrovascular accidents, but also because local blood flow and microvascular function is a key determinant of stem cell niche activity in many stem cell beds. This has given rise to the vascular theory of aging which has been produced by some of the leading researchers at the National Health Lung and Blood Institute at NIH, amongst many others .

It can thus be said not only that “You are as old as your (macrovascular) arteries”, but also that “you are as old as your (microvascular) stem cells.” Hence the now compelling evidence for the little known arteriopathic complications of cannabis and cannabinoids, carry very far reaching implications indeed. This was confirmed directly in the clinical study of arterial stiffness from my clinic mentioned above .

Whilst aging, myocardial infarction and cerebrovascular accidents are all highly significant outcomes and major public health endpoints, these effects assume added significance in the context of congenital anomalies. Some congenital defects, such as gastroschisis, are thought to be due to a failure of vascular supply of part of the anterior abdominal wall . Hence in one recent study the unadjusted odds ratio of having a gastroschisis pregnancy amongst cannabis users (O.R.=8.03, 95%C.I. 5.63-11.46) was almost as high as that for heroin, cocaine and amphetamine users (O.R.= 9.35, 95%C.I.
6.64-13.15), and the adjusted odds ratio for any illicit drug use (of which was 84% cannabis) was O.R.=3.54 (95%C.I. 2.22-5.63) and for cannabis alone was said by these Canadian authors to be O.R.=3.0. Hence cannabis related vasculopathy – arteriopathy beyond its very serious implications in adults also carries implications for paediatric and congenital disorders and may also constitute a major teratogenic mechanism.

Cannabinoid Genotoxicity and Teratogenesis

Cannabis is associated with 11 cancers (lung, throat, bladder, airways, testes, prostate,

cervix, larynx) including;

Four congenital and thus inherited cancers (rhabdomyosarcoma, neuroblastoma,ALL,

AML and AMML);

Sativex product insert in many nations carries standard warning against its use by

males or females who might be having a baby.

Cannabis – and likely also CBD – is known to be associated with epigenetic changes

some of which are believed to be inheritable for at least four generations.

Cannabis is known to interfere with tubulin synthesis and binding and it also

acts via Stathmin so that microtubule function is impeded . This leads directly to

micronucleus formation. Cannabis has been known to test positive in the

micronucleus assay for over fifty years. This is a major and standard test for

genotoxicity. Micronucleus formation is known to lead directly to major chromosomal toxicity including chromosomal shattering – so-called chromothripsis –and is known to be associated with cell death, cancerogenesis and major foetal abnormalities.

Cannabis has also been linked definitively with congenital heart disease is a statement

by the American Heart Association and the American Academy of Pediatrics in 2007, on the basis of just three epidemiological studies, all done in the days before cannabis became so concentrated. Congenital heart defects have also been linked with

the father’s cannabis use . Indeed, one study showed that paternal cannabis use was

the strongest risk factor of all for preventable congenital cardiac defects.

Cannabis has also been linked with gastroschisis in at least seven cohort and case

control studies some of which are summarized in a Canadian Government

Report 200. In that report the geographic incidence of most major congenital anomalies

closely paralleled the use of cannabis as described in other major Canadian reports.

The overall adjusted odds ratio for cannabis induction of gastroschisis was

quoted by these authors as 3.0. Moreover, outbreaks of both congenital heart disease and gastroschisis in North Carolina also paralleled the local use of cannabis in that state as described by Department of Justice Reports . The incidence of gastroschisis was noted to double in North Carolina 1999-2001 in the same period the cannabis trade there was rising.

Figures of cannabis use in pregnant women in California by age were also

recently reported to JAMA 229, age group trend lines by age group which closely

approximate those reported by CDC for the age incidence of gastroschisis in the USA

Importantly much of the cannabis coming into both North Carolina and Florida is said to originate in Mexico. An eight-fold rise in the rate of gastroschisis has been reported from Mexico . Gastroschisis has also risen in Washington state. Cannabis has also been associated with 17 other major congenital defects by major Hawaiian epidemiological study reported by Forrester in 2007 when it was used alone

When considered in association with other drug use – which in many cases cannabis leads to – cannabis use was associated with a further 19 major congenital defects. In addition to the effect of cannabinoids on the epigenome and microtubules, cannabinoids have been firmly linked to a reduction of the ability of the cell to produce energy from their mitochondria. An extensive and robust evidence base now links cellular energy generation to the maintenance and care of cellular DNA .

Moreover, as the cellular energy charge falls so too DNA maintenance collapses, and indeed, the cell can spiral where its remaining energy resources, particularly as NAD+, are routed into failing and futile DNA repair, the cell slips into pseudohypoxic metabolism like the Warburg effect well known in cancerogenesis , NAD+ falls below the level required for further energy generation and cellular metabolism collapses. Hence this well-established collapse of the mitochondrial energy charge and transmembrane potential forms a potent engine of continuing and accelerating genotoxicity .

Moreover, the well documented decline in mitochondrial respiration induced by cannabinoids, including tetrahydrocannabinol, cannabidiol and anandamide achieves particular significance in the light of the robustly documented decline in cellular energetics including NAD+ which not only occurs with age but indeed, has now been shown to be one of the primary drivers of cellular and whole organismal aging. It follows therefore that cannabinoid administration (including THC andCBD) necessarily phenocopies cellular aging. This implies of course that cannabinoid dependent patients are old at the cellular level. Indeed, normal human aging is phenocopied in the clinical syndrome of cannabinoid dependence which includes:

1) Neurological deficits in:

i) attention,

ii) learning and

iii) memory;

iv) social withdrawal and disengagement and

v) academic and

vi) occupational underachievement

2) Psychiatric disorders including

i) Anxiety,

ii) Depression,

iii) Mixed Psychosis

iv) Bipolar Affective disorder and

v) Schizophrenia,

3) Respiratory disorders including:

i) Asthma

ii) Chronic Bronchitis (increased sputum production)

iii) Emphysema (Increased residual volume)

iv) Probably increased carcinomas of the aerodigestive tract

4) Immune suppression which generally implies

i) segmental immunostimulation in some parts of the immune system since the innate and adaptive immune systems exert profound homeostatic mechanisms in response to suppression of one of its parts. A Substantial literature on immunostimulation

5) Reproductive effects generally characterized by reduced

i) Male and

ii) Female fertility

6) Cardiovascular toxicity with elevated rates of

i) Myocardial infarction

ii) Cerebrovascular accident

iii) Arteritis

iv) Vascular age – vascular stiffness

7) Genotoxicity in

i) Respiratory epithelium and

ii) Gonadal tissues.

8) Osteoporosis

9) Cancers of the

i) Head and neck

ii) Larynx

iii) Lung

iv) Leukaemia

v) Prostate

vi) Cervix

vii) Testes

viii) Bladder

ix) Childhood neuroblastoma

x) Childhood acute lymphoblastic leukaemia

xi) Childhood Acuter Myeloid and myelomonocytic leukaemia

xii) Childhood rhabdomyosarcoma 201,202.

The issue here of course is that cannabinoid dependence therefore copies without exception all of the major disorders of old age, each of which is also faithfully phenocopied by cannabis dependence.

The most prominent disorders of older age include:

1) Alzheimer’s disease

2) Cardiovascular and cerebrovascular disease

3) Osteoporosis

4) Systemic inflammatory syndrome

5) Changes in lung volume and the mechanics of breathing

6) Cancers

Hence this provides one powerful pathway by which cannabinoid exposure can replicate and phenocopy the disorders of old age. This is not of course to suggest that this is the only such pathway. Obviously changes of the general level of immune activity, or alterations of the level of DNA repair occurring directly or indirectly associated with cannabis use can form similar such pathways: both are well documented in cannabis use and also in the aging literature as major pathways implicated in systemic aging.

Nevertheless, the decline in mitochondrial energetics together with its inherent genotoxic implications does seem to be a particularly well substantiated and robustly demonstrated pathway which must give serious pause to cannabinoid advocates if the sustainability of the health and welfare systems is to be factored in together with any consideration of individual patient, advocate and industrial-complex rights.

The genotoxicity of THC, CBD and CBN has been noted against sperm since at least 1999 (Zimmerman and Zimmerman in Nahas “Marijuana and Medicine” 1999, Springer). This is clearly highly significant as sperm go directly into the formation of the zygote and the new human individual. CB1R receptors are known to exist intracellularly on both the membranes of endoplasmic reticulum and mitochondria. In both locations they can induce organellar stress and major cell toxicity including disruption of DNA maintenance. Interestingly mitochondrial outer membrane CB1R’s signal via a complex signalling chain involving the G-protein transduction machinery, protein kinase A and cyclic-AMP across the intermembrane space to the inner membrane and cristae, in a fashion replicating much of the G-protein signalling occurring at the cell membrane. This machinery is also implicated in mitonuclear signalling, and the mitonuclear DNA balance between mitochondrial DNA and nuclear DNA transcriptional control, which has long been implicated in inducing the mitochondrial unfolded protein cellular stress response cell aging, stem cell behaviour and DNA genotoxic mechanisms.

You are no doubt aware that human sperm are structured like express outboard motors behind DNA packets with layers of mitochondria densely coiled around the rotating flagellum which powers their progress in the female reproductive tract. These mitochondria also carry CB1R’s and are significantly inhibited even at 100 nanomolar THC. The acrosome reaction is also inhibited .

Cannabidiol is known to act via the PPARγ system 101,302-308. PPARγ is known to have a major effect on gene expression, reproductive and embryonic and zygote function during development 309-332 so that significant genotoxic and / or teratogenic effects seem inevitable via this route. Drugs which act in this class, known as the thiazolidinediones, are classed as category B3 in pregnancy and caution is indicated in their use in pregnancy and lactation.

The Report of the Reproductive and Cancer Hazard Assessment Branch of the Office of Environmental Health Hazard Assessment of the Health Department of California was mentioned above in connection with the carcinogenicity of marijuana smoke . Since virtually all mutagens are also teratogens it follows therefore from the basic tenets of mutagenesis that if cannabis is unsafe as a known carcinogen it must also be at the very least a putative teratogen.

CBD has also been noted to be a genotoxic in other studies . All of which points to major teratogenic activity for both THC and CBD. Some of the quotations from Professor James Graham’s classical book on the effects of THC in hamsters and white rabbits, the best animal models for human genotoxicity, bear repeating:

a) “The concentration of THC was relatively low and the malignancy severe.”

b) “40-100μg resin/ml there occurred marked inhibition of cell division.

c) “large total dose, Hamsters, 25-300mg/kg …“oedema,phocomelia,omphalocoele, spina bifida, exencephaly, multiple malformations and myelocoele. This is a formidable list.”

d) “It is to this anti-mitotic action that the authors attribute the embryotoxic action of cannabis.”

e) “By such criteria resin or extract of cannabis would be forbidden to women

during the first three months of pregnancy.”

Indeed, even from the other side of the world I have heard many exceedingly adverse reports from US states in which cannabis has been legalized including Colorado, Washington, Oregon, Florida and California. Taken together the above evidence suggests that these negative reports stem directly from the now known actions of cannabis and cannabinoids, and are by no means incidental epiphenomena somehow related to social constructs surrounding cannabis use or the product forms, dosages, or routes of administration involved.

Cannabis that contains increasingly high levels of THC is now widely available, particularly in the jurisdictions where the use of cannabis has been legalized. This means that another major genotoxin, akin to Thalidomide, is being unleashed on the USA and the world. This is clearly a very grave, and. indeed, an entirely preventable occurrence.

Dr Frances Kelsey of FDA is said to have the public servant based at FDA who saved American from the thalidomide scandal which devastated so many other English-speaking nations including my own . This occurred because the genotoxicity section of the file application with FDA was blank. It was blank because thalidomide tested positive in various white rabbit and guinea pig assays. It is these same tests which cannabis is known to have failed. Dr Kelsey’s photograph has been published in the medical press with President Kennedy for her service to the nation. The challenge to FDA at this time seems whether Science can triumph over agenda driven populism, its primary vehicle, the mass media, and its primary proximate driver the burgeoning cannabis industry. Since FDA is the Federal agency par excellence where Health Science is weighed, commissioned and thoughtfully considered the challenge in our time would appear to be no less.

Evidence to date does not suggest that major congenital malformations are as common after prenatal cannabis exposure as they are after prenatal thalidomide exposure. Nevertheless the qualitative similarities remain and indeed are prominent. It is yet to be seen whether the rate of congenital anomalies after cannabis are quantitatively as common: epidemiological studies in a high potency era have not been undertaken; and even the birth defects rates from most birth defects registers in western nations including that held by CDC, Atlanta appear to be seriously out of date at the time of writing. Moreover the non-linear dose response curve in many cannabis genotoxicity studies which includes a sharp knee bend upwards beyond a certain threshold level which suggests that we could well be in for a very unpleasant quantitative surprise. At the time of writing this remains to be formally determined.

Dr Bertha Madras, Professor of Addiction Psychiatry at Harvard Medical School has recently argued against re-scheduling of cannabis. Her comments include the following:

“Why do nations schedule drugs? …… Nations schedule psychoactive drugs because we revere this three-pound organ (of our brain) differently than any other part of our body. It is the repository of our humanity. It is the place that enables us to write poetry and to do theater, to conjure up calculus and send rockets to Pluto three billion miles away, and to create I Phones and 3 D computer printing. And that is the magnificence of the human brain. Drugs can influence (the brain) adversely. So, this is not a war on drugs. This is a defense of our brains, the ultimate source of our humanity” .

I look forward to seeing the comments that you post concerning the reasons why the classification for marijuana should not be changed and that, indeed, the public should be alerted to the very harmful effects of marijuana with THC, especially in light of the wide range of marijuana’s harmful effects and the high potency of THC in today’s marijuana and in light of the idiosyncratic effects of marijuana of even low doses of THC and owing to the certain risk of harm to progeny and babies born to users of marijuana.

Please feel free to call on me if you would like further information concerning the research to which I have referred herein.

Yours sincerely,

Professor Dr. Stuart Reece, MBBS (Hons.), FRCS(Ed.), FRCS(Glas.), FRACGP, MD(UNSW). School of Psychiatry and Clinical Neurosciences Edith Cowan University and University of Western Australia, Perth, WA


A small but vocal contingent of drug policy interpreters is attempting again to further the fallacious meme that ‘prohibition’ and ‘supply reduction’ are driving drug deaths in Australia, not poor policy interpretation and use which foster a permission model for the vulnerable and pop-culture informed community – particularly the young, Dalgarno Institute writes.


The National Drug Strategy

The latest National Drug Strategy 2017-26, now puts Demand Reduction as the priority! The strategy states that “Harm Minimisation includes a range of approaches to help prevent and reduce drug related problems…including a focus on abstinence-oriented strategies… [Harm minimisation] policy approach does not condone drug use.” (page 6)“Prevention of uptake reduces personal, family and community harms, allow better use of health and law enforcement resources, generates substantial social and economic benefits and produces a healthier workforce. Demand Reduction strategies that prevent drug use are more cost effective than treating established drug-related problems…Strategies that delay the onset of use prevent longer term harms and costs to the community.” (page 8)

The National Drug Strategy segments the drug issue into three main categories:

Tobacco – Alcohol – Illicit drugs

A quick summary of the policy focus/emphasis on each drug can be encapsulated as follows:


QUIT! Cessation, and exit from tobacco use is the ONLY goal for this drug. There is no illusion about the journey to that destination being difficult, and the reality of failure clear, but the goal posts don’t move QUIT is the ONE message ONE focus and ONE voice in all sectors of the media, community, education and legislation arenas. (Remember this is a legal drug, and until about 20 years ago, utterly socially acceptable) We have reduced smoking rates of 75% of Australian Males (not including females) after World War II down to around 14% of total population. According to health data, approximately 100,000 people give up tobacco each year, but about the same take it up. No prizes for guessing that cohort make up? The 16-24-year-old demographic usually engage (research shows us) in tobacco use mostly when drinking alcohol. Of course, learning ‘smoking’ as a delivery mechanism also equips the tobacco user for ‘smoking’ of other drugs.


‘Moderate! Drink Responsibility!’ However, a growing educative and legislative push (due to the rising costs of alcohol harms to community) is seeing attitudes change, with now approx. 21 per cent of Australians of drinking age now abstinent! (Remember this is a legal and completely socially acceptable drug.)

Illicit drugs

The mantra? ‘Use is likely, so use carefully and don’t die!’ And we are perpetually informed by certain vested interests that for the 3.5 – 4% of illicit drug users in this country (Cannabis use excised from stats here) that cessation of, or exiting from, drug use is virtually impossible – well so the mantra educates, and that ‘learned behaviour’ of powerlessness and choice stripped victimhood is now parroted as reason enough to ‘validate’ the notion of intractability.

So, then it is touted, the only answer for this demographic is either legalisation or a suite of policies or policy interpretations that enables, empowers, endorses or equips on going drug use, because, it is believed any ‘prohibition’ messaging will not only fail, but be counterproductive. But apparently NOT so with Tobacco, where such prohibition messaging has worked brilliantly!!The cognitive dissonance in this space continues to be breathtaking!

So, what of Harm Reduction ONLY policy implementation of our three pillar National Drug Strategy?

Harm Reduction.

Let’s be clear – what we have now in Australia’s drug taking public psyche (learned/taught behaviour), is well educated and fully self-aware, (and product aware) young adults determining that any drug use risk is manageable. Why? These purported intelligent, sophisticated ‘buzz’ seeking and cashed up adult party goers, willingly and deliberately seek out illicit drugs, purchase them with disposable income, not because of the tyranny of addiction, but to ‘enhance the party experience’. They then take these substances to public events and consume these psychotropic toxins.

Of course, they are fully aware of the mantra they have been taught, as early as secondary school, that if something happens all you should do is call the ambulance. Not only will these remarkable and brave tax-payer funded public servants attend to your self-inflicted illegally induced harm, but will ferry you, at cost to the public purse, to an already overcrowded and strained public health facility. There they will be treated by caring professionals, who have more regard for their well-being than the hapless drug user does. Once they are discharged from the hospital, there (for the most part) is no cost to them, and complete impunity from the law. Little, if no legal action or facilitated diversion is taken and the illicit drug user goes on their way until next drug taking episode.

Whilst no one wants to see injury, let alone death from these reckless behaviours, the mechanisms to ‘save lives’ are already well in play and consequently risk/responsibility factors are disregarded. What must not happen, but clearly is happening, is this utter carelessness for wellbeing of self and others cannot, must not be endorsed or worse, enabled/empowered by poor policy or policy interpretation/use.

There is little or absolutely no accountability for this costly, dangerous, self-indulgent and illegal behaviour. And the cry from the pro-drug lobby is not to call for best practice demand reduction, prevention and/or recovery/exit from this activity/behaviour – No, it’s to declare ‘inevitability’ of behaviour and then, the careless equipping, enabling or empowering of mechanisms to assist the educated self-harmer to continue to use!

Again, it is this permission, NOT prohibition that is continuing to put young lives (and more of them) at risk. The no-longer tacit, but now abundantly clear message in the cultural market place, is that ‘you can take drugs anytime and anywhere and nothing will be done, other than assistance for you if things go pear shaped!’

It’s this message, and not demand and supply reduction vehicles which is empowering ongoing drug use.

It’s time to change the narrative around this ever-permissive drug culture – if not for the sake of people’s lives, then for the emerging generation who are watching this model set them up for engagement, not avoidance of illegal drug use.

Genuine compassion driven anti-drug Harm Reduction must always be about the cessation and/or exiting from drug use and any policy or policy interpretation that fosters a contrary outcome is not good drug policy. The drug policy/strategy interpretation narrative has meant that the term ‘harm reduction’ and ‘harm minimisation’ are now interchangeable terms. Essentially this ensures that Harm Reduction becomes the only pillar of the three-pillar strategy is in play.

This has worked marvellously at convincing even anti-drug citizens, that there is only one option available. Time will not permit to table every encounter we’ve had, but the following statement reflects numbers we have heard…

“Pity we can’t use your harm prevention education program, because it’s illegal. We are only allowed to teach harm reduction in schools!” Head of a State Government Regional Education group, Victoria.

Of course, this is patently false, as Demand Reduction and prevention are not only best practice models, but mandated in the NDS, particularly for the demographic with the developing brain – 12-28-year-old! The Key questions that must be asked about illicit drug policy, are the following;

* Does the policy (or interpretation – harm reduction only) lead to an exit from or cessation of drug use, or does it enable, endorse, empower or equip on going drug use?

* Does the policy (or interpretation) increase or reduce demand for illicit drugs?

* Does the policy (or interpretation) undermine or support the other two pillars? (i.e. increase or reduce Demand or Supply for drugs)

If the policy use/interpretation is creating cognitive dissonance in implementation and leads to a conflagration, rather than collaboration of all three pillars, then the strategy is going to have difficulty in effectively moving a culture away from drug use.

Well, perhaps that is exactly the agenda of the pro-drug lobbyists who have inordinate and disproportionate influence in drug policy implementation? I hear even genuine and compassionate harm reductionists, who actually want to stop drug use and see people recover, railing against supply reduction pillar as ‘waste of resources’. And staggeringly many of these same good people are silent on Demand Reduction, the key to seeing change. These two modes of thinking are the key elements of ensuring only one ‘pillar’ of the NDS is focused on, for genuine or disingenuous purposes. Again, one must ask, does the drug policy interpretation facilitate:

Reducing – Remediating – Recovery from drug use?

Or does the policy instead facilitate the:

Enabling – Empowering – Equipping of drug use?

This interpretative matrix needs to be applied to all drug categories and types – for example, do the following strategies lend themselves more to Enabling or Reducing on going drug use?

* Injecting rooms

* Needle Syringe Programs

* Pill Testing

* 12 Step Programs

* Therapeutic Communities


People who inject drugs in Australia can appear to be well provided for with regard to sterile needles and syringes. Across the country there are 3500 needle and syringe programs (NSPs) which distribute almost 50 million pieces of equipment a year. But the international best practice for injecting drugs of a fresh needle for every injection is far from reality. People who inject drugs reuse syringes, share equipment like spoons, water and tourniquets, and a small proportion continue to share injecting equipment with others

. A 20-year survey by the Australian NSP Survey showed that…. Since 2011 the reuse had hovered around 21-25 per cent. The percentage of people who inject drugs who reported they shared syringes with others was also steady at 15-16 per cent from 2011-2015. And the sharing of equipment other than needles remained stable at 28-31 per cent.

This article in a recent ANEX update – notice the nonchalant manner that ‘best practice’ is used and the blithely mentioned MILLIONS of tax-payers funded syringes being unaccountably handed out, yet having 30% of injecting drug users STILL sharing equipment with 16% still sharing needles!

Of course, this proliferation of unaccountable injecting gear has been a key element in the rabid rise in street use and syringe/needle discarding. So, what may be the answer? Will we need to have 3500 injecting rooms open 24/7 for convenience of use and ease of access? Facilities too, with absolute zero accountability as there is absolutely NO potential ‘stigma bestowing’ process permitted that might challenge the behaviour of the self-harming drug taker!

If every injecting episode for every Intravenous drug user was to take place in an injecting room and a sunset clause on such behaviour, ensuring a transitioning to drug use exiting measures, then this might have some merit, as catastrophically expensive and unmanageable as that would be. However, the data tells us that for every single injecting episode that occurs ‘under supervision’, there are over 90 that happen elsewhere!

The appalling ‘health care’ logic, or lack of, is very concerning! It becomes even more so when policy caveats of ‘non-judgemental’ attitudes (whatever that this subjective descriptor can mean) are foisted upon, even the NSP staff – However, NO SUCH MORAL COMMENTARY can be levelled, what-so-ever, at the person who is the self-harming, law breaking, body destroying, and no doubt, family grieving drug taker! This at best is

‘moral’ hypocrisy – at worst unconsumable! (Of course, that last sentence itself is viewed as counterproductive and stigmatizing and thus not permitted in the discourse!)

“The perpetual permission of harm reduction only policies, NOT prohibition is putting lives at risk!” Dalgarno Institute.

Injecting Rooms

Gary Christian, Secretary for Drug Free Australia, has pointed to the lack of success by the Kings Cross Injecting Centre (MSIC) in reducing overdose deaths in the Kings Cross area. He said, “Tracking of overdose deaths in the Kings Cross area from 5 years before the injecting room opened compared with the 9 years after the injecting room was opened showed no change whatsoever in the percentage of deaths in the area as compared to the rest of NSW. The KPMG review showed that Kings Cross had 12% of NSW opiate deaths before the commencement of the MSIC, and in the 9 years after it remained at 12%, such has been its failure to make any difference.”

Evidence given to the NSW Parliament indicates that overdoses in the Kings Cross injecting room are 32 times higher than the overdose histories of those entering the injecting room, indicating that clients are experimenting with higher doses of opiates and cocktails of drugs knowing that if they should overdose in their experimentation, someone will bring them around. NSW Hansard records testimony from ex-clients of the injecting room who were rehabilitating from drugs that experimentation with higher doses of drugs is the reason for the inordinately high overdose rate in the room.

The question now appears to not be about ‘best practice’, but simply what emotive or socio-political drivers dictate when it comes to drug policy – So, where do you land? If you’re all for drug use, then another conversation and investigation in to the why of that is your priority. However, the disturbing reality for the tens of thousands of ex-users who already know the ultimate outcome of illicit drug use is. The reality is, those conversations and investigations are near impossible for a person using the substance in a culture that passively, no, actively permits it!

Any enterprise that inadvertently enables, empowers or equips ongoing illicit drug use has already breached best health care practice. Harm Reduction can never be about the support of on-going, health diminishing substance use. Caring, responsible and civic minded clinicians and policy makers will always be focused on movement toward exit from, and cessation of drug use. Mechanisms that enable any government agency to send a message to the community that we are not only supporting, but enabling tax payer funded illicit drug use, not only breaches care for the illegal drug user, but breaches international conventions. It also demonstrates a lack of concern for most of the non-drug using community.

I trust a thorough ‘best practice’ consideration of any drug policy ‘strategy’ will always seek to reduce demand for and use of any illicit drug, if not for the sake of the drug user, then for the wider community, who the vast majority of are illicit drug free. Our emerging generation need proactive and protective mechanisms to give them best chance to live drug free lives.

Let us be very clear, we are not conducting a ‘war against drugs’. We are however fighting for the brains, potentials, and in many instances, the very future of an entire emerging generation. (Dr Bertha Madras – Harvard) That for any caring civic minded human being is a fight worth having, and one worth joining!

Source: Dalgarno Institute

Interviewed by Mark Gold, MD

FEATURED ADDICTION EXPERT: Brian Fuehrlein, MD, PhD, Assistant Professor, Yale University Director, Psychiatric Emergency Room, VA Connecticut Healthcare System

If a patient has overdosed on opioid, can you describe your approach to the emergency including the exam, medications, observation and discharge-transfer?

As the director of a psychiatric emergency room at VA Connecticut and Yale, I assume the care of patients after medical stabilization. Medical stabilization often includes Narcan administration and other possible treatments. While I am not generally directly involved in the Narcan administration, I will frequently see patients soon after a Narcan reversal (days to weeks). I have a very clear approach to these patients. My approach to a patient post Narcan reversal is aggressive and assertive. In my mind, I may be the last physician that this patient sees alive. I am very aggressive when discussing the severity of the illness and the critical need for treatment. When developing a treatment plan, I am very assertive. I will spend as much time as I can with the patient attempting to motivate them for treatment. When a patient has already required a Narcan reversal (and hence nearly died) they are high risk for this to occur again. This is as critical of a patient that I care for.

We generally refer to opioid overdoses as accidental, but do you have an idea of what percentage of the patients are depressed, wanted to die, or had passive suicidal ideation? Do you formally evaluate them for concurrent psychiatric illness at some time after you save their lives?

All patients who present to the psychiatric emergency room receive a thorough psychiatric and substance use assessment. The prevalence of co-occurring psychiatric illness with opioid use disorder (OUD) is very high. By the time the OUD has progressed to the point of intravenous use leading to Narcan reversal, there are typically many psychosocial consequences and stressors. In addition, these patients are often young (<30). These severe consequences, which often occur quickly, may lead to feelings of hopelessness, helplessness and passive suicidal ideation (SI). While I do not know firm percentages, in my experience the majority of those with severe opioid use disorder suffer from comorbid anxiety and/or depression. A lower percentage, but still significant amount, experience passive SI and will report things like “I was not trying to kill myself, but if I were to never wake up the world would be better off without me”. I would say that a small but significant percentage is actively suicidal at the time of the overdose with intent to die.

Patients will often have a history of multiple overdoses. What is your approach and ideal post rescue plan? Do you transfer them to a locked unit or give them a follow-up appointment? What happens to a person who is given Narcan and rescued by an EMT?

I tend to be as aggressive and assertive as possible while discussing the severity of the illness and the dire need for intensive treatment, especially in a patient who has had multiple overdoses. I attempt to motivate every patient who has experienced an overdose to be initiated on medication-assisted treatment (MAT). If agreeable, I will start buprenorphine in the VA/Yale psychiatric emergency room. Initiating buprenorphine in an emergency room setting is difficult in practice. Given the resources available at the VA we are able to do it. This practice is based upon a recent study at Yale that showed that initiating buprenorphine in emergency setting results in patients more likely to be connected to treatment. I also educate every patient about the need for a psychosocial support structure. I am a proponent of AA/NA programs and I discuss with all patients the importance of meetings/sponsorship. The goal for all patients who present post overdose is to initiate them on buprenorphine, transfer them to our substance use treatment program (either inpatient or IOP level of care) and then to attend 90 meetings in 90 days.

Unfortunately, many patients request discharge without willingness to engage directly in treatment. While state laws differ, in CT it is often hard to commit patients involuntarily specifically for substance use. If the patient is actively or passively suicidal or manic/psychotic, etc., we can often commit them on a psychiatric commitment. But if the risk stems primarily from ongoing substance use, we are often unable to hold the patient and force treatment upon them. We try very hard to motivate them for treatment. We will also engage their family to help with the motivation. But many patients are discharged home with outpatient follow-up only. We will prescribe a Narcan rescue kit, educate about harm reduction strategies, provide an appointment to see mental health within 7 days and place a follow-up phone call the day after discharge. But we are often unable to do more unless the patient is willing.

What is your suggestion for the role of Vivitrol post Narcan care?

I attempt to motivate all patients with opioid use disorder, particularly those post overdose, to initiate buprenorphine in the psychiatric emergency room. The first line treatment is buprenorphine, unless there is a reason/contraindication. For example, if adequate trials of buprenorphine have demonstrated its lack of efficacy in that patient, or if there was an intolerable side effect or adverse reaction. Methadone is generally the second line agent that is used following a buprenorphine failure. Following a Methadone treatment failure (side effect, etc), then Vivitrol the third line agent. Veterans at the VA will have an assigned outpatient treatment coordinator. We will collaborate with the outpatient team to determine the appropriate management of the opioid use disorder. We are able to initiate buprenorphine or Vivitrol the PER but Methadone initiation is deferred to the opioid treatment program. It is critical that patients with OUD are initiated on maintenance medication (one of the 3 mentioned) AND referred to a treatment program AND AA/NA.

Can you compare patients that you would suggest for Methadone vs. Suboxone vs. Vivitrol? How do you decide the doses? How long do you suggest MAT plus therapy and when to stop?

In general, buprenorphine is the first line, Methadone is second line and Vivitrol is third line, though this depends greatly on the individual patient. At times, Methadone is the first line agent if the patient requires the structure of the opioid treatment program or if the severity of the addiction is such that high dose Methadone is preferred. In general, buprenorphine is appropriate for the majority of the patients that I see in the psychiatric emergency room. Duration of MAT therapy remains debated. It depends on many factors and is an individual decision between the physician and the patient. In my opinion, a very important consideration when deciding whether to stop MAT is the patient’s commitment to a recovery program. If the patient is going to daily meetings, has a sponsor and is completing step work, I am more likely to endorse a plan of tapering down the buprenorphine than the same patient who is relying solely on the buprenorphine for sobriety.

Other considerations include IV use, previous OD with Narcan administration and other high risk behaviors. These would make me more likely to recommend longer term use of buprenorphine. In addition, the decision to stop MAT would depend on factors like cost, side effects, etc. Opioid use disorder is a deadly illness that requires long term treatment. When the illness is severe, high risk behaviors are present and the buprenorphine is not causing problems, I am unlikely to recommend tapering it off.

Are you seeing opioid overdose and addicts concurrently using marijuana, alcohol, cocaine, methamphetamine, other? Can you give us a sense of how many patients just use one drug or are just addicted to one drug? Do you do drug testing on all patients in the ED?

Yes, we perform urine drug screens on all patients who present to the psychiatric emergency room (PER). In my experience there are several groups of patients with opioid use disorder.

The most common group of patients with OUD also have a history of other substance use disorders. Most common would be marijuana, alcohol, cocaine and sedatives. While this group has struggled with an addiction to multiple substances, the opioids are the clear drug of choice. Many patients in this group will set all other drugs aside and only use them occasionally once opioids are discovered.

The second most common group with OUD continues to use other drugs concomitantly with the opioids. They may not identify opioids (or any of the others) as a clear drug of choice. This group will often speedball (mix opioids and cocaine). They also may unfortunately mix alcohol or sedatives with opioids, which is an unfortunate combination.

The least common group has OUD with no other history of substance use.

Methamphetamine is not as common in the northeast and hence for regional considerations I do not see it commonly. As a resident in Dallas, TX, methamphetamine use, with or without opioids, was common.

Do you have a protocol for switching someone from Suboxone to Naltrexone?

In the PER we do not generally complete an opioid detox and hence do not generally switch from buprenorphine to Naltrexone. We either initiate and titrate buprenorphine for maintenance or transfer to a local rehab or detox facility for completing detox.

Do you have an opioid detox protocol that you’d use in the hospital or ED?

First, we try hard to not detox OUD patients. Patients with OUD should be on MAT and we use the psychiatric emergency room (PER) visit as a means to initiate buprenorphine. We aggressively recommend buprenorphine initiation. If agreeable, we generally will start buprenorphine 4mg in the PER once withdrawal symptoms are moderate (COWS >8). We will then repeat the 4mg dose if indicated for a maximum dose of 8mg on day 1. The patient will then spend the night in the PER for observation.

On day 2, we titrate up to a maximum dose of 16mg if indicated. At that point the patient is ready for movement to the next level of care. Occasionally, patients will require a second night in the PER to titrate the buprenorphine up and for complete stabilization of withdrawal symptoms.

Once at a stabilizing dose the patients will generally move to our 21-day substance use treatment program. While in the program the buprenorphine is titrated as necessary. Upon completion of the program the patient is referred to the buprenorphine clinic in conjunction with a psychosocial program.

If the patient is unwilling to attend the 21-day program, and buprenorphine is initiated in the PER, the patient is discharged from the PER and seen daily in the outpatient detox/stabilization clinic until an appointment is available in the buprenorphine clinic. Given the resources at the VA we are able to initiate buprenorphine in the PER with confidence that a plan on the backend is achievable.

If the patient is unwilling to be on maintenance therapy then an opioid detox is completed. This is done with either buprenorphine or symptom-driven. Typically for detox, the patient is transferred to a local detox facility that the VA contracts with.

You have worked in both the inpatient and residential drug free drug programs and now Yale in ED and MAT, can you give me a sense of what lessons you have learned from each and how each might have a role and limitations?

Residential programs are a very important part of the recovery process but are not a cure for addiction. I often encounter patients who have completed our 21-day treatment program multiple times, each time having relapsed almost immediately after completion. When patients and/or families expect that years or decades of use will be cured after 21 days in a program they will naturally be disappointed. “Treatment begins when you leave the program” is a very important tenet of recovery. A good residential program will introduce/reinforce recovery principles and motivate the patient to continue this process after completion of the program. Without a solid aftercare program, residential programs are destined to fail.

Regarding the emergency room, many providers may not see the emergency room as an ideal environment for a discussion about recovery. Every patient that I see in the PER will hear about the importance for long term treatment and the need for a solid recovery program. I will discuss long term strategies including MAT, NA and other treatment options. Even with patients who present to the PER frequently, I always spend time discussing the importance of a solid foundation of recovery and the need for MAT. Even in the context of a busy emergency room, there is always time for a brief motivational interaction which may make a real difference and save a life.

Are you seeing meth or cocaine emergencies and/or overdoses? What is your approach?

Methamphetamine is not a common drug of abuse in this region of the country. Cocaine is incredibly common and it is commonly abused in the powder form or in the form of crack. It is often used in conjunction with opioids (speedballs). When cocaine overdoses occur (rarer than opioid overdoses), the patient is seen and stabilized in the medical ER prior to transfer to the PER. With patients who are using cocaine at levels so dangerous that it leads to overdose, I am aggressive and assertive the way I am with opioids. The difference with stimulants is the lack of MAT. Hence the reliance on a psychosocial treatment becomes more important. Patients are referred to the substance use treatment program to begin the recovery process. They are then referred to AA/NA, contingency management, CBT for addiction or other psychosocial support programs.

Source: November 2017

By Christopher Glazek

You’re aware America is under siege, fighting an opioid crisis that has exploded into a public-health emergency. You’ve heard of OxyContin, the pain medication to which countless patients have become addicted. But do you know that the company that makes Oxy and reaps the billions of dollars in profits it generates is owned by one family?

The newly installed Sackler Courtyard at London’s Victoria and Albert Museum is one of the most glittering places in the developed world. Eleven thousand white porcelain tiles, inlaid like a shattered backgammon board, cover a surface the size of six tennis courts. According to the V&A’s director, the regal setting is intended to serve as a “living room for London,” by which he presumably means a living room for Kensington, the museum’s neighborhood, which is among the world’s wealthiest. In late June, Kate Middleton, the Duchess of Cambridge, was summoned to consecrate the courtyard, said to be the earth’s first outdoor space made of porcelain; stepping onto the ceramic expanse, she silently mouthed, “Wow.”

The Sackler Courtyard is the latest addition to an impressive portfolio. There’s the Sackler Wing at New York’s Metropolitan Museum of Art, which houses the majestic Temple of Dendur, a sandstone shrine from ancient Egypt; additional Sackler wings at the Louvre and the Royal Academy; stand-alone Sackler museums at Harvard and Peking Universities; and named Sackler galleries at the Smithsonian, the Serpentine, and Oxford’s Ashmolean. The Guggenheim in New York has a Sackler Center, and the American Museum of Natural History has a Sackler Educational Lab. Members of the family, legendary in museum circles for their pursuit of naming rights, have also underwritten projects of a more modest caliber—a Sackler Staircase at Berlin’s Jewish Museum; a Sackler Escalator at the Tate Modern; a Sackler Crossing in Kew Gardens. A popular species of pink rose is named after a Sackler. So is an asteroid.

The Sackler name is no less prominent among the emerald quads of higher education, where it’s possible to receive degrees from Sackler schools, participate in Sackler colloquiums, take courses from professors with endowed Sackler chairs, and attend annual Sackler lectures on topics such as theoretical astrophysics and human rights. The Sackler Institute for Nutrition Science supports research on obesity and micronutrient deficiencies. Meanwhile, the Sackler institutes at Cornell, Columbia, McGill, Edinburgh, Glasgow, Sussex, and King’s College London tackle psychobiology, with an emphasis on early childhood development.

The Sacklers’ philanthropy differs from that of civic populists like Andrew Carnegie, who built hundreds of libraries in small towns, and Bill Gates, whose foundation ministers to global masses. Instead, the family has donated its fortune to blue-chip brands, braiding the family name into the patronage network of the world’s most prestigious, well-endowed institutions. The Sackler name is everywhere, evoking automatic reverence; the Sacklers themselves, however, are rarely seen. [In 1974, when the Sackler brothers made a large gift to the Met—$3.5 million, to erect the Temple of Dendur—they stipulated that all museum signage, catalog entries, and bulletins referring to objects in the newly opened Sackler Wing had to include the names of all three brothers, each followed by “M.D.”]

The descendants of Mortimer and Raymond Sackler, a pair of psychiatrist brothers from Brooklyn, are members of a billionaire clan with homes scattered across Connecticut, London, Utah, Gstaad, the Hamptons, and, especially, New York City. It was not until 2015 that they were noticed by Forbes, which added them to the list of America’s richest families.

The magazine pegged their wealth, shared among twenty heirs, at a conservative $14 billion. (Descendants of Arthur Sackler, Mortimer and Raymond’s older brother, split off decades ago and are mere multi-millionaires.) To a remarkable degree, those who share in the billions appear to have abided by an oath of omertà: Never comment publicly on the source of the family’s wealth.

That may be because the greatest part of that $14 billion fortune tallied by Forbes came from OxyContin, the narcotic painkiller regarded by many public-health experts as among the most dangerous products ever sold on a mass scale. Since 1996, when the drug was brought to market by Purdue Pharma, the American branch of the Sacklers’ pharmaceutical empire, more than two hundred thousand people in the United States have died from overdoses of OxyContin and other prescription painkillers. Thousands more have died after starting on a prescription opioid and then switching to a drug with a cheaper street price, such as heroin. Not all of these deaths are related to OxyContin—dozens of other painkillers, including generics, have flooded the market in the past thirty years. Nevertheless, Purdue Pharma was the first to achieve a dominant share of the market for long-acting opioids, accounting for more than half of prescriptions by 2001.

According to the Centers for Disease Control, fifty-three thousand Americans died from opioid overdoses in 2016, more than the thirty-six thousand who died in car crashes in 2015 or the thirty-five thousand who died from gun violence that year. This past July, Donald Trump’s Commission on Combating Drug Addiction and the Opioid Crisis, led by New Jersey governor Chris Christie, declared that opioids were killing roughly 142 Americans each day, a tally vividly described as “September 11th every three weeks.” The epidemic has also exacted a crushing financial toll: According to a study published by the American Public Health Association, using data from 2013—before the epidemic entered its current, more virulent phase—the total economic burden from opioid use stood at about $80 billion, adding together health costs, criminal-justice costs, and GDP loss from drug-dependent Americans leaving the workforce. Tobacco remains, by a significant multiple, the country’s most lethal product, responsible for some 480,000 deaths per year. But although billions have been made from tobacco, cars, and firearms, it’s not clear that any of those enterprises has generated a family fortune from a single product that approaches the Sacklers’ haul from OxyContin.

Even so, hardly anyone associates the Sackler name with their company’s lone blockbuster drug. “The Fords, Hewletts, Packards, Johnsons—all those families put their name on their product because they were proud,” said Keith Humphreys, a professor of psychiatry at Stanford University School of Medicine who has written extensively about the opioid crisis. “The Sacklers have hidden their connection to their product. They don’t call it ‘Sackler Pharma.’ They don’t call their pills ‘Sackler pills.’ And when they’re questioned, they say, ‘Well, it’s a privately held firm, we’re a family, we like to keep our privacy, you understand.’ ”

To the extent that the Sacklers have cultivated a reputation, it’s for being earnest healers, judicious stewards of scientific progress, and connoisseurs of old and beautiful things. Few are aware that during the crucial period of OxyContin’s development and promotion, Sackler family members actively led Purdue’s day-to-day affairs, filling the majority of its board slots and supplying top executives. By any assessment, the family’s leaders have pulled off three of the great marketing triumphs of the modern era: The first is selling OxyContin; the second is promoting the Sackler name; and the third is ensuring that, as far as the public is aware, the first and the second have nothing to do with one another.

If you head north on I-95 through Stamford, Connecticut, you will spot, on the left, a giant misshapen glass cube. Along the building’s top edge, white lettering spells out ONE STAMFORD FORUM. No markings visible from the highway indicate the presence of the building’s owner and chief occupant, Purdue Pharma. Originally known as Purdue Frederick, the first iteration of the company was founded in 1892 on New York’s Lower East Side as a peddler of patent medicines. For decades, it sustained itself with sales of Gray’s Glycerine Tonic, a sherry-based liquid of “broad application” marketed as a remedy for everything from anemia to tuberculosis. The company was purchased in 1952 by Arthur Sackler, thirty-nine, and was run by his brothers, Mortimer, thirty- six, and Raymond, thirty-two. The Sackler brothers came from a family of Jewish immigrants in Flatbush, Brooklyn. Arthur was a headstrong and ambitious provider, setting the tone—and often choosing the path—for his younger brothers. After attending medical school on Arthur’s dime, Mortimer and Raymond followed him to jobs at the Creedmoor psychiatric hospital in Queens. There, they coauthored more than one hundred studies on the biochemical roots of mental illness. The brothers’ research was promising—they were among the first to identify a link between psychosis and the hormone cortisone—but their findings were mostly ignored by their professional peers, who, in keeping with the era, favored a Freudian model of mental illness.

Concurrent with his psychiatric work, Arthur Sackler made his name in pharmaceutical advertising, which at the time consisted almost exclusively of pitches from so-called “detail men” who sold drugs to doctors door-to-door. Arthur intuited that print ads in medical journals could have a revolutionary effect on pharmaceutical sales, especially given the excitement surrounding the “miracle drugs” of the 1950s—steroids, antibiotics, antihistamines, and psychotropics. In 1952, the same year that he and his brothers acquired Purdue, Arthur became the first adman to convince The Journal of the American Medical Association, one of the profession’s most august publications, to include a color advertorial brochure.

In the 1960s, Arthur was contracted by Roche to develop an advertising strategy for a new antianxiety medication called Valium. This posed a challenge, because the effects of the medication were nearly indistinguishable from those of Librium, another Roche tranquilizer that was already on the market. Arthur differentiated Valium by audaciously inflating its range of indications. Whereas Librium was sold as a treatment for garden- variety anxiety, Valium was positioned as an elixir for a problem Arthur christened “psychic tension.” According to his ads, psychic tension, the forebear of today’s “stress,” was the secret culprit behind a host of somatic conditions, including heartburn, gastrointestinal issues, insomnia, and restless-leg syndrome. The campaign was such a success that for a time Valium became America’s most widely prescribed medication—the first to reach more than $100 million in sales. Arthur, whose compensation depended on the volume of pills sold, was richly rewarded, and he later became one of the first inductees into the Medical Advertising Hall of Fame.

As Arthur’s fortune grew, he turned his acquisitive instincts to the art market, quickly amassing the world’s largest private collection of ancient Chinese artifacts. According to a memoir by Marietta Lutze, his second wife, collecting, exhibiting, owning, and donating art fed Arthur’s “driving necessity for prestige and recognition.” Rewarding at first, collecting soon became a mania that took over his life. “Boxes of artifacts of tremendous value piled up in numerous storage locations,” she wrote, “there was too much to open, too much to appreciate; some objects known only by a packing list.” Under an avalanche of “ritual bronzes and weapons, mirrors and ceramics, inscribed bones and archaic jades,” their lives were “often in chaos.” “Addiction is a curse,” Lutze noted, “be it drugs, women, or collecting.”

When Arthur donated his art and money to museums, he often imposed onerous terms. According to a memoir written by Thomas Hoving, the Met director from 1967 to 1977, when Arthur established the Sackler Gallery at the Metropolitan Museum of Art to house Chinese antiquities, in 1963, he required the museum to collaborate on a byzantine tax-avoidance maneuver. In accordance with the scheme, the museum first sold Arthur a large quantity of ancient artifacts at the deflated 1920s prices for which they had originally been acquired. Arthur then donated back the artifacts at 1960s prices, in the process taking a tax deduction so hefty that it likely exceeded the value of his initial donation. Three years later, in connection with another donation, Arthur negotiated an even more unusual arrangement. This time, the Met opened a secret chamber above the museum’s auditorium to provide Arthur with free storage for some five thousand objects from his private collection, relieving him of the substantial burden of fire protection and other insurance costs. (In an email exchange, Jillian Sackler, Arthur’s third wife, called Hoving’s tax-deduction story “fake news.” She also noted that New York’s attorney general conducted an investigation into Arthur’s dealings with the Met and cleared him of wrongdoing.)

In 1974, when Arthur and his brothers made a large gift to the Met—$3.5 million, to erect the Temple of Dendur—they stipulated that all museum signage, catalog entries, and bulletins referring to objects in the newly opened Sackler Wing had to include the names of all three brothers, each followed by “M.D.” (One museum official quipped, “All that was missing was a note of their office hours.”)

Hoving said that the Met hoped that Arthur would eventually donate his collection to the museum, but over time Arthur grew disgruntled over a series of rankling slights. For one, the Temple of Dendur was being rented out for parties, including a dinner for the designer Valentino, which Arthur called “disgusting.” According to Met chronicler Michael Gross, he was also denied that coveted ticket of arrival, a board seat. (Jillian Sackler said it was Arthur who rejected the board seat, after repeated offers by the museum.) In 1982, in a bad breakup with the Met, Arthur donated the best parts of his collection, plus $4 million, to the Smithsonian in Washington, D. C.

Arthur’s younger brothers, Mortimer and Raymond, looked so much alike that when they worked together at Creedmoor, they fooled the staff by pretending to be one another. Their physical similarities did not extend to their personalities, however. Tage Honore, Purdue’s vice-president of discovery of research from 2000 to 2005, described them as “like day and night.” Mortimer, said Honore, was “extroverted—a ‘world man,’ I would call it.” He acquired a reputation as a big-spending, transatlantic playboy, living most of the year in opulent homes in England, Switzerland, and France. (In 1974, he renounced his U. S. citizenship to become a citizen of Austria, which infuriated his patriotic older brother.) Like Arthur, Mortimer became a major museum donor and married three wives over the course of his life.

Mortimer had his own feuds with the Met. On his seventieth birthday, in 1986, the museum agreed to make the Temple of Dendur available to him for a party but refused to allow him to redecorate the ancient shrine: Together with other improvements, Mortimer and his interior designer, flown in from Europe, had hoped to spiff up the temple by adding extra pillars. Also galling to Mortimer was the sale of naming rights for one of the Sackler Wing’s balconies to a donor from Japan. “They sold it twice,” Mortimer fumed to a reporter from New York magazine. Raymond, the youngest brother, cut a different figure—“a family man,” said Honore. Kind and mild-mannered, he stayed with the same woman his entire life. Lutze concluded that Raymond owed his comparatively serene nature to having missed the worst years of the Depression. “He had summer vacations in camp, which Arthur never had,” she

wrote. “The feeling of the two older brothers about the youngest was, ‘Let the kid enjoy himself.’ ”

Raymond led Purdue Frederick as its top executive for several decades, while Mortimer led Napp Pharmaceuticals, the family’s drug company in the UK. (In practice, a family spokesperson said, “the brothers worked closely together leading both companies.”) Arthur, the adman, had no official role in the family’s pharmaceutical operations. According to Barry Meier’s Pain Killer, a prescient account of the rise of OxyContin published in 2003, Raymond and Mortimer bought Arthur’s share in Purdue from his estate for $22.4 million after he died in 1987. In an email exchange, Arthur’s daughter Elizabeth Sackler, a historian of feminist art who sits on the board of the Brooklyn Museum and supports a variety of progressive causes, emphatically distanced her branch of the family from her cousins’ businesses. “Neither I, nor my siblings, nor my children have ever had ownership in or any benefit whatsoever from Purdue Pharma or OxyContin,” she wrote, while also praising “the breadth of my father’s brilliance and important works.” Jillian, Arthur’s widow, said her husband had died too soon: “His enemies have gotten the last word.”

The Sacklers have been millionaires for decades, but their real money—the painkiller money—is of comparatively recent vintage. The vehicle of that fortune was OxyContin, but its engine, the driving power that made them so many billions, was not so much the drug itself as it was Arthur’s original marketing insight, rehabbed for the era of chronic-pain management. That simple but profitable idea was to take a substance with addictive properties—in Arthur’s case, a benzo; in Raymond and Mortimer’s case, an opioid—and market it as a salve for a vast range of indications.

In the years before it swooped into the pain-management business, Purdue had been a small industry player, specializing in over-the-counter remedies like ear-wax remover and laxatives. Its most successful product, acquired in 1966, was Betadine, a powerful antiseptic purchased in industrial quantities by the U. S. government to prevent infection among wounded soldiers in Vietnam. The turning point, according to company lore, came in 1972, when a London doctor working for Cicely Saunders, the Florence Nightingale of the modern hospice movement, approached Napp with the idea of creating a timed-release morphine pill. A long-acting morphine pill, the doctor reasoned, would allow dying cancer patients to sleep through the night without an IV. At the time, treatment with opioids was stigmatized in the United States, owing in part to a heroin epidemic fueled by returning Vietnam veterans. “Opiophobia,” as it came to be called, prevented skittish doctors from treating most patients, including nearly all infants, with strong pain medication of any kind. In hospice care, though, addiction was not a concern: It didn’t matter whether terminal patients became hooked in their final days. Over the course of the seventies, building on a slow-release technology the company had already developed for an asthma medication, Napp created what came to be known as the “Contin” system. In 1981, Napp introduced a timed-release morphine pill in the UK; six years later, Purdue brought the same drug to market in the U. S. as MS Contin.

MS Contin quickly became the gold standard for pain relief in cancer care. At the same time, a number of clinicians associated with the burgeoning chronic-pain movement started advocating the use of powerful opioids for noncancer conditions like back pain and neuropathic pain, afflictions that at their worst could be debilitating. In 1986, two doctors from Memorial Sloan Kettering hospital in New York published a fateful article in a medical journal that purported to show, based on a study of thirty-eight patients, that long-term opioid treatment was safe and

effective so long as patients had no history of drug abuse. Soon enough, opioid advocates dredged up a letter to the editor published in The New England Journal of Medicine in 1980 that suggested, based on a highly unrepresentative cohort, that the risk of addiction from long-term opioid use was less than 1 percent. Though ultimately disavowed by its author, the letter ended up getting cited in medical journals more than six hundred times.

As the country was reexamining pain, Raymond’s eldest son, Richard Sackler, was searching for new applications for Purdue’s timed-release Contin system. “At all the meetings, that was a constant source of discussion—‘What else can we use the Contin system for?’ ” said Peter Lacouture, a senior director of clinical research at Purdue from 1991 to 2001. “And that’s where Richard would fire some ideas—maybe antibiotics, maybe chemotherapy—he was always out there digging.” Richard’s spitballing wasn’t idle blather. A trained physician, he treasured his role as a research scientist and appeared as an inventor on dozens of the company’s patents (though not on the patents for OxyContin). In the tradition of his uncle Arthur, Richard was also fascinated by sales messaging. “He was very interested in the commercial side and also very interested in marketing approaches,” said Sally Allen Riddle, Purdue’s former executive director for product management. “He didn’t always wait for the research results.” (A Purdue spokesperson said that Richard “always considered relevant scientific information when making decisions.”)

Perhaps the most private member of a generally secretive family, Richard appears nowhere on Purdue’s website. From public records and conversations with former employees, though, a rough portrait emerges of a testy eccentric with ardent, relentless ambitions. Born in 1945, he holds degrees from Columbia University and NYU Medical School. According to a bio on the website of the Koch Institute for Integrative Cancer Research at MIT, where Richard serves on the advisory board, he started working at Purdue as his father’s assistant at age twenty-six before eventually leading the firm’s R&D division and, separately, its sales and marketing division. In 1999, while Mortimer and Raymond remained Purdue’s co-CEOs, Richard joined them at the top of the company as president, a position he relinquished in 2003 to become cochairman of the board. The few publicly available pictures of him are generic and sphinxlike—a white guy with a receding hairline. He is one of the few Sacklers to consistently smile for the camera. In a photo on what appears to be his Facebook profile, Richard is wearing a tan suit and a pink tie, his right hand casually scrunched into his pocket, projecting a jaunty charm. Divorced in 2013, he lists his relationship status on the profile as “It’s complicated.” WHEN PURDUE EVENTUALLY PLEADED GUILTY TO FELONY CHARGES IN 2007 FOR CRIMINALLY “MISBRANDING” OXYCONTIN, IT ACKNOWLEDGED EXPLOITING DOCTORS’ MISCONCEPTIONS ABOUT OXYCODONE’S STRENGTH.

Richard’s political contributions have gone mostly to Republicans—including Strom Thurmond and Herman Cain—though at times he has also given to Democrats. (His ex-wife, Beth Sackler, has given almost exclusively to Democrats.) In 2008, he wrote a letter to the editor of The Wall Street Journal denouncing Muslim support for suicide bombing, a concern that seems to persist: Since 2014, his charitable organization, the Richard and Beth Sackler Foundation, has donated to several anti-Muslim groups, including three organizations classified as hate groups by the Southern Poverty Law Center. (The family spokesperson said, “It was never Richard Sackler’s intention to donate to an anti-Muslim or hate group.”) The foundation has also donated to True the Vote, the “voter-fraud watchdog” that was the original source for Donald Trump’s inaccurate claim that three million illegal immigrants voted in the 2016 election.

Former employees describe Richard as a man with an unnerving intelligence, alternately detached and pouncing. In meetings, his face was often glued to his laptop. “This was pre-

smartphone days,” said Riddle. “He’d be typing away and you would think he wasn’t even listening, and then all of the sudden his head would pop up and he’d be asking a very pointed question.” He was notorious for peppering subordinates with unexpected, rapid-fire queries, sometimes in the middle of the night. “Richard had the mind of someone who’s going two hundred miles an hour,” said Lacouture. “He could be a little bit disconnected in the way he would communicate. Whether it was on the weekend or a holiday or a Christmas party, you could always expect the unexpected.”

Richard also had an appetite for micromanagement. “I remember one time he mailed out a rambling sales bulletin,” said Shelby Sherman, a Purdue sales rep from 1974 to 1998. “And right in the middle, he put in, ‘If you’re reading this, then you must call my secretary at this number and give her this secret password.’ He wanted to check and see if the reps were reading this shit. We called it ‘Playin’ Passwords.’ ” According to Sherman, Richard started taking a more prominent role in the company during the early 1980s. “The shift was abrupt,” he said. “Raymond was just so nice and down-to-earth and calm and gentle.” When Richard came, “things got a lot harder. Richard really wanted Purdue to be big—I mean really big.”

To effectively capitalize on the chronic-pain movement, Purdue knew it needed to move beyond MS Contin. “Morphine had a stigma,” said Riddle. “People hear the word and say, ‘Wait a minute, I’m not dying or anything.’ ” Aside from its terminal aura, MS Contin had a further handicap: Its patent was set to expire in the late nineties. In a 1990 memo addressed to Richard and other executives, Purdue’s VP of clinical research, Robert Kaiko, suggested that the company work on a pill containing oxycodone, a chemical similar to morphine that was also derived from the opium poppy. When it came to branding, oxycodone had a key advantage: Although it was 50 percent stronger than morphine, many doctors believed—wrongly—that it was substantially less powerful. They were deceived about its potency in part because oxycodone was widely known as one of the active ingredients in Percocet, a relatively weak opioid- acetaminophen combination that doctors often prescribed for painful injuries. “It really didn’t have the same connotation that morphine did in people’s minds,” said Riddle.

A common malapropism led to further advantage for Purdue. “Some people would call it oxy-codeine” instead of oxycodone, recalled Lacouture. “Codeine is very weak.” When Purdue eventually pleaded guilty to felony charges in 2007 for criminally “misbranding” OxyContin, it acknowledged exploiting doctors’ misconceptions about oxycodone’s strength. In court documents, the company said it was “well aware of the incorrect view held by many physicians that oxycodone was weaker than morphine” and “did not want to do anything ‘to make physicians think that oxycodone was stronger or equal to morphine’ or to ‘take any steps . . . that would affect the unique position that OxyContin’ ” held among physicians.

Purdue did not merely neglect to clear up confusion about the strength of OxyContin. As the company later admitted, it misleadingly promoted OxyContin as less addictive than older opioids on the market. In this deception, Purdue had a big assist from the FDA, which allowed the company to include an astonishing labeling claim in OxyContin’s package insert: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.”

The theory was that addicts would shy away from timed-released drugs, preferring an immediate rush. In practice, OxyContin, which crammed a huge amount of pure narcotic into a single pill, became a lusted-after target for addicts, who quickly discovered that the timed-release mechanism in OxyContin was easy

to circumvent—you could simply crush a pill and snort it to get most of the narcotic payload in a single inhalation. This wasn’t exactly news to the manufacturer: OxyContin’s own packaging warned that consuming broken pills would thwart the timed-release system and subject patients to a potentially fatal overdose. MS Contin had contended with similar vulnerabilities, and as a result commanded a hefty premium on the street. But the “reduced abuse liability” claim that added wings to the sales of OxyContin had not been approved for MS Contin. It was removed from OxyContin in 2001 and would never be approved again for any other opioid.

The year after OxyContin’s release, Curtis Wright, the FDA examiner who approved the pharmaceutical’s original application, quit. After a stint at another pharmaceutical company, he began working for Purdue. In an interview with Esquire, Wright defended his work at the FDA and at Purdue. “At the time, it was believed that extended-release formulations were intrinsically less abusable,” he insisted. “It came as a rather big shock to everybody—the government and Purdue—that people found ways to grind up, chew up, snort, dissolve, and inject the pills.” Preventing abuse, he said, had to be balanced against providing relief to chronic-pain sufferers. “In the mid-nineties,” he recalled, “the very best pain specialists told the medical community they were not prescribing opioids enough. That was not something generated by Purdue—that was not a secret plan, that was not a plot,that was not a clever marketing ploy. Chronic pain is horrible. In the right circumstances, opioid therapy is nothing short of miraculous; you give people their lives back.” In Wright’s account, the Sacklers were not just great employers, they were great people. “No company in the history of pharmaceuticals,” he said, “has worked harder to try to prevent abuse of their product than Purdue.”

Purdue did not invent the chronic-pain movement, but it used that movement to engineer a crucial shift. Wright is correct that in the nineties patients suffering from chronic pain often received inadequate treatment. But the call for clinical reforms also became a flexible alibi for overly aggressive prescribing practices. By the end of the decade, clinical proponents of opioid treatment, supported by millions in funding from Purdue and other pharmaceutical companies, had organized themselves into advocacy groups with names like the American Pain Society and the American Academy of Pain Medicine. (Purdue also launched its own group, called Partners Against Pain.) As the decade wore on, these organizations, which critics have characterized as front groups for the pharmaceutical industry, began pressuring health regulators to make pain “the fifth vital sign”—a number, measured on a subjective ten-point scale, to be asked and recorded at every doctor’s visit. As an internal strategy document put it, Purdue’s ambition was to “attach an emotional aspect to non cancer pain” so that doctors would feel pressure to “treat it more seriously and aggressively.” The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American.

The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American. By 2001, annual OxyContin sales had surged past $1 billion.

OxyContin’s sales started out small in 1996, in part because Purdue first focused on the cancer market to gain formulary acceptance from HMOs and state Medicaid programs. Over the next several years, though, the company doubled its sales force to six hundred—equal to the total number of DEA diversion agents employed to combat the sale of prescription drugs on the black market—and began targeting general practitioners, dentists, OB/GYNs, physician assistants, nurses, and residents. By 2001, annual OxyContin sales had surged past $1 billion. Sales reps were encouraged to downplay addiction risks. “It was sell, sell,

sell,” recalled Sherman. “We were directed to lie. Why mince words about it? Greed took hold and overruled everything. They saw that potential for billions of dollars and just went after it.” Flush with cash, Purdue pioneered a high-cost promotion strategy, effectively providing kickbacks—which were legal under American law—to each part of the distribution chain. Wholesalers got rebates in exchange for keeping OxyContin off prior authorization lists. Pharmacists got refunds on their initial orders. Patients got coupons for thirty- day starter supplies. Academics got grants. Medical journals got millions in advertising. Senators and members of Congress on key committees got donations from Purdue and from members of the Sackler family.

It was doctors, though, who received the most attention. “We used to fly doctors to these ‘seminars,’ ” said Sherman, which were, in practice, “just golf trips to Pebble Beach. It was graft.” Though offering perks and freebies to doctors was hardly uncommon in the industry, it was unprecedented in the marketing of a Schedule II narcotic. For some physicians, the junkets to sunny locales weren’t enough to persuade them to prescribe. To entice the holdouts—a group the company referred to internally as “problem doctors”—the reps would dangle the lure of Purdue’s lucrative speakers’ bureau. “Everybody was automatically approved,” said Sherman. “We would set up these little dinners, and they’d make their little fifteen-minute talk, and they’d get $500.”

Between 1996 and 2001, the number of OxyContin prescriptions in the United States surged from about three hundred thousand to nearly six million, and reports of abuse started to bubble up in places like West Virginia, Florida, and Maine. (Research would later show a direct correlation between prescription volume in an area and rates of abuse and overdose.) Hundreds of doctors were eventually arrested for running pill mills. According to an investigation in the Los Angeles Times, even though Purdue kept an internal list of doctors it suspected of criminal diversion, it didn’t volunteer this information to law enforcement until years later. As criticism of OxyContin mounted through the aughts, Purdue responded with symbolic concessions while retaining its volume-driven business model. To prevent addicts from forging prescriptions, the company gave doctors tamper-resistant prescription pads; to mollify pharmacists worried about robberies, Purdue offered to replace, free of charge, any stolen drugs; to gather data on drug abuse and diversion, the company launched a national monitoring program called RADARS.

Critics were not impressed. In a letter to Richard Sackler in July 2001, Richard Blumenthal, then Connecticut’s attorney general and now a U. S. senator, called the company’s efforts “cosmetic.” As Blumenthal had deduced, the root problem of the prescription-opioid epidemic was the high volume of prescriptions written for powerful opioids. “It is time for Purdue Pharma to change its practices,” Blumenthal warned Richard, “not just its public-relations strategy.”

It wasn’t just that doctors were writing huge numbers of prescriptions; it was also that the prescriptions were often for extraordinarily high doses. A single dose of Percocet contains between 2.5 and 10mg of oxycodone. OxyContin came in 10-, 20-, 30-, 40-, and 80mg formulations and, for a time, even 160mg. Purdue’s greatest competitive advantage in dominating the pain market, it had determined early on, was that OxyContin lasted twelve hours, enough to sleep through the night. But for many patients, the drug lasted only six or eight hours, creating a cycle of crash and euphoria that one academic called “a perfect recipe for addiction.” When confronted with complaints about “breakthrough pain”—meaning that the pills weren’t working as long as advertised—Purdue’s sales reps were given strict instructions to tell doctors to strengthen the dose rather than increase dosing frequency.

Sales reps were encouraged to downplay addiction risks. “It was sell, sell, sell,” recalled Sherman. “We were directed to lie. Why mince words about it?”

Over the next several years, dozens of class-action lawsuits were brought against Purdue. Many were dismissed, but in some cases Purdue wrote big checks to avoid going to trial. Several plaintiffs’ lawyers found that the company was willing to go to great lengths to prevent Richard Sackler from having to testify under oath. “They didn’t want him deposed, I can tell you that much,” recalled Marvin Masters, a lawyer who brought a class-action suit against Purdue in the early 2000s in West Virginia. “They were willing to sit down and settle the case to keep from doing that.” Purdue tried to get Richard removed from the suit, but when that didn’t work, the company settled with the plaintiffs for more than $20 million. Paul Hanly, a New York class-action lawyer who won a large settlement from Purdue in 2007, had a similar recollection. “We were attempting to take Richard Sackler’s deposition,” he said, “around the time that they agreed to a settlement.” (A spokesperson for the company said, “Purdue did not settle any cases to avoid the deposition of Dr. Richard Sackler, or any other individual.”)

When the federal government finally stepped in, in 2007, it extracted historic terms of surrender from the company. Purdue pleaded guilty to felony charges, admitting that it had lied to doctors about OxyContin’s abuse potential. (The technical charge was “misbranding a drug with intent to defraud or mislead.”) Under the agreement, the company paid $600 million in fines and its three top executives at the time—its medical director, general counsel, and Richard’s successor as president—pleaded guilty to misdemeanor charges. The executives paid $34.5 million out of their own pockets and performed four hundred hours of community service. It was one of the harshest penalties ever imposed on a pharmaceutical company. (In a statement to Esquire, Purdue said that it “abides by the highest ethical standards and legal requirements.” The statement went on: “We want physicians to use their professional judgment, and we were not trying to pressure them.”)

Fifty-three thousand Americans died from opioid overdoses in 2016, more than the thirty-six thousand who died in car crashes in 2015 or the thirty-five thousand who died from gun violence that year.

No Sacklers were named in the 2007 suit. Indeed, the Sackler name appeared nowhere in the plea agreement, even though Richard had been one of the company’s top executives during most of the period covered by the settlement. He did eventually have to give a deposition in 2015, in a case brought by Kentucky’s attorney general. Richard’s testimony—the only known record of a Sackler speaking about the crisis the family’s company helped create—was promptly sealed. (In 2016, STAT, an online magazine owned by Boston Globe Media that covers health and medicine, asked a court in Kentucky to unseal the deposition, which is said to have lasted several hours. STAT won a lower-court ruling in May 2016. As of press time, the matter was before an appeals court.)

In 2010, Purdue executed a breathtaking pivot: Embracing the arguments critics had been making for years about OxyContin’s susceptibility to abuse, the company released a new formulation of the medication that was harder to snort or inject. Purdue seized the occasion to rebrand itself as an industry leader in abuse-deterrent technology. The change of heart coincided with two developments: First, an increasing number of addicts, unable to afford OxyContin’s high street price, were turning to cheaper alternatives like heroin; second, OxyContin was nearing the end of its patents. Purdue suddenly argued that the drug it had been selling for nearly fifteen years was so prone to abuse that generic manufacturers should not be allowed to copy it.

On April 16, 2013, the day some of the key patents for OxyContin were scheduled to expire, the FDA followed Purdue’s lead, declaring that no generic versions of the original OxyContin formulation could be sold. The company had effectively won several additional years of patent protection for its golden goose.

Opioid withdrawal, which causes aches, vomiting, and restless anxiety, is a gruesome process to experience as an adult. It’s considerably worse for the twenty thousand or so American babies who emerge each year from opioid-soaked wombs. These infants, suddenly cut off from their supply, cry uncontrollably. Their skin is mottled. They cannot fall asleep. Their bodies are shaken by tremors and, in the worst cases, seizures. Bottles of milk leave them distraught, because they cannot maneuver their lips with enough precision to create suction. Treatment comes in the form of drops of morphine pushed from a syringe into the babies’ mouths. Weaning sometimes takes a week but can last as long as twelve. It’s a heartrending, expensive process, typically carried out in the neonatal ICU, where newborns have limited access to their mothers.

But the children of OxyContin, its heirs and legatees, are many and various. The second- and third-generation descendants of Raymond and Mortimer Sackler spend their money in the ways we have come to expect from the not-so-idle rich. Notably, several have made children a focus of their business and philanthropic endeavors. One Sackler heir helped start an iPhone app called Red Rover, which generates ideas for child-friendly activities for urban parents; another runs a child- development center near Central Park; another is a donor to charter-school causes, as well as an investor in an education start-up called AltSchool. Yet another is the founder of Beespace, an “incubator for emerging nonprofits,” which provides resources and mentoring for initiatives like the Malala Fund, which invests in education programs for women in the developing world, and Yoga Foster, whose objective is to bring “accessible, sustainable yoga programs into schools across the country.” Other Sackler heirs get to do the fun stuff: One helps finance small, interesting films like The Witch; a second married a famous cricket player; a third is a sound artist; a fourth started a production company with Boyd Holbrook, star of the Netflix series Narcos; a fifth founded a small chain of gastropubs in New York called the Smith.

Holding fast to family tradition, Raymond’s and Mortimer’s heirs declined to be interviewed for this article. Instead, through a spokesperson, they put forward two decorated academics who have been on the receiving end of the family’s largesse: Phillip Sharp, the Nobel-prize-winning MIT geneticist, and Herbert Pardes, formerly the dean of faculty at Columbia University’s medical school and CEO of New York-Presbyterian Hospital. Both men effusively praised the Sacklers’ donations to the arts and sciences, marveling at their loyalty to academic excellence. “Once you were on that exalted list of philanthropic projects,” Pardes told Esquire, “you were there and you were in a position to secure additional philanthropy. It was like a family acquisition.” Pardes called the Sacklers “the nicest, most gentle people you could imagine.” As for the family’s connection to OxyContin, he said that it had never come up as an issue in the faculty lounge or the hospital break room. “I have never heard one inch about that,” he said.

Pardes’s ostrich like avoidance is not unusual. In 2008, Raymond and his wife donated an undisclosed amount to Yale to start the Raymond and Beverly Sackler Institute for Biological, Physical and Engineering Sciences. Lynne Regan, its current director, told me that neither students nor faculty have ever brought up the OxyContin connection. “Most people don’t know about that,” she said. “I think people are mainly oblivious.” A spokesperson for the university added, “Yale does not vet donors for controversies that may or may not arise.”

In May, a dozen lawmakers in Congress sent a bipartisan letter to the World Health Organization warning that Sackler-owned companies were preparing to flood foreign countries with legal narcotics.

The controversy surrounding OxyContin shows little sign of receding. In 2016, the CDC issued a startling warning: There was no good evidence that opioids were an effective treatment for chronic pain beyond six weeks. There was, on the other hand, an abundance of evidence that long-term treatment with opioids had harmful effects. (A recent paper by Princeton economist Alan Krueger suggests that chronic opioid use may account for more than 20 percent of the decline in American labor-force participation from 1999 to 2015.) Millions of opioid prescriptions for chronic pain had been written in the preceding two decades, and the CDC was calling into question whether many of them should have been written at all. At least twenty-five government entities, ranging from states to small cities, have recently filed lawsuits against Purdue to recover damages associated with the opioid epidemic.

The Sacklers, though, will likely emerge untouched: Because of a sweeping non-prosecution agreement negotiated during the 2007 settlement, most new criminal litigation against Purdue can only address activity that occurred after that date. Neither Richard nor any other family members have occupied an executive position at the company since 2003.

The American market for OxyContin is dwindling. According to Purdue, prescriptions fell 33 percent between 2012 and 2016. But while the company’s primary product may be in eclipse in the United States, international markets for pain medications are expanding. According to an investigation last year in the Los Angeles Times, Mundipharma, the Sackler-owned company charged with developing new markets, is employing a suite of familiar tactics in countries like Mexico, Brazil, and China to stoke concern for as-yet-unheralded “silent epidemics” of untreated pain. In Colombia, according to the L.A. Times, the company went so far as to circulate a press release suggesting that 47 percent of the population suffered from chronic pain. [Napp is the family’s drug company in the UK. Mundipharma is their company charged with developing new markets.]

In May, a dozen lawmakers in Congress, inspired by the L.A. Times investigation, sent a bipartisan letter to the World Health Organization warning that Sackler-owned companies were preparing to flood foreign countries with legal narcotics. “Purdue began the opioid crisis that has devastated American communities,” the letter reads. “Today, Mundipharma is using many of the same deceptive and reckless practices to sell OxyContin abroad.” Significantly, the letter calls out the Sackler family by name, leaving no room for the public to wonder about the identities of the people who stood behind Mundipharma.

The final assessment of the Sacklers’ global impact will take years to work out. In some places, though, they have already left their mark. In July, Raymond, the last remaining of the original Sackler brothers, died at ninety-seven. Over the years, he had won a British knighthood, been made an Officer of France’s Légion d’Honneur, and received one of the highest possible honors from the royal house of the Netherlands. One of his final accolades came in June 2013, when Anthony Monaco, the president of Tufts University, traveled to Purdue Pharma’s headquarters in Stamford to bestow an honorary doctorate. The Sacklers had made a number of transformational donations to the university over the years—endowing, among other things, the Sackler School of Graduate Biomedical Sciences. At

Tufts, as at most schools, honorary degrees are traditionally awarded on campus during commencement, but in consideration of Raymond’s advanced age, Monaco trekked to Purdue for a special ceremony. The audience that day was limited to family members, select university officials, and a scrum of employees. Addressing the crowd of intimates, Monaco praised his benefactor. “It would be impossible to calculate how many lives you have saved, how many scientific fields you have redefined, and how many new physicians, scientists, mathematicians, and engineers are doing important work as a result of your entrepreneurial spirit.” He concluded, “You are a world changer.”

Source: This article appears in the November ’17 issue of Esquire.

Executive Summary


Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) is tracking the impact of marijuana legalization in the state of Colorado. This report will utilize, whenever possible, a comparison of three different eras in Colorado’s legalization history:

· 2006 – 2008: Medical marijuana pre-commercialization era

· 2009 – Present: Medical marijuana commercialization and expansion era

· 2013 – Present: Recreational marijuana era

Rocky Mountain HIDTA will collect and report comparative data in a variety of areas, including but not limited to:

· Impaired driving and fatalities

· Youth marijuana use

· Adult marijuana use

· Emergency room admissions

· Marijuana-related exposure cases

· Diversion of Colorado marijuana

This is the fifth annual report on the impact of legalized marijuana in Colorado. It is divided into ten sections, each providing information on the impact of marijuana legalization. The sections are as follows:

Section 1 – Impaired Driving and Fatalities:

· Marijuana-related traffic deaths when a driver was positive for marijuana more than doubled from 55 deaths in 2013 to 123 deaths in 2016.

· Marijuana-related traffic deaths increased 66 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

o During the same time period, all traffic deaths increased 16 percent.

· In 2009, Colorado marijuana-related traffic deaths involving drivers testing positive for marijuana represented 9 percent of all traffic deaths. By 2016, that number has more than doubled to 20 percent.

Section 2 – Youth Marijuana Use:

· Youth past month marijuana use increased 12 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012).

· The latest 2014/2015 results show Colorado youth ranked #1 in the nation for past month marijuana use, up from #4 in 2011/2012 and #14 in 2005/2006.

· Colorado youth past month marijuana use for 2014/2015 was 55 percent higher than the national average compared to 39 percent higher in 2011/2012.

Section 3 – Adult Marijuana Use:

· College age past month marijuana use increased 16 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012).

· The latest 2014/2015 results show Colorado college-age adults ranked #2 in the nation for past-month marijuana use, up from #3 in 2011/2012 and #8 in 2005/2006.

· Colorado college age past month marijuana use for 2014/2015 was 61 percent higher than the national average compared to 42 percent higher in 2011/2012.

· Adult past-month marijuana use increased 71 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012).

· The latest 2014/2015 results show Colorado adults ranked #1 in the nation for past month marijuana use, up from #7 in 2011/2012 and #8 in 2005/2006.

· Colorado adult past month marijuana use for 2014/2015 was 124 percent higher than the national average compared to 51 percent higher in 2011/2012.

Section 4 – Emergency Department and Hospital Marijuana-Related Admissions:

· The yearly rate of emergency department visits related to marijuana increased 35 percent after the legalization of recreational marijuana (2011-2012 vs. 2013-2015).

· Number of hospitalizations related to marijuana:

o 2011 – 6,305

o 2012 – 6,715

o 2013 – 8,272

o 2014 – 11,439

o Jan-Sept 2015 – 10,901

· The yearly number of marijuana-related hospitalizations increased 72 percent after the legalization of recreational marijuana (2009-2012 vs. 2013-2015).

Section 5 – Marijuana-Related Exposure:

· Marijuana-related exposures increased 139 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

· Marijuana-Only exposures more than doubled (increased 210 percent) in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

Section 6 – Treatment:

· Marijuana treatment data from Colorado in years 2006 – 2016 does not appear to demonstrate a definitive trend. Colorado averages 6,683 treatment admissions annually for marijuana abuse.

· Over the last ten years, the top four drugs involved in treatment admissions were alcohol (average 13,551), marijuana (average 6,712), methamphetamine (average 5,578), and heroin (average 3,024).

Section 7 – Diversion of Colorado Marijuana:

· In 2016, RMHIDTA Colorado drug task forces completed 163 investigations of individuals or organizations involved in illegally selling Colorado marijuana both in and out of state.

o These cases led to:

§ 252 felony arrests

§ 7,116 (3.5 tons) pounds of marijuana seized

§ 47,108 marijuana plants seized

§ 2,111 marijuana edibles seized

§ 232 pounds of concentrate seized

§ 29 different states to which marijuana was destined

· Highway interdiction seizures of Colorado marijuana increased 43 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

· Of the 346 highway interdiction seizures in 2016, there were 36 different states destined to receive marijuana from Colorado.

o The most common destinations identified were Illinois, Missouri, Texas, Kansas and Florida.

Section 8 – Diversion by Parcel:

· Seizures of Colorado marijuana in the U.S. mail has increased 844 percent from an average of 52 parcels (2009-2012) to 491 parcels (2013-2016) in the four-year average that recreational marijuana has been legal.

· Seizures of Colorado marijuana in the U.S. mail has increased 914 percent from an average of 97 pounds (2009-2012) to 984 pounds (2013-2016) in the four-year average that recreational marijuana has been legal.

Section 9 – Related Data:

· Crime in Denver increased 17 percent and crime in Colorado increased 11 percent from 2013 to 2016.

· Colorado annual tax revenue from the sale of recreational and medical marijuana was 0.8 percent of Colorado’s total statewide budget (FY 2016).

· As of June 2017, there were 491 retail marijuana stores in the state of Colorado compared to 392 Starbucks and 208 McDonald’s.

· 66 percent of local jurisdictions have banned medical and recreational marijuana businesses.

Section 10 – Reference Materials:

This section lists various studies and reports regarding marijuana.


Source: WWW.RMHIDTA.ORG October 2017

Drug trafficking is now the most murderous criminal activity in American history. Overdose deaths from illegal drugs passed 50,000 in 2015 — many times the number of Americans killed by all Islamic terrorists over almost 20 years. Yet stopping the skyrocketing body count will require overcoming a pervasive misunderstanding of how drug abuse and addiction are caused.

Blaming the victim has created confusion and policy failure. No one starts using drugs intending to become an addict. While addiction may seem like slow-motion suicide, most addicts do not want to die — the poison hooks them, taking over their life. Media reports of addiction are mixed with entertainment and social media that present drug use as commonplace. More and more Americans are drawn to the flame, many introduced to substance abuse by a friend or family member. “Just say no” is dead. Yes, encouraging young people not to use drugs can save individual lives, but personal morality is not the right battleground.

There are multiple factors that may be contributing to this crisis. Does expanding supply trigger drug experimentation? Does human biology simply include a dangerous susceptibly to runaway addiction? Or is cultural confusion about freedom and self-destruction enabling and normalizing drug addiction? All these factors (and possibly more) likely play a part. But what causes an epidemic is the addictive poison itself, spread in sufficient quantities. Ultimately, America’s addiction catastrophe is properly understood as a mass poisoning.

As a result, cutting the drug supply — and only cutting supply — will reduce deaths and addiction. The evidence for this conclusion is manifest; ignoring it will cost countless more lives.

Curtailing Supply

There was no demand for crack before it was created and distributed by Colombian traffickers. There was no demand for meth before it was created by criminal gangs and then “cooked” by users. Similarly, there was no massive abuse of prescription opioids until they were irresponsibly marketed by some manufacturers and prescribed by physicians contrary to sound medical practice.

The increase in heroin and fentanyl use, addiction, and deaths followed the increase in the supply from Mexico and China. Conversely, during the George W. Bush Administration, when the supply of cocaine, crack, and meth began declining, use declined. Now, as cocaine production in Colombia has grown again, use and overdose deaths are climbing. Finally, the leveling trend in the abuse of prescription opioids has followed enforcement actions against pill mills and criminal physicians — that is, it follows an apparent reduction in supply. Americans have long accepted the claim that it is impossible to stop drug trafficking, even in the face of extensive evidence to the contrary. Anti-terrorism efforts must stop just a few dedicated individuals. This is a tough problem that Americans see solved every day. Yet the poisoning of millions is supposedly unstoppable. It isn’t.

Moreover, misunderstanding the cause of drug epidemics has shifted the policy debate away from the right goals: reducing the supply of drugs and returning addicts to sobriety. With deaths at historic levels, some still maintain that drug use is a right or otherwise not worth the cost of controlling. This harm reduction position is at odds with both supply control and all forms of prevention education — and increasingly at odds with treatment understood as having the goal of abstinence.

Many drug policy progressives now insist on medically supervised addiction. Such medication assisted treatment (MAT) amounts to government-supervised facilities for drug use (injection sites) or even government-supplied drugs for the addicted. The model here is the Netherlands, where endless, government-supported drug use is treated as a means of treating addiction. These addicts continue to be victimized by their own country, fostering a separate and profoundly dysfunctional underclass.

In the face of expanding supply, prevention and treatment efforts cannot be strategic — they can save individual lives, but new lives will be put at risk. This is merely squeezing an uncontained balloon. Moreover, if supply is reduced significantly, use and addiction will necessarily fall without respect to prevention and treatment efforts. The evidence of almost 50 years indicates that prevention and treatment efforts only contribute to strategic results when supply is reduced.

Prevention and treatment save lives, but their strategic effect is overwhelmed if supply and trafficking are not curtailed.

Policy proposals placing emphasis on reviving drug overdose victims mistake cause and effect. In the case of opioid addiction, the cause is the opioids themselves and increasingly, fentanyl. Revived addicts are still victims, and, sadly, many treated for opioid addiction will relapse in the face of burgeoning supply. Fentanyl and its variants are now driving the rapid rise in opioid deaths and drug overdoses in general. Information, albeit inadequate, suggests China is the source for these substances and the precursors to produce them. It seems there is no large-scale legitimate use for these chemicals outside of what is supposed to be controlled production for limited medical use — thus, industrial diversion is not a primary issue. Unfortunately, however, this means U.S. officials cannot attack fentanyl directly, but only via Chinese enforcement action.

China is likely to be sensitive to sustained pressure by authoritative American voices, whether from federal officials or prominent private individuals. America should ramp up this pressure soon. If executive branch officials cannot lead the charge, individuals from outside the executive, including members of Congress, should take the lead.

The Chinese are likely to act only in response to threats to their political or economic interests. Spurring them to act may require frequent confrontations over their performance in stopping fentanyl trafficking to the U.S. and Mexico. But sustained, genuine pressure works.

It is also possible that fentanyl and precursors are being trafficked from other Asian countries. Hence further — and swift — investigation is needed.

Bolstering Intelligence Resources

It is reasonable to anticipate that traffickers will seek to move production in response to pressure. If that happens, other Asian nations can be pressured by a range of escalating sanctions. Identification, especially public charging of foreign criminals, can be particularly helpful in disrupting trafficking operations, along with attacks on criminal funds and individuals through U.S. law.

An attack of sufficient power to collapse trafficking networks requires detailed intelligence. Such intelligence is also needed to prod foreign governments to act within their authority. Greater intelligence resources are also crucial for attacking trafficker finance, corruption operations, and measuring policy effectiveness. Attacking networks and responding to the drug epidemic requires comprehensive, real-time data. This data — from foreign intelligence services, domestic law enforcement agencies, and public health reports — should be fused into a strategic whole.

Fortunately, American intelligence has developed tools to attack such networked terrorist threats. At over 50,000 overdose deaths a year, the mass poisoning of drug trafficking is the most profound attack on America today. It is time to fully unleash intelligence tools on trafficking networks.

Without adequate intelligence, the magnitude of trafficking on the internet and “dark web” is unknown. Available information suggests it is significant, however. Federal drug enforcement has generally made electronic investigations a low priority, rejecting proposals to disrupt such markets by means of false sites, service denials, and cross-referencing data from multiple sources. All national security capacities are not yet deployed against opioid trafficking on the internet; this should change immediately. Past efforts to mount internet attacks by federal drug enforcement agencies have been crippled by ignorance, lack of experience, lack of vision, and complacency. The primary strategic goal should not just be to make future cases, but permanent market disruption; make it difficult to use the internet for trafficking by destroying the ability of buyers to connect with sellers.

Even the incomplete information on the opioid epidemic suggests that enforcement actions against pill mills and criminal physicians have reduced addiction and death driven by U.S. pharmaceutical sources. This has been a “supply control” success. Nonetheless, there is evidence of lower, but continued diversion. The pharmaceutical industry, the health insurance industry, and the federal government (the largest single health-care payer) all have information that should be brought together to identify and stop criminal diversion. The key point should be to focus attention on the biggest threat and its biggest components. There are regular reports of misuse of federal health-care funds to support addiction; some reports suggest areas where such practices are concentrated, which may serve as a starting point for enforcement actions.

Disrupting Networks Colombia is now back to producing more cocaine than it did prior to the dramatic drop in coca cultivation through Plan Colombia, which was largely due to the cooperation of former President Alvaro Uribe. Aside from a corresponding rise in cocaine overdose deaths, there are now reports of deaths resulting from cocaine-fentanyl mixtures. This deadly combination was seen about 10 years ago and may now be poised to cause harm on a greater scale. Much more fentanyl is available to Mexican traffickers carrying opioids and cocaine into the U.S. The Obama administration downplayed drug control in Colombia to pursue other goals. Colombian institutions are, again, put at risk by narcoterrorism. The previous security partnership needs reinvigoration, but the U.S. should make clear that the current trends are unacceptable for an ally and trading partner. A first step might be to have a government official or prominent private citizen warn the Colombian president that “if he doesn’t stop sending the cocaine, perhaps it is time to ask him to stop sending the coffee and the flowers.” Fortunately, former-president Uribe remains politically active and he knows how to attack the cocaine problem — Colombians would be wise to give him the job.

Contrary to the widespread belief that prescription diversion is driving the opioid crisis, available evidence indicates that most opioids and other illegal are produced outside the U.S. Further, these drugs seem to be arriving from Mexico. It is likely that most of them pass within six feet of a uniformed federal officer at our southern border. This is an unacceptable failure. Additional personnel will be useful, but the most important missing element is access to intelligence about trafficker operations. Enforcement agencies need to “see” into Mexico, and they need to see the structure of foreign and domestic trafficking networks.

Drug enforcement agencies and prosecutors need to treat individual cases as a means of network disruption, not as ends in themselves. In fact, it is likely that many smaller cases involving lesser charges that can be brought quickly will damage street-level trafficking networks more effectively than larger cases requiring longer investigations. In short, enforcement efforts need to become urgent and strategic.

Moreover, traffickers deserve stiff prison sentences. Such sentences are important leverage for turning traffickers against each other. Prison capacity for these death merchants must be made available to save lives. Enforcement pressure needs to be scaled to the threat.

Overall, drug enforcement management is insufficiently threat-based and seldom shifts resources rapidly to the greatest threats. While drug trafficking is killing more Americans than all other criminal activity combined, drug enforcement does not receive resources remotely proportional to the threat. The criminal-justice system is merely trying (and failing) to cope with the drug threat. It must come to see its mission as systematically destroying the threat — and plan, budget, and staff accordingly.

A Counter-Drug Strategy

An effective counter-drug strategy must attack at three points: source, distribution, and retail. If any one point of attack is particularly effective, it will substantially reduce use. It is probable, however, that the different points of attack will be effective in different degrees, while results will be cumulative and reinforcing.

At the retail level of street sales and use, the targets are whole communities, large geographic areas. Local and state efforts will be most important because there are insufficient federal resources to create the magnitude of the response required at the retail level. Local and state elements can be “enlisted” in a more unified national effort. That means encouraging and offering supplementary, strategic support with national personnel and resources.

Nevertheless, it may be critical to begin with willing state and local partners — those who commit their personnel and resources to the new strategy. These initial sites will also refine the elements of the strategy and demonstrate the effectiveness of more controversial components. Sites should be in priority areas and on as wide a scale as circumstances permit, but they should also be understood as points from which localized effort will flow outward — as ink spots on paper. Taking back individual communities in this way is an application of counterinsurgency concepts — it is also an established means of fighting epidemics.

At the retail level, the dealer and user are the center of gravity. Street-level enforcement needs to respond to opioid distribution as an immediate threat to life. Every sale can bring an overdose and every overdose can result in death. Each dealer is more like an active shooter than a house thief. Yet police response is frequently more focused on victim than on victimizer. The low-level dealer is also a low priority for enforcement personnel and prosecutors. This misguided policy is feeding the epidemic at the local level.

Accordingly, street-level enforcement should be reconceived in two ways. First, much greater urgency should be given to finding and incapacitating the dealer. Second, arresting users should be seen as a public health measure to screen for and treat addiction, as with the successful drug court model. Drug courts and diversion programs are already a major source of treatment admissions in the U.S. But this has been understood as a means of reducing the burden on the criminal-justice system. It should be seen as a necessary means of getting addicts who are in denial (as the vast majority are) into treatment and keeping them there through detoxification and stable sobriety. Street-level enforcement should be targeted to collapse dealer networks and should be tuned to become an intake channel for treatment.

All this will mean more arrests and more resources devoted to creating appropriate responses for users and dealers after arrest. Occasional, non-addicted users have a much lower probability of arrest at the point of drug sales because their purchases are infrequent. The risk to addicts is greater because they commonly need multiple doses per day. Thus, the normal pressure of street-level enforcement will tend to involve the larger dealers and the heavier users. Arrest and referral to treatment will save the lives of the addicted and even the arrest and warning of occasional users could be a potentially life-saving deterrent.

Such enforcement effort needs to be targeted, however. The obvious way to locate addicts and their dealers is to follow the reports of overdose victims. These reports provide a painful — but clear — geographic map of the epidemic. That map should be the basis for identifying priority areas nationally.

Currently, national information on overdose deaths lags by more than a year. This is unacceptable, and public health officials should be held accountable for creating a local, state, and national, real-time map of the epidemic. Preventing death means stopping traffickers and bringing effective outreach to the addicted in real time.

Finally, while attacking the source and border interdiction take the form of “outside-in” efforts, street enforcement and treatment involves an “inside-out” movement. Is this possible? Can individual communities make progress in the absence of full national success against the drug supply? Can a neighborhood-by-neighborhood strategy work?

Certainly, there is a risk of the epidemic moving back into improved areas from nearby trafficker enclaves. But, in fact, there are many law enforcement examples demonstrating that crime and drug trafficking is displaceable and containable with sustained, effective effort. The pace of the attack matters, and must run ahead of criminal replacement efforts. Local law enforcement agencies successfully contain certain crimes within specific geographic areas, and respond aggressively if criminals overstep boundaries. As in other matters, overwhelming the problem requires capable leadership with the authority, resources, and determination to prevail. For each part of the strategy above, it is important that one individual receive overall responsibility and that this individual understand that they will be removed in the absence of rapid progress. There is no accountability if there is no individual accountability.

The future of addiction in America rests on whether the supply of addictive drugs is dramatically reduced. The drug policy of the Trump administration will determine whether use and addiction are diminished or if they are more deeply embedded in American life — further expanding the underclass of addicted individuals living in misery and dying too young.

John P. Walters, chief operating officer of the Hudson Institute, was Director of National Drug Control Policy (2001–09).


Comment from Carla Lowe in the USA:

Hello from California,

A most informative article on the opioid epidemic from our friend John Walters. But I wonder how he would justify not addressing marijuana as a key link to this problem.

Perhaps he, like others far from California, is not aware of our 50,000 illegal marijuana grows, a 35 billion dollar business supplying 60% of the nation’s pot. And this is all in the name of so-called “medical” marijuana.

This situation will become significantly worse after January 1st when marijuana will be available just for fun for those over 21. Only Fools would think that kids’ use won’t rise in our formally golden state, now tragically turning green.

Please help us call on President Trump to enforce federal drug laws. It is absolutely our only hope in turning back this madness.

Carla Lowe

Comment from Dr. Stuart Reece in Australia

Yes John. The above is correct but only a partial analysis. Addiction is often based on the gateway drugs cannabis, alcohol and tobacco. Not only is this addictive basis not being addressed by current policies and practice but it is actively being sponsored by many US state Governments in the extremely false belief that reimbursement through taxation with compensate the community for the virtually endless destruction wrecked by drugs at all levels. Up till now the Feds have not addressed this issue either.

Worse still is what is being done to the next generation. It is not rocket science to observe that the children of these addicted patients are mostly not normal. This is very different to the rest of the community. Not only so but cannabis almost certainly underlies the international “gastroschisis epidemic” (where babies are born with their bowels hanging outside of their body) which no one is talking about, and is commonest in the youngest parents – because they smoke the most weed.

If we don’t start telling the truth about addiction in its totality the web of lies will engulf and enslave us all. The hardest hit will be the children and the poor. And, just as has happened in every single community across the globe in developed and developing nations, social decay and distress will become rampant and profligate.

Freedom begins with the truth – and showing a way out of our seductive mess – and breaking the spell of those who cannot wait to cash in on the collapse of the West.

[As illustrated in the Obituary of pioneering FDA scientist, Frances Oldham Kelsey in The Washington Post 8/8/15.]


Edited excerpts with commentary follow: The full article is available at the following link:

Frances Oldham Kelsey, FDA scientist who kept thalidomide off U.S. market, dies at 101

In the annals of modern medicine, it was a horror story of international scope: thousands of babies dead in the womb and at least 10,000 others in 46 countries born with severe deformities… The cause, scientists discovered by late 1961, was thalidomide, a drug that, during four years of commercial sales… was marketed to pregnant women as a miracle cure for morning sickness and insomnia.

The tragedy was largely averted in the United States, with much credit due to Frances Oldham Kelsey, a medical officer at the Food and Drug Administration in Washington, who raised concerns about thalidomide before its effects were conclusively known. For a critical 19-month period, she fastidiously blocked its approval while drug company officials maligned her as a bureaucratic nitpicker…

The global thalidomide calamity precipitated legislation…in October 1962 that substantially strengthened the FDA’s authority over drug testing. The new regulations, still in force, required pharmaceutical companies to conduct phased clinical trials, obtain informed consent from participants in drug testing, and warn the FDA of adverse effects, and granted the FDA with important controls over prescription-drug advertising…

In Washington, (Kelsey) joined a corps of reform-minded scientists who, although not yet empowered by the 1962 law that required affirmative FDA approval of any new drug, demanded strong evidence of effectiveness before giving their imprimatur.

At the time, a drug could go on the market 60 days after the manufacturer filed an application with the FDA… Meanwhile, pharmaceutical drug companies commonly supplied doctors with new drugs and encouraged them to test the product on patients, an uncontrolled and dangerous practice that relied almost entirely on anecdotal evidence. NICAP note: Much like today’s treatment of “medical marijuana.”

Thalidomide, which was widely marketed as a sedative as well as a treatment for pregnancy-related nausea during the first trimester of pregnancy, had proven wildly popular in Europe and a boon for its German manufacturer. NICAP note: Much like pro-pot propaganda today has created “wildly popular” support among a fact-deprived public, and boom-times for the Big Marijuana industry.

By the fall of 1960, a Cincinnati-based drug company, William S. Merrell, had licensed the drug and began to distribute it under the trade name Kevadon to 1,200 U.S. doctors in advance of what executives anticipated would be its quick approval by the FDA. NICAP note: Today, illegal drug companies produce and market hundreds of uncontrolled marijuana products and distribute them to corrupt doctors willing to “recommend” such unapproved marijuana “medicines.”

The Merrell application landed on Dr. Kelsey’s desk within weeks of her arrival at the agency…Immediately the application alarmed her. Despite what she called the company’s “quite fulsome” claims, the absorption and toxicity studies were so incomplete as to be almost meaningless. NICAP note: Much like the “quite fulsome claims” for pot medicines are legion today, as is the dearth of valid

studies verifying those claims. For the true documented scientific case against smoking weed as “medicine” see “The DEA Position on Marijuana” at link:

Dr. Kelsey rejected the application numerous times and requested more data. Merrell representatives, who had large potential profits riding on the application, began to complain to her bosses and show up at her office, with respected clinical investigators in tow, to protest the hold-up. NICAP note: Much as the Pot Legalization Lobbyists and ACLU show up at any attempts to limit sales and use of marijuana—and for the same reason: “large potential profits.”

Another reason for her concern was that the company had apparently done no studies on pregnant animals. At the time, a prevailing view among doctors held that the placental barrier protected the fetus from (harms from) what Dr. Kelsey once called “the indiscretions of the mother,” such as abuse of alcohol, tobacco or illegal drugs. Earlier in her career, however, she had investigated the ways in which drugs did in fact pass through the placenta from mother to baby… NICAP note: Today there are numerous valid studies showing that both mental and physical defects in children can be caused by a pregnant mother’s use of marijuana and other illegal drugs.

While Dr. Kelsey stood her ground on Kevadon, infant deaths and deformities were occurring at an alarming rate in places where thalidomide had been sold… NICAP note: Today, drug addiction, drug-related permanent disabilities and overdose deaths are “occurring at an alarming rate,” nearly all of which began with a shared joint of marijuana from a schoolmate or friend.

Dr. Kelsey might have remained an anonymous bureaucrat if not for a (previous) front-page story in The Post. The newspaper had received a tip about her from staffers working for Sen. Estes Kefauver, a Tennessee Democrat who had been stalled in his years-long battle with the pharmaceutical industry to bolster the country’s drug laws.

The coverage of Dr. Kelsey gave her — and Kefauver — a lift. As thousands of grateful letters flowed in to Dr. Kelsey from the public, the proposed legislation became hard to ignore or to water down. The new law was widely known as the Kefauver-Harris Amendments.

“She had a huge effect on the regulations adopted in the 1960s to help create the modern clinical trial system,” said Daniel Carpenter, a professor of government at Harvard University and the author of “Reputation and Power,” a definitive history of the FDA. “She may have had a bigger effect after thalidomide than before.”…

For decades, Dr. Kelsey played a critical role at the agency in enforcing federal regulations for drug development — protocols that were credited with forcing more rigorous standards around the world…

In Chicago, she helped Geiling investigate the 107 deaths that occurred nationwide in 1937 from the newly marketed liquid form of sulfanilamide, a synthetic antibacterial drug used to treat streptococcal infections. In tablet form, it had been heralded as a wonder-drug of the age, but it tasted unpleasant.

Because the drug was not soluble in water or alcohol, the chief chemist of its manufacturer, S.E. Massengill Co. of Bristol, Tenn., dissolved the sulfanilamide with an industrial substance that was a chemical relative of antifreeze. He then added cherry flavoring and pink coloring to remedy the taste and appearance.

Massengill rushed the new elixir to market without adequately testing its safety. Many who took the medicine — including a high number of children — suffered an agonizing death.

At the time, the FDA’s chief mandate, stemming from an obsolete 1906 law, was food safety. At the agency’s request, Geiling joined the Elixir Sulfanilamide investigation and put Dr. Kelsey to work on animal testing of the drug. She recalled observing rats as they “shriveled up and died.”

Amid national outrage over Elixir Sulfanilamide, Congress passed the Federal Food, Drug and Cosmetic Act of 1938, legislation that vastly expanded federal regulatory oversight over drugs and set a new benchmark for drug safety before marketing… NICAP note: Today, pro-pot politicians are rushing headlong into a massive campaign to block that objective FDA approval process for drugs and instead substitute a money-driven political process that will create a new “Thalidomide” out of marijuana and destroy many more American lives and futures.

Babies who suffered from the effects of thalidomide and survived grew up with a range of impairments. Some required lifelong home care… NICAP note: Is this to be the legacy of current politicians whose corrupt abandonment of the nation’s premier drug approval system will create generations of children “who suffered from the effects of POLITICAL APPROVED “medical” marijuana and survived with a range of impairments, some requiring lifelong home care?”


Source: National Institute of Citizen Anti-drug Policy (NICAP)

NICAP COMMENTARY BY: DeForest Rathbone, Chairman.NICAP 8/9/15, Rev. 8/26/15

Louise Stanger is a speaker, educator, licensed clinician, social worker, certified daring way facilitator and interventionist who uses an invitational intervention approach to work with complicated mental health, substance abuse, chronic pain and process addiction clients.

In the mid-to-late 2000s, Red Bull, an energy drink high on energy and low on nutritional value, made its North American debut with the famous “Red Bull gives you wings” campaign. The tag line, a nod to the “pick me up” qualities it gives to drinkers of the product, set the stage for the way in which teens and young adults relate to the nascent product category.

In essence, advertising birthed energy drinks as the way to find uplift, fight fatigue, and give that extra boost. Regrettably, no one was paying attention to the drinks’ negative side effects.

Red Bull has since spawned its own grocery store aisle of knock-offs – Monster, Rockstar, Full Throttle, Amp – to name a few. In 2016, U.S. retail sales of energy drinks topped $11 billion (Red Bull generated $5.1B in revenue in 2010). By comparison, that number is roughly how much Hollywood makes on movie tickets in a year.

Paradoxically, energy drinks’ meteoric rise in popularity and consumption has coincided with major health risks and the onslaught of addiction to other harmful substances. How did a drink that tastes like cough syrup land with such a huge impact?

Long before Red Bull “gave us wings,” Chaleo Yoovidhya, a Southeast Asian pharmacist, developed energy “tonics” aimed at labourers and truck drivers in the 1960s, according to The Dragonfly Effect, a book that looks at successful branding campaigns for products like energy drinks.

Then in the 1980s, an Austrian billionaire businessman named Dietrich Mateschitz discovered the tonics and married them with innovative guerrilla marketing to launch in North America. The aim was to put cans of Red Bull, the syrupy concoction of sugar and caffeine, in the hands of their target market: young adult males and teens who are oblivious to the drinks’ ingredients. The ad campaign struck like a lightning bolt and a multibillion dollar industry took ro

The key ingredient in energy drinks that gives the consumer energizing effects is caffeine. Though caffeine, found in commonly consumed drinks like coffee, tea and sodas, isn’t outright bad for you, the serving size, frequency and consumption patterns are cause for alarm.

Most energy drinks contain 70-200 milligrams of caffeine; for example, Rockstar 2X has 250 mg per 12 ounces, a 12 ounce can of Red Bull has 111 mg, and a 5-Hour Energy shot, a variation of the energy drink craze, is a whopping 207 mg of caffeine in just 2 ounces.

To put these concentration levels into perspective, the American Academy of Paediatrics maintains adolescents must not consume more than 100 mg of caffeine per day (it’s 500 mg for adults).

And more alarming than the serving sizes are the rates at which teens consume energy drinks. When young adults and teenagers get with their friends, they’ll consume 3-4 drinks in a short period of time or even chug (i.e. “shotgun”) whole cans in an instant. Despite this binge-style consumption, teens remain oblivious to the high caffeine content and unaware of the effects energy drinks have on the body. Other studies and researchers have observed energy drinks become the chaser for alcohol consumption in certain situations.

At these high levels of consumption, the Journal of the American Medical Association (JAMA) reports serious health risks associated with energy drinks. These include:

· Increased heart rate, irregularities and palpitations

· Increased blood pressure

· Sleep disturbances, insomnia

· Diuresis or increased urine production

· Hyperglycaemia (increased blood sugar), due to the high levels of sugar content, which may be harmful for people at risk for diabetes or already diabetic

Perhaps most dangerous are the serious side effects caused when energy drinks are consumed with alcohol. According to University Health News Daily, “the dangers of energy drinks mixed with alcohol are related to reduced sensation of intoxication and impaired judgment.”

Here’s how it goes: the user gets a burst of energy and alertness (increased heart rate and dilated blood vessels) from the high content of caffeine in the energy drink, prompting the person to feel less intoxicated and therefore drinking more alcohol and putting themselves at risk for alcohol poisoning and severely impaired judgment.

Teens, young adults and college-aged students who play drinking games or drink in high-risk environments such as parties, boating, swimming, beach days, etc. put themselves at greater risk of injury and bodily harm with these combinations.

In addition to high-risk environments and dangerous situations, energy drink and alcohol mixing lowers inhibitions, making room for engaging in high-risk behaviours such as unwanted sexual encounters, driving vehicles, boats and jet skis under the influence, and other behaviours that may lead to hospitalization or encounters with law enforcement.

We need look no further than the case of Four Loko, an energy drink that comes ready made with alcohol and caffeine for proof that mixing the two is dangerous. The drink gets its name from its four signature ingredients: alcohol, caffeine, taurine and guarana.

According to a report in The Week, the company that produced Four Loko, Phusion Projects of Chicago aka Drink Four Brewing Company, came under ethical fire for marketing to adolescents under the age of 21 (as most energy drink companies do – though this was the first to pre-mix alcohol and caffeine).

Four Loko also caught fire with college students and it didn’t take long for reports of blackouts and other alcohol overdose related incidents to take hold of its users. University campuses across the nation including the University of Rhode Island, Central Washington University and Worcester State University began to ban the beverage and companies with similar beverages have since reformulated its drinks and reduced its marketing toward underage students and young adults. In 2014, the company reached a settlement to stop production and distribution of Four Loko in the United States, according to a report in The Atlantic.

Moreover, the University of Maryland’s research on the topic has found a link between high energy drink consumption and developing addiction to other harmful substances later on. Researchers looked at the health and risk-taking habits of 1,099 college students over a four year period.

Their analysis of the study found that participants who consumed highly caffeinated drinks (energy drinks, sodas, etc.) are more likely to develop an addiction to cocaine, alcohol, or other substances when compared to students who did not consume such beverages. “The results suggest that energy drink users might be at heightened risk for other substance use, particularly stimulants,” says Amelia Arria, an associate professor and lead author of the study.

New research from Purdue University found that mixing alcohol and highly caffeinated drinks could significantly change the brain activity of a teenager. Dr. Richard van Rijn, the lead researcher, says “it seems the two substances (energy drinks and alcohol) together push [teenagers] over a limit that causes changes in their behaviour and changes the neurochemistry in their brains.”

Although energy drinks are regulated by the Food and Drug Administration, little oversight is given to labelling cans and packages with the risks related to consumption. As an educator, I believe the FDA must first do a better job of labelling. Just as cigarettes and alcohol have warning labels, so too must energy drinks.

Grocery stores should move energy drink products to areas where alcohol is sold – away from wandering young eyes. Public health discussions in high schools and middle schools need to take place. Youth and young adult sports teams must reconsider energy drink sponsorships and greater oversight concerning marketing practices toward under-aged youth.

As a young adult, if you do choose to consume these beverages, be sure to read the labels for serving sizes, caffeine content, and try to avoid mixing with alcohol. Parents, teachers, sports coaches, and community leaders must communicate to teenagers and young adults the harm energy drinks may cause. Together we must work together to be educated and informed against aggressive advertising to keep our teens and young adults healthy and engaged.

To learn more about Louise Stanger and her interventions and other resources, visit her website.

Source:    6th Sept.2017




New Hampshire has the second-highest rate of drug overdoses in the country. Eric Adams in Laconia (population 16,000) has been assigned one task to stop them.

Eric Adams is a handsome, clean-shaven man, almost 41, with a booming voice and hair clipped short enough for the military, which once was an ambition of his. After high school, he tried to join the Marines but was turned away because of his asthma. He needed three different inhalers then, plus injections. Today he has outgrown the problem. He is 5-foot-10, weighs 215 pounds and can dead lift 350.

Adams has worked in law enforcement for almost two decades.

He began as a guard at the New Hampshire state prison, where he asked to work in maximum security, then left to become a police officer in Tilton and was soon recommended for the Drug Task Force, a statewide operation against narcotics dealers. Adams grew his hair long and arranged undercover buys, a Glock 27 concealed in a holster beneath his jeans. Later he would return wearing a bulletproof vest, surrounded by fellow officers, to kick in the door with his pistol drawn.

Eric Adams in his office at the Laconia Police Department.
CreditNatalie Keyssar for The New York Times

Laconia, where Adams works today, is a former mill town in central New Hampshire surrounded by lakes. In midwinter, Laconia is home to 16,000 residents, though in summer that number swells to 30,000. Those are gleaming, sun-dappled days. Then winter falls on New England like a gavel.

A blight in the region is especially acute. Of the 13 states with the highest death rates from drug overdoses, five are in New England. New Hampshire in particular has more per capita overdose deaths than anywhere but West Virginia. In 2012, the state had 163 such deaths, a majority of them (as elsewhere in the country) from heroin and prescription opioids. In 2015, the state had nearly 500 deaths, the most in its history. In Manchester, its largest city, the police seized more than 27,000 grams of heroin that year, up from 1,314 grams a year earlier. In certain neighborhoods, a single dose of heroin can cost less than a six pack of Budweiser. Waiting lists for treatment programs stretch as long as eight weeks.

Those years spent guarding prisoners, and later kicking down doors, changed Adams’s thinking. So many of the drug users he saw had made one bad decision and then became chained to it, Adams realized. Or they had begun on a valid prescription for pain medication, after an injury, and then grew addicted. When refills grew scarce, they turned to alternatives. Many were no longer even using to get high, only to avoid the agony of withdrawal.

They were teenaged, middle-aged and elderly; they were students, bankers and grocery clerks. They were businesswomen with six-figure salaries and homeless men with shopping carts. Arresting a person like this did no good, because there was always another to replace him or her — and regardless, any jail sentence had limits. Afterward, Adams saw, everyone landed right back where they started.

‘‘We’re not getting anywhere,’’ he told his chief, Christopher Adams (the two men are not related), and his lieutenant. It turned out that they had already reached a similar conclusion. Until recently, Christopher Adams told me, he couldn’t recall ever hearing of a heroin case. ‘‘Now it’s every day,’’ he said. ‘‘It’s a majority. Not just in Laconia. It’s all over.’’ He and his lieutenant sat down to consider what their department might do. It seemed that there were three conceivable approaches to a drug problem: prevention, enforcement and treatment. To accomplish all three would mean regarding drug users, and misusers, as not only criminals. They were also customers who were being targeted and sold to; they were also victims who needed medical treatment. To coordinate all those approaches would require a particular sort of officer.

In September 2014, Eric Adams became the first person in New England — to his knowledge, the only person in the country — whose job title is prevention, enforcement and treatment coordinator. ‘‘I never thought I’d be doing something like this,’’ he told me. ‘‘I learned fast.’’ The department printed him new business cards: ‘‘The Laconia Police Department recognizes that substance misuse is a disease,’’ they read. ‘‘We understand you can’t fight this alone.’’ On the reverse, Adams’s cell phone number and email address were listed. He distributed these to every officer on patrol and answered his phone any time it rang, seven days a week. Strangers called him at 3 a.m., and Adams spoke with them for hours.

The department assigned him an unmarked Crown Victoria, and in it he followed the blips and squawks of a police scanner, driving to the scene of any overdose it reported and introducing himself to the victim, as well as any friends or family he could locate. Residents like these often shrank from the police or stiffened defensively. But when Adams told them that they weren’t under arrest, that he had only come to help, they seemed to sag in relief.

People who work with addicts generally agree that this moment, immediately after an overdose, offers the greatest chance to sway an addict, when he or she feels most vulnerable. ‘‘You’re at a crossroads right then and there,’’ a local paramedic told me. If an addict agreed to Adams’s help, Adams drove him to a treatment facility, sat beside him in waiting rooms, ferried his parents or siblings to visit him there or at the jail or hospital. He added the names of everyone he encountered to a spreadsheet, and he kept in touch even with those who relapsed. Were they feeling safe? Attending support meetings? Did they have a job? A place to sleep?

In the nearly three years since, as overdose rates have climbed across New Hampshire, those in Laconia have fallen. In 2014, the year Adams began, the town had 10 opioid fatalities. In 2016, the number was five. Fifty-one of its residents volunteered for treatment last year, up from 46 a year before and 14 a year before that. The county as a whole, Belknap, had fewer opioid-related emergency-room visits than any other New Hampshire county but one. Of the 204 addicts Adams has crossed paths with, 123 of them, or 60 percent, have agreed to keep in touch with him. Adams calls them at least weekly. Ninety-two have entered clinical treatment. Eighty-four, or just over 40 percent of all those he has met, are in recovery, having kept sober for two months or longer. Zero have died.

On most mornings, Adams arrives at his office well before 9 to answer email. By then, his phone is already chiming. ‘‘I thought when I got this position: Monday through Friday, day shifts, weekends off. I’m going to see my kids and wife more,’’ Adams said, laughing. ‘‘That’s not the case.’’ Pinned to the walls of his office, a windowless room on the second floor of the department, are pamphlets and resource guides for homelessness, peer-support groups and addiction hotlines, as well as a dry-erase board listing drug-treatment centers statewide. In December, when I visited one morning, the floor was cluttered with toys for local families in preparation for Christmas: doll sets, wireless headphones, a pillow the color of sorbet.

As soon as he began the job, Adams researched what social-service organizations the region had to offer and drove to their offices to introduce himself. A few employees at places like these knew one another from previous referrals, but many didn’t, so Adams went about acquainting them. At health conferences, he arrived to the quizzical frowns of social workers and realized that, of some 200 attendees, he was the only police officer. A network gradually sprouted around him. One morning in December, his first call was from Daisy Pierce, the director of a non-profit organization whose doors opened two weeks earlier; Adams is its chairman. Might Adams help her get a teenager into the Farnum Center, a treatment facility in Manchester, an hour south? Adams dialled a pastor he knew, who phoned a recovery coach. ‘‘For the first year and a half, I was the only transportation around here,’’ he told me when he hung up. ‘‘I would drive people down to Farnum all the time.’’

Next, Adams turned to a matter unresolved from the day before: a woman the county prosecutor had phoned about, asking if Adams could find her housing. Until recently, the woman had been staying at a homeless shelter, but that stay had ended and, because she was on probation, with nowhere else to sleep, Adams’s fellow officers had taken her to jail, though they could hold her for only one night. She would be released that day, still with nowhere else to stay. The next 48 hours would be critical, Adams felt. Here was a person who wanted to get sober but for whom the local authorities had little to offer.

From his desk, he dialled a treatment center, then various landlords and non-profit directors he knew. ‘‘Hi, this is Eric Adams over at the Laconia Police Department. I’m calling to see if you have anything. . . . ’’ Then he tried calling back the county prosecutor, tapping his fingers impatiently as the phone rang. When no one answered, he pulled a cellphone from his pocket and looked through it for numbers to dial on his office phone, while scribbling notes on two different legal pads. A cup from Dunkin’ Donuts sat on his desk, but he hadn’t had time to sip from it. After a half-dozen calls, he hung up the phone and sighed. ‘‘This is the biggest problem in the area,’’ he said. ‘‘It’s housing. There are only a handful of landlords that own so many properties.’’ Adams tried to be up front with landlords, and he didn’t blame them for sometimes rebuffing him, because they had to look out for their other tenants. But it meant limited options for a woman like the one he was trying to help.

He swivelled toward his computer and began scrolling through notes. Finding nothing, he rubbed his eyes with frustration, propped his elbows onto his desk and rested his chin on his hands to think. ‘‘Oh! Let me try — I haven’t talked with her in a while.’’ He dialled another number. ‘‘Hi, this is Eric Adams over at the Laconia Police Department. . . . ’’ A moment later, he hung up. ‘‘All right, this is the last one I can think of.’’ He dialled again. ‘‘I was wondering if you had any rentals available for a female. Oh, really? That’d be great.’’ He recited his email address. ‘‘Thank you!’’

Good news?  Adams shook his head. ‘‘Not for a couple weeks.’’ He stood, pushing back his chair, and cursed. Out of the office he strode to make a lap around the building to clear his head, then returned and looked at the clock — 9:40 a.m. He had a meeting at 10 at the local branch of the Bank of New Hampshire to help Pierce, the nonprofit director, apply for a new line of credit for their organization. Halfway to the door, he backtracked to pluck the Dunkin’ Donuts cup from his desk and sipped. ‘‘My coffee’s cold.’’

On a glass table in the bank lobby lay that morning’s copy of The Laconia Daily Sun. ‘‘Drug Sweep in Laconia Results in 17 Arrests,’’ its front page read. Headlines like that had become increasingly common, especially as the drugs themselves changed — first to opiates, then to opioids. They weren’t the same thing, Adams had learned. Opiates are derived from nature, and there are only so many, drugs like morphine, heroin and codeine. By contrast, opioids — though the word is now often used as an umbrella term for all these substances — technically means synthetic drugs like Vicodin, Percocet, fentanyl and OxyContin, all of which were invented in a laboratory.

This is why detectives sometimes encountered new opioids that were 20, 50, 100 times as potent as heroin. In a lab, you can do nearly anything. A dealer, even if he or she knows the difference, rarely bothers labelling, so a dose of so-called heroin might include fractions of nearly anything — meaning, of course, that the potency might be nearly anything. Overdoses happen not just when a person knowingly ingests a large dose but also when he or she ingests a dose of unknown composition.

After the meeting at the bank, Adams’s phone rang, and he vanished briefly. The call was from a woman whose son was arrested on charges of dealing meth. She wanted an intervention and hoped Adams might help. Steering toward the Belknap County jail, past homes spangled with Christmas lights, Adams admitted that he felt wary. He had already met this young man, who wanted nothing to do with him. Still, Adams would try. He never knew when an addict might begin saying ‘‘yes’’ to him. Sometimes this happened quickly: Adams’s phone would ring, and it was someone he met the previous day. ‘‘I’m exhausted,’’ the person would confess. Others waited a year or longer. All that time, they had hung onto his card. ‘‘I think I’m ready now,’’ they said.

Occasionally an addict used similar words even in rebuffing him — ‘‘I don’t think I’m ready yet’’ — a phrase that implicitly acknowledged a problem even as he or she denied one. It was the kind of sign Adams kept on the lookout for. Possibly this moment had come for the young man in jail.

When we arrived, Adams hustled through the drably carpeted lobby, hardly slowing before a receptionist and a guard waved him inside. A half-hour later, he returned, his face tight with frustration, and strode past me to the car without speaking. ‘‘He doesn’t have a problem,’’ he told me. ‘‘That’s what he said. He doesn’t have a problem.’’

Inside, he told me, guards had brought the young man from his cell into a windowed conference room, where he recognized Adams, as Adams predicted. ‘‘You know why I’m here,’’ Adams began gently.  ‘‘You’re trying to be nosy,’’ the man replied.

‘‘If you want to think of it that way, that’s fine.’’ Adams glanced at the young man’s file and explained that the man’s mother had called. ‘‘So I wanted to talk to you a little bit. This is an opportunity for you to get some help.’’ The young man went silent. ‘‘I mean, you got arrested,’’ Adams added, gesturing toward the file.  The man told him that he didn’t do the stuff, just sold it. He didn’t need help.

‘‘O.K.,’’ Adams told him, crossing his arms and leaning forward. Was the young man on any weight-loss program, then? ‘‘Because when I saw you before, to now, you’ve lost a lot of weight.’’ He nodded toward the young man, who was twitching uncomfortably in his chair. ‘‘And you’re all over the place, just sitting there.’’

When the man told Adams he was innocent, Adams reminded him that he was always available and slid him another one of his cards. Adams wished him well, then he asked guards to briefly fetch the woman they were holding overnight — the one for whom Adams was searching for housing — to check in and promise that he was trying.

Even as Adams nosed the Crown Vic out of the parking lot, he couldn’t get the episode out of his head. ‘‘Why won’t you just say, ‘I need this’?’’ he asked aloud, thinking of the young man. ‘‘Your life is going this way. You’ve been arrested. You’re homeless. It’s all drug-related.’’ He sighed. ‘‘The thing I had the hardest time learning was you’re not going to save everyone. That was very hard for me to accept.’’

A common sentiment among the police was that officers interacted with just 5 percent or so of the residents they served. In certain communities, that fraction was smaller. Laconia wasn’t a large town. ‘‘You think, mathematically,’’ Adams began, before pausing, ‘‘why can’t I? Why can’t I fix this?’’

For several miles he steered quietly, past muddied snowbanks. ‘‘It bothers me, but I’ve done what I can do right now. I can’t force him to want help.’’ He turned into the lot of the department and slowed into a parking spot.

‘‘Is there such a thing as an addict you have no sympathy for?’’ I wondered.  Adams considered this, letting the engine idle, and dropped his hands into his lap. Eleven seconds passed in silence. ‘‘I don’t think so,’’ he said finally. ‘‘There are reasons they are the way they are.’’

A kit with Narcan, a nasal spray that blocks the effect of opioids on the central nervous system. CreditNatalie Keyssar for The New York Times

Adams could list, from memory, addicts who had opened their lives to him, had volunteered for treatment, had wept in relief and gratitude. Already I had met two young adults who were newly in recovery and partly credited Adams for the lives they had regained. But those weren’t the names that tormented him.

Inside his office, he noticed two new voice-mail messages. The first was from a woman who read of Adams in the newspaper. ‘‘If you could tell me what to do? I’m more than willing to do whatever I need.’’ Adams scribbled something on a legal pad, then played the second voice mail. The same voice filled the room again, but now it broke into tears. Could Adams please tell her what to do?

Adams jotted another note, then checked his watch. Just past noon. Because he knew the work schedule of the mother of the young man he visited in jail, he knew she would be off soon and expecting his call. ‘‘She’s not going to be happy,’’ he said, mostly to himself. Rubbing his forehead, he sat down and dialed.

In so many towns all across the country, it is difficult to talk about an issue like heroin, not only because there is a stigma or because people worry about sounding impolite, but because everyone calibrates differently, based on neighbors and co-workers they see all day, how much of a problem it is or whether it is a problem at all. There were towns near Laconia — diplomatically, Adams declined to name them — that denied they had any drug crisis, even as the numbers they had showed otherwise. When presented with those numbers, some officials found alternative explanations.

Those were residents from other towns who just happened to cross the border, they argued. This reasoning just contributed to the problem, Adams said. Between 2004 and 2013, the number of New Hampshire residents receiving state-funded treatment for heroin addiction climbed by 90 percent. The number receiving treatment for prescription-opiate abuse climbed by 500 percent. But in terms of availability of beds, New Hampshire ranks second to last in New England in access to drug-treatment programs, ahead of only Vermont. The number who still need treatment is probably much higher. In October 2014, New Hampshire became the second-to-last state in the country to begin a prescription-drug-monitoring program, leaving only Missouri without one.

Engler, who was cautious and businesslike, with slicked hair and a graying goatee, had been mayor for three years, though he had lived in Laconia for almost 17 and owned The Laconia Daily Sun. Over his dress shirt he wore a fleece vest embroidered with the paper’s logo. Engler referred to what was happening in Laconia as ‘‘this so-called heroin epidemic,’’ his tone melodramatic, raising his hands defensively above his head.

‘‘We’re the county seat,’’ Engler told me. ‘‘We’re also the home of the regional hospital. Towns in New Hampshire are extremely close together. I think we tend to get credit for more things than are directly attributable to our residents.’’ Though he thought highly of Eric Adams, he also felt sceptical that heroin deserved to be considered an epidemic, regardless of the statistics. ‘‘When I go to a Rotary Club meeting, I don’t hear people sitting around talking about, ‘Woe is us, everybody’s dying of heroin.’ ’’

Might that be because, in a setting like the Rotary Club, heroin was not a topic of polite conversation?

‘‘There could be something to that,’’ Engler admitted. Still, an overdose death was an overdose death — it would appear in the news that way, and Engler would have heard of it. ‘‘I don’t believe there has been a huge, communitywide reaction to this. There’s not 100 people showing up at City Council meetings saying: ‘You have to do something about this. This is terrible.’ The papers aren’t full of letters to the editor. Not at all. And I think there’s a reason for that. The reason for that is’’ — Engler paused and crossed his arms — ‘‘since we have been in the so-called heroin epidemic in New Hampshire, I don’t believe there has been an instance in the Lakes Region, in Belknap County, where we have had a tragic story involving the son or daughter of someone from a prominent family. All it takes is one, usually. Somebody in Londonderry, some girl who was valedictorian of her class, her dad was a doctor or a lawyer or something like that, overdoses and dies, and suddenly it’s a crisis to everyone in town.’’

That very week, I told Engler, while tagging along with Adams for a meeting at the high school, I’d heard teachers mention a current student, a well-liked senior athlete, a team captain, whose sister had struggled with addiction and who had been open about the experience. Another member of the same graduating class, a girl whose grades ranked her in the top 10, had been walking with a friend in 2012 when a local mother, high while driving to pick up her own child from the middle school, swerved and struck them on the sidewalk. The girl survived. Her friend was killed.

The mayor was unmoved. ‘‘That was oxycodone,’’ Engler said dismissively. ‘‘Here, locally, the heroin epidemic, whatever you want to call it, has not crossed over in any obvious way from the underclass to the middle, middle–upper class.’’

Chadwick Boucher, a former addict and an early client of Eric Adams’s, with his work truck in his father’s yard. CreditNatalie Keyssar for The New York Times

Later that week, another prospective client phoned Adams. ‘‘I’m at wits’ end,’’ the man said. For the woman who needed housing, Adams helped track down a relative, at whose home she could stay until an apartment opened. On Friday evening, two more residents overdosed. Adams intended to visit them. Whether either one would accept Adams’s card, would call him, would enter treatment, would achieve recovery, would some day relapse, Adams couldn’t predict. There were no guarantees in this sort of work.

Early in his tenure, Adams made a presentation to ‘‘some prominent people in the community’’ — he didn’t want to name anyone — and afterward, as much of the room applauded, a man approached to shake Adams’s hand. As he reached out, the man said: ‘‘It’s a really good job you’re doing. I think it’s great. But my opinion is, if they stick a needle in their arm, they should die.’’

‘‘I’m sorry you feel that way,’’ Adams said, startled. ‘‘I’d hope you would feel differently if it was your own family member.’’  But the man shook his head. ‘‘That will never happen.’’

This sort of thing happened all the time when Adams began. Today it happened far less frequently. So many others had grown into Adams’s approach: fellow officers, downtown business owners, the captain at the Belknap County jail. Police officers from around New England and even farther away had phoned or travelled to Laconia to learn what Adams was doing, and whether the model could be replicated. Other towns, independently, had been pressed by the crisis to conceive approaches of their own. Manchester had turned its firehouses into safe stations. Gloucester, across the border in Massachusetts, had a network of community volunteers.

A city as large as Philadelphia or Boston could sensibly implement a PET approach too, Adams’s supervisors argued; a community like that would simply need more than one officer, with each assigned to a geographical area. But the shift this required would be profound, asking departments that for so long had thought mainly of enforcement to think differently. In Adams’s daily work, it was unavoidable that certain values competed. A client might divulge a crime to him, and he would be forced to interrupt her to give a Miranda warning. ‘‘If there is a crime, that individual needs to be held accountable,’’ he said. ‘‘But this is where our prosecutor, our judges, come into play.’’ Some attorneys had expressed discomfort with him and had insisted on being present when he met their clients. ‘‘I’m totally fine with that,’’ he said, ‘‘because it’s an opportunity for me to educate the attorney, to let them know what I do, how I do it, what the processes are.’’ In a role so complicated, with so much at stake, clearly it was vital that the right officer held the job.

In an empty conference room on the first floor of the department, I met a young man named Chadwick Boucher, an early client of Adams’s. The two men hugged when they saw each other, and then Adams disappeared upstairs to make calls while Boucher and I spoke. He was 27, though he had the calm demeanour of someone two or three times as old. As early as middle school, Boucher began sneaking his parents’ liquor, partly to fit in with older boys he admired, he told me. Soon he added marijuana. He played hockey then, and played well — invitations came from showcases in Boston and scouts from Division I colleges, including the University of New Hampshire, a national power. Instead, Boucher quit. It was too much pressure. He finished high school and moved in with a friend, who introduced him to OxyContin.

What followed was difficult to align into a neat chronology. He bounced from one friend’s apartment to another, from Oxy to Percocet and finally, when pills grew scarce, to heroin. There was a criminal distribution charge, probation, two treatment programs that he abandoned, feeling as though he didn’t belong. There were short-term jobs tending bar or waiting tables, collecting pay-checks before inevitably being fired. Suddenly he was high behind the wheel of his father’s Cutlass — not in the road, but in a driveway — startling awake to the police rapping on his window. Then he was at the Laconia police station, in a room with a plainclothes officer named Eric Adams.

‘‘He opened his arms to me,’’ Boucher recalled. It had felt bizarre, sharing the truth with a cop. But things had changed so quickly. Most of his family had stopped returning his calls, and all his friends had vanished. The only people around him now were strangers who shared his addiction, and he didn’t like or trust them. The difference in meeting someone like Adams was obvious. ‘‘He cares about my well-being,’’ Boucher said. ‘‘I needed that.’’

Adams wanted him to call every day, so Boucher called every day. Then every week. He entered another treatment program, and this time he graduated. He was now nearing a year sober. He owned a business and was caught up on his bills. He lived up the road in an apartment and had friends again, some of whom were in recovery, too. They made a point to talk openly about it, to keep an eye out for one another. Some he referred to Adams. He knew that recovery demanded his full attention, that it probably always would. If he lost anything else in his life — an apartment, a business — he lost that one thing only and could do without it. If he lost his recovery, he would lose everything, all at once.

I asked Boucher how he preferred to be named in this article — by only ‘‘Chad’’? Or would he prefer anonymity? But he shook his head. It was important to him to be honest about who he was. He hoped this would send a message to other addicts and to those who encountered them. ‘‘It’s important that people know there’s a way out.’’ Recovery from addiction was an achievable thing and, having discovered this fact, having discovered Eric Adams, Boucher intended to share it. The news might save lives. He knew it was possible that a business client might discover his unflattering past, that he might lose an account or two. ‘‘I’ve come way too far for that,’’ he said.





LOWELL, Mass. — They hide in weeds along hiking trails and in playground grass. They wash into rivers and float downstream to land on beaches. They pepper baseball dugouts, sidewalks and streets. Syringes left by drug users amid the heroin crisis are turning up everywhere.

In Portland, Maine, officials have collected more than 700 needles so far this year, putting them on track to handily exceed the nearly 900 gathered in all of 2016. In March alone, San Francisco collected more than 13,000 syringes, compared with only about 2,900 the same month in 2016. People, often children, risk getting stuck by discarded needles, raising the prospect they could contract blood-borne diseases such as hepatitis or HIV or be exposed to remnants of heroin or other drugs.

Activist Rocky Morrison, of the “Clean River Project,” holds up a fish bowl filled with hypodermic needles, that were recovered during 2016, on the Merrimack River. Charles Krupa / AP

It’s unclear whether anyone has gotten sick, but the reports of children finding the needles can be sickening in their own right. One 6-year-old girl in California mistook a discarded syringe for a thermometer and put it in her mouth; she was unharmed.

“I just want more awareness that this is happening,” said Nancy Holmes, whose 11-year-old daughter stepped on a needle in Santa Cruz, California, while swimming. “You would hear stories about finding needles at the beach or being poked at the beach. But you think that it wouldn’t happen to you. Sure enough.”

They are a growing problem in New Hampshire and Massachusetts — two states that have seen many overdose deaths in recent years.  “We would certainly characterize this as a health hazard,” said Tim Soucy, health director in Manchester, New Hampshire’s largest city, which collected 570 needles in 2016, the first year it began tracking the problem. It has found 247 needles so far this year.

Needles turn up in places like parks, baseball diamonds, trails and beaches — isolated spots where drug users can gather and attract little attention, and often the same spots used by the public for recreation. The needles are tossed out of carelessness or the fear of being prosecuted for possessing them.

One child was poked by a needle left on the grounds of a Utah elementary school. Another youngster stepped on one while playing on a beach in New Hampshire.

Even if adults or children don’t get sick, they still must endure an unsettling battery of tests to make sure they didn’t catch anything. The girl who put a syringe in her mouth was not poked but had to be tested for hepatitis B and C, her mother said.

Some community advocates are trying to sweep up the pollution. Rocky Morrison leads a clean-up effort along the Merrimack River, which winds through the old milling city of Lowell, and has recovered hundreds of needles in abandoned homeless camps that dot the banks, as well as in piles of debris that collect in floating booms he recently started setting.

He has a collection of several hundred needles in a fishbowl, a prop he uses to illustrate that the problem is real and that towns must do more to combat it.

“We started seeing it last year here and there. But now, it’s just raining needles everywhere we go,” said Morrison, a burly, tattooed construction worker whose Clean River Project has six boats working parts of the 117-mile river.

Among the oldest tracking programs is in Santa Cruz, California, where the community group Take Back Santa Cruz has reported finding more than 14,500 needles in the county over the past 4 1/2 years. It says it has gotten reports of 12 people getting stuck, half of them children.

“It’s become pretty commonplace to find them. We call it a rite of passage for a child to find their first needle,” said Gabrielle Korte, a member of the group’s needle team. “It’s very depressing. It’s infuriating. It’s just gross.”

Some experts say the problem will ease only when more users get treatment and more funding is directed to treatment programs.  Others are counting on needle exchange programs, now present in more than 30 states, or the creation of safe spaces to shoot up — already introduced in Canada and proposed by U.S. state and city officials from New York to Seattle.  Studies have found that needle exchange programs can reduce pollution, said Don Des Jarlais, a researcher at the Icahn School of Medicine at Mount Sinai hospital in New York.

But Morrison and Korte complain poor supervision at needle exchanges will simply put more syringes in the hands of people who may not dispose of them properly.

After complaints of discarded needles, Santa Cruz County took over its exchange from a non-profit in 2013 and implemented changes. It did away with mobile exchanges and stopped allowing drug users to get needles without turning in an equal number of used ones, said Jason Hoppin, a spokesman for the Santa Cruz County.

Along the Merrimack, nearly three dozen riverfront towns are debating how to stem the flow of needles. Two regional planning commissions are drafting a request for proposals for a clean-up plan. They hope to have it ready by the end of July.

“We are all trying to get a grip on the problem,” said Haverhill Mayor James Fiorentini. “The stuff comes from somewhere. If we can work together to stop it at the source, I am all for it.”

Source:  July 2017


Patterns of illicit drug use in each UK country analysed in annual report

An overview of illicit drug use across the whole of the UK in 2016 has been published by the Home Office.

The ‘United Kingdom Drug Situation: Focal Point Annual Report 2016’ has collated data across all four home nations and includes specific analysis of policy, prevention, treatment, drug-related deaths, infectious diseases and drug markets.

Key points relating to the UK as a whole:

· Prevalence in the general population is lower now than ten years ago, with cannabis being the main driver of that reduction. However, there has been little change in recent years.

· Seizures data suggests that herbal cannabis has come to dominate the market. While resin was involved in around two-thirds of cannabis seizures in 2000, it was involved in only five per cent in 2015/16.

· Using the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) definition, which refers to deaths caused directly by the consumption of at least one illicit drug, the total number of drug-related deaths in the UK during 2014 was 2,655; a five per cent increase from 2013 and the highest number reported to date.

· Over the last decade the average age of death has increased from 37.6 years in 2004 to 41.6 in 2014, with males being younger than females (40.3 years and 44.6 years respectively). The largest proportion of deaths in the UK in 2014 was in the 40–44 years age group.

· There were 124,234 treatment presentations in the UK in 2015. This total includes for the first time, data from individuals presenting to treatment services in prisons in England.

· Benzodiazepines were cited as a primary problem substance in far greater proportion of cases in Scotland and Northern Ireland than in England or Wales, whereas Wales had a far higher proportion of clients citing amphetamines/methamphetamines than in any of the other countries.

· National Take-Home Naloxone programmes continue to supply naloxone to those exiting prison in Scotland and Wales: there were 932 kits issued by NHS staff in prisons in Scotland, and 146 in Wales, in 2015/16.

· There were 50 new diagnoses of HIV among people who inject drugs reported from Scotland, compared with 17 in 2014. This increase was due to an outbreak of HIV in people who inject drugs in Glasgow.


 A New Agenda to  Turn Back the Drug Epidemic

Robert L. DuPont, MD, President , Institute for Behavior and Health, Inc.

A. Thomas McLellan, PhD, Senior Strategy Advisor , Institute for Behavior and Health, Inc.  May 2017

Institute for Behavior and Health, Inc. , 6191 Executive Blvd , Rockville, MD 20852 , 1


The Institute for Behavior and Health, Inc. (IBH) is a 501(c)3 non-profit substance use policy and research organization that was founded in 1978. Non-partisan and non-political, IBH develops new ideas and serves as a force for change.

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health was published in November 2016. Four months later, in March 2017, IBH held a meeting of 25 leaders in addiction treatment, health care, insurance, government and research to discuss the scope and implications of this historic document. The US Surgeon General, VADM Vivek H. Murthy, MD, was an active participant in the meeting. The significance of this new Surgeon General’s Report is analogous to the historic 1964 Surgeon General’s report, Smoking and Health, a document that inspired an extraordinarily successful public health response in the United States that has reduced the rates of cigarette smoking by over 64% and continues its impact even today, more than 50 years following its release.

The following is a summary of the discussion at the March 2017 meeting and the conclusions and recommendations that were developed.

Introduction: The 2016 Surgeon General’s Report 

The two primary objectives of the US Surgeon General’s Report of 2016 are first to provide scientific evidence that shows that in addition to nicotine, other substance misuse and addiction issues (e.g., alcohol, opioids, marijuana, etc.) also are best understood and addressed as public health problems; and second to encourage the inclusion of addiction – its prevention, early recognition and intervention, treatment and active long-term recovery management – into the mainstream of American health care. At present these elements are not integrated either as a stand-alone continuum or within the general medical system. As is true for other widespread illnesses, addiction to nicotine, alcohol, marijuana, opioids, cocaine and other substances is a serious chronic illness. This perspective is contrary to the common perception that addiction reflects a moral failing, a personal weakness or poor parenting. Such opinions have stigmatized individuals who are suffering from these often deadly substance use disorders and have led to expensive and ineffective public policies that segregate prevention and treatment outside of mainstream medical care. A better public health approach encourages afflicted individuals and their family members to seek and receive help within the current health care system for these serious health problems.

An informed public health approach to reducing the prevalence and the harms associated with substance use disorders requires more than the brief treatment of serious cases. Particularly important are substance use prevention programs in schools, healthcare and in all other parts of the community to protect adolescents (ages 12 – 21), the group most at risk for the initiation of substance-related harms and substance use disorders.  Importantly, abundant tragic experience and accumulating science show that substance use disorders are not effectively treated with only short-term care. Because substance use disorders produce 2 significant long-lasting changes in the brain circuits responsible for memory, motivation, inhibition, reward sensitivity and stress tolerance, addicted individuals remain vulnerable to relapse years following specialized treatment.1, 2, 3 Thus, as is true for all other chronic illnesses, long periods of personalized treatment and monitoring are necessary to assure compliance with care, continued sobriety, and improved health and social function. In combination, science-based prevention, early intervention, continuing care and monitoring comprise a modern continuum of public health care. The overall goals of this continuum comport well with those of other chronic illnesses:

1 US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Chapter 2. The Neurobiology of Substance Use, Misuse, and Addiction. In: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available:

2 US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Chapter 5. Recovery: The Many Paths to Wellness. In: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available:

3 Betty Ford Institute Consensus Panel. (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment, 33(3), 221-228.

4 White, W. L. (2012). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific reports, 1868-2011. Philadelphia, PA: Philadelphia Department of Behavioral Health and Intellectual Disability Services.

· sustained reduction of the cardinal symptom of the illness, i.e., substance use;

· improved general health and function; and,

· education and training of the patient and the family to self-manage the illness and avoid relapses.

In the addiction field achieving these goals is called “recovery.” This word is used to describe abstention from the use of alcohol, marijuana and other non-prescribed drugs as well as improved personal health and social responsibility.3,4 Over 25 million formerly addicted Americans are in stable, long-term recovery of a year or longer.4 Understanding how to consistently accomplish the life-saving goal of recovery must inform health care decisions.

The 2016 Surgeon General’s Report offers a science-informed vision and path to recovery in response to the nation’s serious addiction problem, including specifically the opioid overdose epidemic. Research shows that it is possible to prevent or delay most cases of substance misuse; and to effectively treat even the most serious substance use disorders with recovery as an expectable result of comprehensive, continuous care and sustained monitoring. To do this, substance use disorders must be recognized as serious, chronic health conditions that are both preventable and treatable. The nation must integrate the short-term siloed episodes of specialty treatment that now are isolated from mainstream healthcare into a fully integrated continuum of care comparable to that currently available to those with other chronic illnesses such as diabetes, hypertension, asthma and chronic pain.

Meeting Discussion and Conclusions 

The Surgeon General’s Report and the meeting convened by the Institute for Behavior and Health, Inc. (IBH) to promote its recommendations are significant responses to the expanding epidemic of opioid 3 and other substance use disorders, an epidemic that struck nearly 21 million Americans aged 12 and older in 2015 alone.5 That year saw more than 52,000 overdose deaths.6 This drug epidemic has devastated countless families and communities throughout the US. Unlike earlier and smaller drug epidemics, the current opioid epidemic is not limited to a few regions or communities or a narrow range of ethnicities or incomes in the United States. Instead it afflicts all communities and all socioeconomic groups; its impacts include smaller communities and rural areas as well as suburban areas and inner cities. Fuelled by the suffering of countless grieving families, the nation is in the early stages of confronting the new epidemic. A growing national determination to turn back this deadly epidemic has opened the door to innovation that is sustained by strong bipartisan political support for new and improved efforts in both prevention and treatment of substance use disorders.

5 Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available:

6 Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016, December 30). Increases in drug and opioid-involved overdose deaths – United States. Morbidity and Mortality Weekly Report, 65(50-51), 1445-1452. Available:

7 Levy, S. J., Williams, J. F., & AAP Committee on Substance Use and Prevention. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161211. Available:

8 US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Chapter 3. Prevention Programs and Policies. In: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available:

Abstinence is an Achievable Goal, both for Prevention and for Treatment 

Embracing and synthesizing the 30 years of science supporting the findings of the 2016 Surgeon General’s Report, the group discussed a single goal for the prevention of addiction: no use of alcohol, nicotine, marijuana or other non-prescribed drugs by youth for reasons of health. This goal should be the core prevention message to all children from a very young age. Health care professionals, educators and parents should understand the importance of this simple, clear health message. They should continue to reinforce this message of no-use for health as children grow to adulthood. Even when prevention fails, it is possible for parents, other family members, friends, primary care clinicians, educators and others to identify and to intervene quickly to stop youth substance use from becoming addiction.7

The science behind this ambitious but attainable prevention goal is clear. Alcohol, nicotine products, marijuana and other non-prescribed drug use is uniquely harmful to the still-developing brains of adolescents. Thus any substance “use” among youth must be considered “misuse” – use that may harm self or others. The goal of no substance use is not just for the purpose of preventing addiction, though that is one clear and important by product of successful prevention. Addiction is a biological process that can take years to develop. In contrast, even a single episode of high-dose use of alcohol or other substance could immediately produce an injury, accident or even death. While it is true that most episodes of substance misuse among adults do not produce serious problems, it is also true that substance misuse is associated with 70% or more of the injuries, disabilities and deaths of young people.8 These figures are even higher for minority youth. Many adolescent deaths are preventable 4 because most are related to substance use – including substance-related motor vehicle crashes and overdose.9

9 Subramaniam, G. A., & Volkow, N. D. (2014). Substance misuse among adolescents. To screen or not to screen? JAMA Pediatrics, 168(9), 798-799. Available:

10 Data analyzed by the Center for Behavioral Health Statistics and Quality. CBHS. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15- 4927, NSDUH Series H-50).

11 2014 data obtained by IBH from the Monitoring the Future study. For discussion of data through 2013 see DuPont, R. L. (2015, July 1). It’s time to re-think prevention; increasing percentages of adolescents understand they should not use any addicting substances. Rockville, MD: Institute for Behavior and Health, Inc. Available:

Youth who use any one of the three most common “gateway” substances, i.e., alcohol, nicotine and marijuana, are many times more likely than those who do not use that single drug to use the other two substances as well as other illegal drugs.10 The use of any drug opens the door to an endless series of highly risky decisions about which drugs to use, how much to use, and when to use them. This perspective validates the public health goal for youth of no use of any drug.

Complete abstinence from the use of alcohol or any other drug among adolescents is not simply an idealistic goal – it is a goal that can be achieved. Data were presented at the meeting from the nationally representative Monitoring the Future study showing that 26% of American high school seniors in 2014 reported no use of alcohol, cigarettes, marijuana or other non-prescribed drugs in their lifetimes. 11 This is a remarkable increase from only 3% reported by American high school seniors in 1983. Moreover, in the same survey, 50% of high school seniors had not used any alcohol, cigarettes, marijuana or other non-prescribed substance in the past 30 days, up from 16% in 1982. These largely overlooked and important findings show that youth abstinence from any substance use is already widespread and steadily increasing.

In parallel with the goal of abstinence for prevention, the recommended goal for the treatment of those who are addicted is sustained abstinence from the use of alcohol and other drugs, with the caveat, explicitly acknowledged by the group, that individuals who are taking medications as-prescribed in the treatment of substance use disorders (e.g., buprenorphine, methadone and naltrexone) and who do not use alcohol or other non-prescribed addictive substances – are considered to be abstinent and ”in recovery.” Abstinence from all non-prescribed substance use is the scientifically-informed goal for individuals in addiction treatment. This treatment goal is widely accepted in the large national recovery community. The long-lasting effects of addiction to drugs are easily seen among cigarette smokers: smoking only a single cigarette is a serious threat to the former smoker, even decades after smoking the last cigarette. There is incontrovertible evidence from brain and genetic research showing the long-term effects of substance misuse on critical brain regions.2 It is unknown when or if these brain changes will return to being entirely normal following cessation of substance use; however, it is known that the recovering brain is particularly vulnerable to the effects of return to any substance use, often leading to overdose or rapid re-addiction. 5

Participants in the IBH meeting supported the idea that abstinence is the high-value outcome in addiction treatment; and that while any duration of abstinence is valuable, longer-term, stable abstinence of 5 years is analogous to the widely-used standard in cancer treatment of 5-year survival. The scientific basis for the value of sustained recovery is validated by the experience of the estimated 25 million Americans now in recovery. This increasingly visible recovery community is a remarkable and very positive new force in the country.

Measuring and Attaining these Goals 

The mantra from the IBH meeting was, if you don’t measure it, it won’t happen. The group of leaders recognized the paucity of current models for systematic integration of addiction treatment and general healthcare. The group encouraged the identification of promising models and the promotion of innovation to achieve the goal of sustained recovery. Even programs that include fully integrated care of other diseases, managed care and other comprehensive health programs do not reliably achieve the goal of sustained or even temporary recovery for substance use disorders. The meeting participants noted the absence of long-term outcome studies of the treatment of substance use disorders and encouraged all treatment programs not only to extend the care of discharged patients but also to systematically study the trajectories of discharged patients to improve their long-term treatment outcomes. The increasing range of recovery support services after treatment is an important and promising new trend that is now actively promoting sustained recovery.

Meeting participants noted one particularly promising model of public health goal measurement and attainment – the 90-90-90 goals for the treatment of HIV/AIDS: 90% of people with HIV will be screened to know their infection status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all patients receiving antiretroviral therapy will have viral suppression (i.e., zero viral load).12 These measurable goals provide an operational definition of public health success for the country, states and individual healthcare organizations.

12 UNAIDS. (2014). 90-90-90: An Ambitious Treatment Target to Help End the AIDS epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS. Available:

With this model as background, the IBH group concluded that a similar public health approach and similarly specific numeric goals should be established for preventing and treating substance use disorders. Examples of parallel national prevention goals could include 90% rates of screening for substance misuse among adolescents; 90% provision of interventions and follow-up for those screening positive; and 90% total abstinence rates among youth aged 12-21. While these are admittedly ambitious prevention goals, adoption of them could incentivize families, schools and communities to increase the percentage of youth who do not use any alcohol, nicotine, marijuana or other drugs every year.

A similar approach was adopted by the IBH group to improve the impact of addiction treatment. Again, there would be significant public health value if the US adopted the following goals: 90% of individuals aged 12 or older receive annual screening for substance misuse and substance use disorders; 90% of those who receive a diagnosis of a substance use disorder are referred and meaningfully engaged (at 6 least three sessions) in some form of addiction treatment; and 90% of those engaged in treatment achieve sustained abstinence as measured by drug testing, during and for six months following treatment.

Source:  IBH-Report-A-New-Agenda-to-Turn-Back-the-Drug-Epidemic  May 2017

In Southern Ohio, the number of drug-exposed babies in child protection custody has jumped over 200%.  The problem is so dire that workers agreed to break protocol to invite a reporter to hear their stories.  Foster care placements are at record levels, and the number of drug-exposed newborns in their custody has jumped over 200% in the past decade

Inside the Clinton County child protection office, the week has been tougher than most.

Caseworkers in this thinly populated region of southern Ohio, east of Cincinnati, have grown battle-weary from an opioid epidemic that’s leaving behind a generation of traumatized children. Drugs now account for nearly 80% of their cases. Foster-care placements are at record levels, and the number of drug-exposed newborns in their custody has jumped over 200% in the past decade. Funding, meanwhile, hasn’t budged in years.

“Many of our children have experienced such high levels of trauma that they can’t go into traditional foster homes,” said Kathi Spirk, director of Clinton County job and family services. “They need more specialized care, which is very expensive.”

The problem is so dire that workers agreed to break protocol and invite a reporter to camp out in a conference room and hear their stories. For three days, they relived their worst cases and unloaded their frustrations, in scenes that played out like marathon group therapy, for which they have no time. Many agreed that talking about it only made them feel worse, yet still they continued, one after another.

Hence the bad week.

Given the small size of their community, they asked that their names be changed out of concern for their own safety and the privacy of the children.

The caseworkers, like most, are seasoned in despair. Many worked in the 1990s when crack cocaine first arrived, followed by crystal meth in the early 2000s. In 2008, after the shipping giant DHL shuttered its domestic hub here in Wilmington and shed more than 7,000 jobs, prescription pill mills flourished while the economy staggered. Back then, a typical month saw 30 open cases, only a few of them drug-related. But the flood of cheap heroin and fentanyl, now at its highest point yet, has changed everything. A typical month now brings four times as many cases, while institutional knowledge has been flipped on its head.

“At least with meth and cocaine, there was a fight,” said Laura, a supervisor with over 20 years of experience. “Parents used to challenge you to not take their kids. And now you have them say: ‘Here’s their stuff. Here’s their formula and clothes.’ They’re just done. They’re not going to fight you any more.”

Heroin has changed how they approach every step of their jobs, they said, from the first intake calls to that painstaking decision to place a child into temporary foster care or permanent custody. Intake workers now fear what used to be routine.

“Occasionally, we’d get thrown a dirty house, something easy to close and with little trauma to the child,” said Leslie, another worker. “We’re not getting those any more.

Now they’re all serious, and most of them have a drug component. So you may get a dirty house, but it’s never just a dirty house.”

‘I had a four-year old whose mom had died in front of her and she described it like it was nothing’ Children come into the system in two ways. The first is through a court order after caseworkers deem their environment unsafe, and if no friends or family can be found.

Because of the added trauma, removing a child is always the last option, caseworkers said. But in a county with only 42,000 people spread out over 400 square miles, the magnitude of the epidemic has compromised an already delicate safety net. Relatives are overwhelmed financially. Multiple generations are now addicted, along with cousins, uncles, and neighbors. In many cases, a safe house with a grandparent or other relative will eventually attract drug activity.

Law enforcement will also bring children in, usually after parents overdose. These cases often reveal the most horrendous neglect: a three-year old who needed every tooth pulled because he’d never been made to brush them, or kids found sleeping on bug-infested mattresses, going to the toilet in buckets because the water had been shut off. Children are coming in more hardened, they said, older than their years.

“I had a four-year-old whose mom had died in front of her and she described it like it was nothing,” said Bridgette, another caseworker. “She knew how to roll up a dollar bill and snort white powder off the counter. That’s what she thought dollar bills were for.” She added that many of the children could detail how to cook heroin. One foster family had a five-year-old boy who put his medicine dropper in his shoe. “Because that’s where daddy hid his needles,” she said.

“The kids are used to surviving in that mess,” added Carole, another veteran. “Now all the sudden the system is going in and saying it’s not safe. All their survival instincts are taken away and they go ballistic. They don’t know what to do.”

During the first weeks of foster care, meltdowns, tantrums, and violence are common as children navigate new landscapes and begin to process what they’ve experienced.

One afternoon, the caseworkers brought in a foster couple who’d taken in two sisters, an infant born drug-exposed, and her four-year old sister. The baby had to be weaned off opioids and now suffered chronic respiratory problems. Part of her withdrawal had included non-stop hiccups. The older girl had lived with her parents in a drug house and displayed clear signs of post-traumatic stress. Once, a family friend sitting next to her in a car had overdosed and turned purple. She’d witnessed domestic abuse, and one day a neighbor shot and killed her dog while she watched (she’d let the dog out). After a meltdown at a classmate’s pool party, over a year after entering foster care, she revealed having seen a toddler drown in a pond while adults got high. Through therapy, she’d also revealed sexual assault. The foster mother described how the girl suffered flashbacks, triggered by stress and certain anniversaries, like the day of her removal, and other seemingly random events. When this happened, she slipped into catatonic seizures.

“Her eyes are closed and you can’t wake her,” she said. “It’s like narcolepsy, a deep, unconscious sleep. We later discovered it was a coping mechanism she’d developed in order to survive.”

Despite what they’ve endured, most children wish desperately to return to their parents. Many come to see themselves as their parents’ caretakers and feel guilty for being taken away, especially if they were the ones to report an overdose, as in the case of a four-year-old girl who climbed out of a window to alert a neighbor. “She asked me: if I took her away, who was going to take care of mommy?” Bridgette remembered.

For caseworkers, reunification is the endgame. After children enter temporary foster care, the agency spends up to two years working closely with the family while the parents try to stay sober. The only contact with their children comes in the form of twice-weekly visits held in designated rooms here at the office. Each contains a tattered sofa and some second-hand toys. Currently, the agency runs about 200 visits each week. The encounters are monitored through closed-circuit cameras. For everyone involved, it can be the most trying period.

Many parents use the time to build trust and re-establish bonds. “During those first four years, a child gets such good stuff from their parents,” said Sherry, the caseworker who monitors the visits. “The kids are just trying to get that back.” Some parents bring doughnuts and pictures, while others need more guidance. Caseworkers hold parenting classes. Some moms lost newborns at the hospital after they tested positive for drugs; workers teach them how to feed and hold the child, and encourage them to bring outfits to dress their babies.

For other children, the visits trigger a storm of emotion that churns up the trauma of removal. “We had one girl who’d scream and wail at the end of every visit,” Laura, the supervisor, remembered. “Each time she thought she’d never see her mother again. We’d have to pry her out of mom’s arms and carry her down the hallway.”

“We’d sit in our offices and just sob,” added another worker. “But that girl’s cries weren’t enough to keep Mom off heroin.”

The number of available foster families is dwindling, while the cost of supporting them has never been higher

Perhaps the greatest difference with heroin and opioids, caseworkers said, is their iron grasp. Staying sober is a herculean task, especially in this rural community short on resources, where the nearest treatment facilities are over 30 miles away in Dayton, Cincinnati, or Columbus. At some point, nearly every parent falls off the wagon. They disappear and miss visits, leaving children to wait. One of the hardest parts of the job is telling a child that mom or dad isn’t coming, or that they can’t even be found.

“You see the hurt in their eyes,” Sherry said. “It’s a look of defeat, and it just breaks your heart.” She remembered a mother who’d failed to show up for months, then made it for her twin boys’ birthday. “The next day she overdosed and died.”

A tally sheet is used to track how many times prospective clients waiting to enter the program call a detox center, in Huntington, West Virginia. Photograph: Brendan Smialowski/AFP/Getty Images

When parents fail drug screenings during the 18-month period, caseworkers use discretion. Parents might be doing better in other areas like landing a job, or finding secure housing, so workers help them to get back on the wagon. “It’s all about showing progress,” Laura said. Some parents make it 16, 17 months sober and fully engaged. “And they’re the toughest cases, because we’ve been rooting for them this whole time and helping them. We’re giving kids pep talks, saying: ‘Mom’s doing great, she’s getting it together!’ They’re so happy to be going home. And then it all falls apart.”

With heroin, defeat is something the workers have learned to reckon with. Lately they’ve started snapping photos of parents and children during their first visit together, getting medical histories and other vital information – something they used to do much later. “Because we know the parents probably aren’t going to make it,” Laura admitted. “And if we never see them again, this is the info we need.” When asked how many opioid cases had ended in reunification, only two workers raised their hands.

The repeated disappointments come as resources and morale have reached their tipping point. The number of available foster families is dwindling, they said, while the cost of supporting them – over $1.5m a year – has never been higher.

Spirk, the agency’s director, said that all the agency’s budget was paid for with federal dollars and a county tax levy, although they’ve been flat-funded for nearly 10 years. The state contributes just 10%. When it comes to investing in child protection, Ohio ranks last in the country – despite having spent nearly $1bn fighting its opioid problem in 2016 alone.

The Ohio house of representatives recently passed a new state budget with an additional $15m for child protective services, but the state senate has yet to pass its own version. The only bit of hope came in March, when the Ohio attorney general’s office announced a pilot program that will give Clinton County, along with others, additional resources to help treat children for trauma, and to assist with drug treatment. It starts in October.

The epidemic’s unrelenting barrage has also taken a toll on mental health. “Our caseworkers are experiencing secondary trauma and frustration at not being able to reunify children with their parents because of relapses,” Spirk said.

Almost every caseworker said they had experienced depression or some form of PTSD, although no one had sought professional help. The privacy of their cases also means that few can speak openly with friends or family members. Some chose to drink, while others leaned on their faiths. But most said coping mechanisms they once relied on had failed.

“I used to have a routine on my drive home,” Laura said. “I’d stop in front of a church, roll down my window, and throw out all the day’s problems. The next morning I’d pick them back up. These days, I can’t do that anymore.”

“There’s no more outlet,” added Shelly, another supervisor. “You think you’re able to separate but you can’t let it go anymore. You try to eat healthy, do yoga, whatever they tell you to do. But it’s just so horrific now, and it keeps getting worse.”

At some point, the inevitable happens. When a parent can’t stay sober, or stops showing progress, the decision is made to place the child into permanent custody and put them up for adoption. For everyone, including caseworkers, it’s the most wrenching day.

The final act of every case is the “goodbye visit”, held in one of the nicer conference rooms. It’s a chance for parents to let their children know they love them and will miss them, and that it’s time to move on. Adoptive parents can choose to stay in contact, but it isn’t mandatory.

To make the time less stressful, Sherry, the worker who monitors the visits, has them draw pictures together, which she scans and gives to them as mementoes. She also tapes the meetings for them to keep. Watching from her tiny room full of TV screens, she can’t help but cry. “What people don’t realize is that when a baby comes into our custody, they’re still in a carrier seat. By the time the case is over, we’ve helped to potty train them. Two years is a very long time with a child. So in a way, it’s like my goodbye visit, too.”

Caseworkers have started making “life books” for kids once they come into the system. It’s where they put the photos they’ve taken, plus any pictures of birth parents or relatives they can find, report cards, ribbons and medals – the souvenirs of any childhood.  “It’s their history,” Sherry said, “so that one day they can make sense of their lives.”   She noted that one kid, after turning 18, tore his to pieces, taking with him only the good memories.



Childhood maltreatment increases the risk of subsequent depression, anxiety and alcohol abuse, but the rate of resilient victims is unknown. Here, we investigated the rate of victims that do not suffer from clinical levels of these problems after severe maltreatment in a population-based sample of 10980 adult participants.

Compared to men, women reported more severe emotional and sexual abuse, as well as more severe emotional neglect. For both genders, severe emotional abuse (OR = 3.80 [2.22, 6.52]); severe physical abuse (OR = 3.97 [1.72, 9.16]); severe emotional neglect (OR = 3.36 [1.73, 6.54]); and severe physical neglect (OR = 11.90 [2.66, 53.22]) were associated with depression and anxiety while only severe physical abuse (OR = 3.40 [1.28, 9.03]) was associated with alcohol abuse.

Looking at men and women separately, severe emotional abuse (OR = 6.05 [1.62, 22.60] in men; OR = 3.74 [2.06, 6.81] in women) and severe physical abuse (OR = 6.05 [1.62, 22.60] in men; OR = 3.03 [0.99, 9.33] in women) were associated with clinical levels of depression and anxiety. In addition, in women, severe sexual abuse (OR = 2.40 [1.10, 5.21]), emotional neglect (OR = 4.78 [2.40, 9.56]), and severe physical neglect (OR = 9.86 [1.99, 48.93]) were associated with clinical levels of depression and anxiety.

Severe emotional abuse in men (OR = 3.86 [0.96, 15.48]) and severe physical abuse in women (OR = 5.18 [1.48, 18.12]) were associated with alcohol abuse. Concerning resilience, the majority of severely maltreated participants did not report clinically significant levels of depression or anxiety (72%), or alcohol abuse (93%) in adulthood. Although the majority of severely abused or neglected individuals did not show clinical levels of depression, anxiety or alcohol use, severe childhood maltreatment increased the risk for showing clinical levels of psychopathology in adulthood.


Severe child maltreatment is conventionally defined within child protection practice as severe physical, emotional, sexual abuse and/or severe physical and emotional neglect by adults [1]. Severity can be defined on the basis of the type of maltreatment, its frequency, if the child was subjected to multiple forms of maltreatment, if a weapon had been used, if the maltreatment resulted in an injury, and if the abuse was considered severe by the victim. For sexual abuse, even a single experience is often considered to be severe [1].

Childhood maltreatment and its psychosocial consequences

There are annually over one million victims of childhood maltreatment in the USA alone and childhood maltreatment has a large public health impact [2]. Several studies show that childhood physical, emotional, and sexual abuse are all related to an increased risk of depression and anxiety disorders in adulthood [3–9]. Other studies have found that the severity of abuse and neglect is associated with increased depression and anxiety symptoms in adulthood [10–12]. This means that as a general rule, the more severe the abuse and neglect, the more likely the abused individuals are to show symptoms of depression and anxiety.

There is also a robust relationship between childhood maltreatment and later alcohol abuse [13–16]. For example, Young-Wolff et al. [17] found that men who had experienced childhood maltreatment were 1.7 times more likely to suffer from alcohol abuse in adulthood than men who did not report experiences of childhood maltreatment. Similar findings have been made when investigating the consequences of abuse and neglect in women (e.g., [18]). Findings from a study by Schwandt et al. [19] suggested that the severity of emotional and physical abuse plays a prominent role in the development of alcohol abuse. In line with these results suggesting a role of the severity of childhood abuse on later substance misuse, Hyman et al. [20] found that the severity of abuse was predictive of cocaine use after having been discharged from an inpatient treatment for cocaine addiction.  This was true for women but not for men. Kendler et al. [21] showed that women who had experienced child sexual abuse reported higher incidences of alcohol abuse. Twin studies have also shown that childhood sexual abuse increases the risk of alcohol abuse and addiction later in life [21–24]. To summarize, there is a strong, robust relationship between childhood maltreatment and mental disorders in adulthood. These associations include associations between childhood experiences of physical abuse, emotional abuse, and neglect, respectively, and mental disorders such as depression and anxiety disorders, and alcohol abuse [25–26]. Moreover, multi-type maltreatment in childhood is associated with greater impairment in adulthood, and this association also includes a range of psychological and behavioral problems, such as depression, anxiety, and alcohol abuse [27].

However, not all victims of childhood maltreatment develop symptoms of substance abuse or psychopathology in adulthood. Meta-analyses suggest that many (but not all) children who have experienced abuse succeed in overcoming some of the possible negative outcomes [28]. For example, Klika and Herrenkohl [28] found that some individuals who have experiences of abuse in childhood do not suffer long-term negative sequelae. Collishaw et al. [29] reported that despite serious experiences of childhood sexual or physical abuse, some individuals did not develop psychiatric problems during adulthood. Moreover, Hamilton et al. [30] reported that emotional neglect did not significantly predict increases in depressive or anxiety symptoms later in life. It has been estimated that 12–22% of maltreated individuals are functioning well despite experiencing childhood maltreatment [31].

The current study

Several studies have focused on only experiencing one type of maltreatment (e.g., sexual abuse) or one type of outcome (e.g., depression). Moreover, most previous studies have relied on either convenience samples or samples from health care services, and especially samples of the latter kind might bias the results and show less resilience than is actually the case.

In the present study, we used a large, population-based sample of Finnish men and women. The types of maltreatment included emotional, physical, and sexual abuse as well as emotional and physical neglect.   Thus, the aims of the present study were to:

1. Investigate gender differences in severe experiences of different types of childhood abuse;

2. Compare if and how individuals reporting severe experiences of different types of childhood abuse differ from individuals who did not report experiencing childhood abuse, in terms of presence of clinically significant symptoms of depression and anxiety in adulthood; and

3. Compare if and how individuals reporting severe experiences of different types of childhood abuse differ from individuals who did not report experiencing childhood abuse in terms of presence of alcohol abuse symptoms in adulthood.


Descriptive results

The proportion of participants with severe experiences of emotional abuse was 0.6% (n = 64). The corresponding proportion for severe experiences of physical abuse was 0.2% (n = 26) while the proportions for severe experiences of sexual abuse was 0.4% (n = 43). For severe experiences of emotional neglect, the proportion was 0.4% (n = 44) and for severe experiences of physical neglect 0.1% (n = 7).  With regard to gender differences in the different types of severe experiences of abuse, Table 2 shows that there were statistically significant differences between men and women in the proportion of individuals with severe experiences of emotional abuse, sexual abuse and emotional neglect. All of these were more prevalent in women. There were no statistical differences between men and women in terms of having severe experiences of physical abuse and physical neglect.

We then investigated whether the proportion of individuals having clinical levels of depression and anxiety was higher in individuals with severe experiences of abuse and neglect compared to individuals with less severe (or no) experiences of abuse and neglect. Table 3 shows that, for both genders, severe experiences of emotional and physical abuse and emotional and physical neglect increased the likelihood of suffering from clinical depression or anxiety compared to less severe experiences of the said forms of childhood maltreatment.

In men, severe abuse experiences were significantly associated with increases in the prevalence of clinical depression or anxiety when it came to experiences of severe emotional and physical abuse and physical neglect. No association was observed for severe sexual abuse and severe emotional neglect. For women, severe experiences of all childhood maltreatment types increased the likelihood of suffering from clinical depression or anxiety compared to other lower experiences of maltreatment.

Next, we explored the proportions of both men and women who were resilient to severe experiences of childhood maltreatment with regards to not suffering from clinical levels of depression or anxiety in adulthood. Depending on the abuse type, 55.6% to 100% of men with experiences of severe abuse did not show clinically significant levels of depression or anxiety. For women, 50% to 80.5% did not show clinically significant levels of depression or anxiety.


The present study investigated five types of maltreatment: emotional, physical and sexual abuse, and physical and emotional neglect; and their relationships to depression, anxiety and alcohol abuse. The study used a population-based sample of 10980 participants and used validated measures of experiences of childhood maltreatment, current depression and anxiety, and current alcohol abuse.

More particularly, our aim was to investigate gender differences in victims of severe childhood maltreatment, as well as to compare if and how individuals reporting severe experiences of different types of childhood abuse differ from individuals without such severe experiences in terms of presence of clinically significant symptoms of depression, anxiety and alcohol abuse in adulthood.

The present study found that women reported more childhood experiences of severe emotional, sexual abuse and emotional neglect than men. Our findings are inconsistent with the results of those of previous studies indicating that men reported more childhood experiences of abuse than women [3, 38]. However, our results are consistent with findings suggesting that women are more sensitive than men to the effects of experiences abuse in childhood [29].

Compared to another Finnish population based sample, the frequencies of severe abuse were relatively low in our sample. This could be due to samples being obtained at different times, as abuse in Finland has been decreasing [39], or that in the present study the complete CTQ was used: in the study by Albrecht’s et al. [33], only one item per factor was used. The decrease in measurement reliability that follows from removing 80% of the original items might have inflated the estimates in Albrecht’s study [33].

More specifically, our results revealed that, in men, severe experiences of emotional and physical abuse as well as physical neglect were significantly associated with increases in the prevalence of depression and anxiety symptoms. For women, there was an association between all types of severe childhood maltreatment (emotional, physical and sexual abuse, and physical and emotional neglect) with depression and anxiety symptoms in adulthood.

These results were consistent with previous literature indicating that physical abuse and/or emotional abuse are related to depression and anxiety disorders [4–5, 40–41]. These findings also corroborate findings from meta-analyses and extend previous reports of severe experiences of abuse or neglect being associated with greater risk of developing depressive and anxiety disorders in adulthood [26].

When we examined each type of maltreatment for associations with alcohol abuse, the results showed that severe emotional abuse was associated with alcohol abuse in men. For women, severe physical abuse emerged as a predictor for problematic alcohol use. This is consistent with research suggesting that childhood experiences of emotional and physical abuse were found to be the primary predictor of alcohol abuse [19, 42].

It is intriguing, however, that there appears to be a gender difference in response to abuse type, with men having a considerably more severe response to emotional abuse in terms of propensity to develop alcoholism later in life. For example, an explanation for why women appear to suffer greater consequences in terms of abusing alcohol later in life could be that boys are more likely to engage in rough-and-tumble play and play fights [43], and are thus desensitized to physical abuse to a higher extent than women. It is also, however, possible that measurement invariance could explain the perceived gender differences.

Our current findings suggest that, fortunately, more than half of the participants who have severe experiences of abuse and neglect in childhood seem to succeed in overcoming some of the possible consequences with regards to depression and anxiety symptoms and alcohol abuse in adulthood. While the present study did not investigate mediators of resilience, many studies have considered successful psychosocial adjustment as a mediator of psychological resilience following adverse events [44–45]. It should also be mentioned that some individuals likely have heritable factors that have been shown to protect against adverse effects of maltreatment, by means of gene–environment interaction (i.e., the concept that individuals respond differently to environmental stressors depending on their genotype) [46].

Limitations of the research

Despite the strengths of the present study, it is also characterized by some limitations worth mentioning. First, memories are usually influenced by later experiences, and since the questionnaire was about events that happened during childhood, the obtained information might be somewhat biased. Second, we did not consider the possible overlap between experiences of maltreatment types. Because experiencing one type of abuse or form of neglect is associated with experiencing also another type of abuse or form of neglect [10, 47], it is possible that also severe forms of abuse and neglect are correlated across types or maltreatment. This could, for example, mean that several of the individuals with clinical cases of depression and anxiety or alcohol abuse, not only had experienced one form of severe abuse, but several. Should this be the case, the additive effect of multiple types of abuse could influence the results.

In the present study, it is possible that the true prevalence of anxiety, depressive symptoms or alcohol abuse has been underestimated, as we have only one cross-sectional assessment of the above mentioned indicators (i.e., some individuals may have experienced clinically significant symptoms before study participation, or may experience symptoms in the future, but did not do so at the time of assessment). A longitudinal assessment of adulthood symptoms would thus arguable have been more appropriate than a single, cross-sectional measure.

Also, some of our results and group comparisons were based on very few individuals. This might both influence the estimated prevalence of depression and anxiety or problematic alcohol use and undermines the statistical power to detect differences. Finally, we only included three known consequences of experiencing childhood maltreatment: Depression and anxiety and problematic alcohol use. It is possible that individuals showing resilience on these possible consequences of maltreatment are not resilient with respect to other negative outcomes, such as social functioning or health-risk behavior.


To our knowledge, this is the first study that has looked at the effects of severe experiences of abuse in childhood on depression and anxiety symptoms and alcohol abuse in adulthood in a relatively large sample.

We found that a majority of individuals with severe experiences of childhood maltreatment did not meet the criteria for clinical of levels depression and anxiety or clinical significant levels of alcohol abuse. Although this is a positive message, it is important to remember that experiences of child maltreatment increase the risk of psychosocial problems in adulthood and several of the victims of severe maltreatment included in our study may have had increased, but non-clinical significant levels of depression, anxiety, and alcohol abuse.


O, let me not be mad, not mad, sweet heaven. Keep me in temper and keep the Liberal Democrats away from government. For they would make us all mad.

On Friday, new meaning was given to the Progressive Alliance. Maybe the Lib Dems have taken pity seeing Labour struggling to convince even the BBC that the nationalisation of everything can be paid for just by whacking more taxes on the rich. That was my first thought on reading of their pledge to completely legalise cannabis.

In the spirit of cooperation, I thought they have dreamt up a way to raise a billion quid of Labour’s shortfall. People won’t notice, not when they are stoned anyway.

Yes, the Lib Dems’ great money-raising wheeze depends on getting all us puffing away on the weed, just like we knock back the alcohol or used to grab a fag at the first excuse. Why not? Cigarettes and alcohol have always proved nice little earners, even if smuggling went up with every tax hike.  So why not add dope and kill two birds with one stone (no pun intended) and make yourself popular with all those ageing liberal hippies like Simon Jenkins, Mary Ann Seighart and Camilla Cavendish, former head of David Cameron’s policy unit, who are all forever bellyaching on about accepting drugs as part of the fabric of life and restoring sanity to society.

Hang on a minute – that’s the Lib Dem plan! It’s nothing to do with helping Labour out of a hole. It’s to finance their own mental health programme. Yes, you have read that. Wasn’t it last week that the well-meaning Norman Lamb earmarked, guess what, but a billion quid to fight that historic injustice, he says, is faced by people with mental ill health? An historic injustice that goes back all of 2 years.

‘Under the Conservative Government, services have been stretched to breaking point at a time when the prevalence of mental ill health appears to be rising.’

It is more than bizarre that the Lib Dems fail to join up the dots of mental illness and treatment (on which they have been campaigning vigorously) with increased use of drugs, particularly cannabis (which is what legalisation means).

Have they missed entirely the connection between cannabis use and mental ill health? Are they unaware that cannabis use triples psychosis risk? And from 17 to 38 can lose you 8 IQ points? Perhaps they are suffering that IQ loss already.

In Lib Dem happy land, everything can be squared – even Tiny Tim’s evangelical religious beliefs with gay marriage – and on drugs it is back to the future of hippy protest.

They have all been out straggling the airwaves, forgotten but former Lib Dem MPs – Dr Evan Harris (Dr Death as he was better known) and Dame Molly Meacher’s former sidekick Dr Julian Huppert – emerging into the daylight blinking to press their old cause, along with their Frankenstein master, the suitably named Professor David Nutt, of magic mushroom and alcohol antidote research fame.

One wonders whether the God-fearing Tim knows what he’s conjured up.  As a concerned parent, he should know that if legalisation means anything at all it means drug use going up as the latest stats from Colorado underline. Past-month marijuana use among 12-to-17 year-olds there has increased from 9.82 per cent to 12.56 per cent, according to the most recent year-by-year comparison looking at pre-legalisation data.

Well I for one am looking forward to seeing the contortions he’ll have to go through to join up the dots on his mental health and drugs legalisation policies. I suggest before he finds himself being asked to justify adding to our already overcrowded and underfunded secure psychiatric units – peopled with male psychotics addicted to cannabis – he reads one of the many comprehensive reviews of the link between cannabis and mental illness.

However, I am not holding my breath that Andrew Marr or any other progressive liberal BBC interviewer will press him on it.

Source:   14th May 2017

How do you know when you are being softened up for something? One sure sign is when what you are being asked to give your support to is sold to you as entirely unproblematic or as a panacea to a host of problems. Never believe it.

My antennae began twitching when the latest round in the campaign for legalised ‘medical cannabis’ began back last autumn. The instigator was the All Party Parliamentary Group for Drugs Policy Reform chaired by one Baroness Molly Meacher and its ammunition a misleading and derivative report: Accessing Medicinal Cannabis: Meeting Patients’ Needs.

With a general election under way it seems the good Baroness and her backers have decided to give their ‘medipot’ campaign another crack of the whip, ever hopeful of a change of government heart over legalising so-called medicinal cannabis.

What could be wrong with that, I hear you ask. Well, if I was sceptical about the stated purpose of this report when it was first published, I am even more so this time. Why? First, because the case for medicinal cannabis is based on a false premise, which the recent licensing of cannabidiol demonstrates again. Second, the scientific research on its efficacy doesn’t stack up too well. And third, there no safe way of using the unprocessed plant for recreational let alone medical purposes.

To recap, contrary to received wisdom, no one has stopped or is stopping  the scientific study of the chemicals in cannabis for medicinal purposes. Two approved cannabis-derived medications, Marinol and Sativex, exist already and a third, Epidiolex is undergoing clinical trials at the moment. In addition to this, the non psycho-active CBD or cannabidiol has been approved by Britain’s medicines regulatory authority, the MHRA, and the compound is now to be licensed and regulated as a medicine. Evidence of the efficacy of the derived compounds of cannabis for the wide range of symptoms they have been tested on is at best weak. This is what a dispassionate systematic research review conducted by the American Academy of Neurology and endorsed by the American Autonomic Society, the American Epilepsy Society, the Consortium of Multiple Sclerosis Centers, the International Organization of Multiple Sclerosis Nurses, and the International Rett Syndrome Foundation, shows.

There are indisputable  scientific and safety reasons for why the whole unprocessed cannabis plant is not and will never be approved as a medicine; that’s unless we chose to revert to medieval quackery and throw all scientific and safety advances  out of the window. It is not just that cannabis risks (addiction, psychosis, cancer, impaired cognitive functioning, to name but some) outweigh any possible benefits, but that as a natural ‘herb’ it is untested for pathogens and bacteria. Who is their right mind would chose mould over an approved antibiotic? And where is the luminary who thinks smoking is a sensible medication delivery system? – which how most cannabis users chose to ingest the weed.

But rational science hasn’t stopped the medipot activists in their tracks. Over the last few months they’ve been relentlessly pressing their victimhood status on the media and the inequity they suffer of not having a free and easy access to their preferred untested drug, i.e. dope.  They have really been doing rather well at convincing the media of their non-existent problem. The Daily Mail even fell for it this week, reiterating the campaigners’ victim meme of being sick people unjustly prosecuted by harsh and uncompromising authorities for the crime of tending to their pain when, in fact, it is the regulatory authorities who are protecting people from poisoning themselves. No wonder Baroness Meacher, chair of the aforesaid APPG, sounded so triumphant on the airwaves yesterday as she pushed the case for medipot to an all believing radio host. Even the Mail (all that has stood between us and drugs legalisation, she as much as said) had finally written a balanced article on the topic, she crowed.

She herself certainly was not balanced. I cannot make up my mind, given her ‘economy with truth’ regarding drug statistics on previous occasions that I have taken her up on, here, and here whether the Baroness is just daft and deluded, genuinely ingenuous, or, more worryingly, actively disingenuous. Running true to form, Baroness Meacher failed in her interview (go to circa one hour, 6 minutes into the programme) to either mention the medicines approval system or the recent licensing of cannabidiol as a medicine.  She also misled the public, deliberately it seemed, by giving the impression that the UK government has actively frustrated cannabis-based research when it hasn’t. In fact, the opposite is the case, as drugs policy analyst David Raynes made clear on the same programme.  The UK government broke ground when it licensed research into cannabis in 1998.

In the  absence of research, her spurious argument went, there remains a medical need for public access to the raw cannabis plant and therefore an end to its classification as a harmful recreational drug. There we had it.

The truth is that the APPG on Drugs Policy Reform she chairs is hardly an independent or dispassionate body. It is funded by The Open Society, which is in turn is a George Soros front. According to the Washington Times (Source: 2nd April 2014) this is the billionaire philanthropist who, with a cadre of like-minded, wealthy donors, has dominated the pro-legalisation side of the marijuana debate in the US by funding grass-roots movements in every state. No wonder so many capitulated.  Through a network of nonprofit groups,  Mr. Soros has spent at least $80 million on these drugs legalisation efforts since 1994. And more in the last three years. I fear the APPG’s effort (ably backed by Nick Clegg who also seems oblivious to the relationship between cannabis and mental illness) is but the latest in a line of such campaigns whose objective is effectively to legalise recreational cannabis. These go back to 1979 when Keith Stroup of NORML, the group “that speaks for pot users’ originally admitted that medipot was  a red herring to get pot a good name.  More recently he revealed that he was not too keen on cannabis compounds being subjected to scientific drug research trials. He said that the “pharmaceuticalisation” of cannabis was a battleground to be fought in order to protect ‘the options of patients’ – to smoke dope as it is.

I wonder if this too is why Meacher is so reluctant to give a full account of cannabis research and medical regulation? It rather pulls her medi-pot carpet from under her feet.

Source:   May 2017

“We should all be dead,” said Jonathan Goyer one bright morning in January as he looked across a room filled with dozens of his co-workers and clients. The Anchor Recovery Community Center, which Goyer helps run, occupies the shell of an office building in Pawtucket, Rhode Island. Founded seven years ago, Anchor specializes in “peer-to-peer” counselling for drug addicts. With state help and private grants, Anchor throws everything but the kitchen sink at addiction. It hosts Narcotics Anonymous meetings, cognitive behavioral therapy sessions, art workshops, and personal counselling. It runs a telephone hotline and a hospital outreach program. It has an employment center for connecting newly drug-free people to sympathetic hirers, and banks of computers for those who lack them. And all the people who work here have been in the very pit of addiction—shoplifting to pay for a morning dose, selling their bodies, or dragging out their adult lives in prison. Some have been taken to emergency rooms and “hit” with powerful anti-overdose drugs to bring them back from respiratory failure.

That is how it was with Goyer. His father died of an overdose at forty-one, in 2004. His twenty-nine-year-old brother OD’d and died in 2009. When he was shooting heroin he slept on the floor of a public garage. He would pick up used hypodermic needles if they were new enough that the volume gauges inked on the outside hadn’t been rubbed off with use. He OD’d several times before getting clean in 2013. Now he visits people after overdoses and tells them, “I was right where you’re at.”

There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. Fifty-two thousand Americans died of overdoses in 2015—about four times as many as died from gun homicides and half again as many as died in car accidents. Pawtucket is a small place, and yet 5,400 addicts are members at Anchor. Six hundred visit every day. Rhode Island is a small place, too. It has just over a million people. One Brown University epidemiologist estimates that 20,000 of them are opioid addicts—2 percent of the population.

Salisbury, Massachusetts (pop. 8,000), was founded in 1638, and the opium crisis is the worst thing that has ever happened to it. The town lost one young person in the decade-long Vietnam War. It has lost fifteen to heroin in the last two years. Last summer, Huntington, West Virginia (pop. 49,000), saw twenty-eight overdoses in four hours. Episodes like these played a role in the decline in U.S. life expectancy in 2015. The death toll far eclipses those of all previous drug crises.

And yet, after five decades of alarm over threats that were small by comparison, politicians and the media have offered only a muted response. A willingness at least to talk about opioid deaths (among other taboo subjects) surely helped Donald Trump win last November’s election. In his inaugural address, President Trump referred to the drug epidemic (among other problems) as “carnage.” Those who call the word an irresponsible exaggeration are wrong.

Jazz musicians knew what heroin was in the 1950s. Other Americans needed to have it explained to them. Even in the 1960s and 1970s, with bourgeois norms and drug enforcement weakening, heroin lost none of its terrifying underworld associations. People weren’t shooting it at Woodstock. Today, with much of the discourse on drug addiction controlled by medical bureaucrats, it is common to speak of addiction as an “equal-opportunity disease” that can “strike anyone.” While this may be true on the pharmacological level, it was until quite recently a sociological falsehood. In fact, most of the country had powerful moral, social, cultural, and legal immunities against heroin

and opiate addiction. For 99 percent of the population, it was an adventure that had to be sought out. That has now changed.

America had built up these immunities through hard experience. At the turn of the nineteenth century, scientists isolated morphine, the active ingredient in opium, and in the 1850s the hypodermic needle was invented. They seemed a godsend in Civil War field hospitals, but many soldiers came home addicted. Zealous doctors prescribed opiates to upper-middle-class women for everything from menstrual cramps to “hysteria.” The “acetylization” of morphine led to the development of heroin. Bayer began marketing it as a cough suppressant in 1898, which made matters worse. The tally of wrecked middle-class families and lives was already high by the time Congress passed the Harrison Narcotics Tax Act in 1914, threatening jail for doctors who prescribed opiates to addicts. Americans had had it with heroin. It took almost a century before drug companies could talk them back into using drugs like it.

If you take too much heroin, your breathing slows until you die. Unfortunately, the drug sets an addictive trap that is sinister and subtle. It provides a euphoria—a feeling of contentment, simplification, and release—which users swear has no equal. Users quickly develop a tolerance, requiring higher and higher amounts to get the same effect. The dosage required to attain the feeling the user originally experienced rises until it is higher than the dosage that will kill him. An addict can get more or less “straight,” but approaching the euphoria he longs for requires walking up to the gates of death. If a heroin addict sees on the news that a user or two has died from an overly strong batch of heroin in some housing project somewhere, his first thought is, “Where is that? That’s the stuff I want.”

Tolerance ebbs as fast as it rises. The most dangerous day for a junkie is not the day he gets arrested, although the withdrawal symptoms—should he not receive medical treatment—are painful and embarrassing, and no picnic for his cellmate, either. But withdrawals are not generally life-threatening, as they are for a hardened alcoholic. The dangerous day comes when the addict is released, for the dosage he had taken comfortably until his arrest two weeks ago may now be enough to kill him.

The best way for a society to avoid the dangers of addictive and dangerous drugs is to severely restrict access to them. That is why, in the twentieth century, powerful opiates and opioids (an opioid is a synthetic drug that mimics opium) were largely taboo—confined to patients with serious cancers, and often to end-of-life care. But two decades ago, a combination of libertarian attitudes about drugs and a massive corporate marketing effort combined to instruct millions of vulnerable people about the blessed relief opioids could bring, if only mulish oldsters in the medical profession could get over their hang-ups and be convinced to prescribe them. One of the rhetorical tactics is now familiar from debates about Islam and terrorism: Industry advocates accused doctors reluctant to prescribe addictive medicines of suffering from “opiophobia.”

In 1996, Purdue Pharmaceuticals brought to market OxyContin, an “extended release” version of the opioid oxycodone. (The “-contin” suffix comes from “continuous.”) The time-release formula meant companies could pack lots of oxycodone into one pill, with less risk of abuse, or so scientists claimed. Purdue did not reckon with the ingenuity of addicts, who by smashing or chewing or dissolving the pills could release the whole narcotic load at once. That is the charitable account of what happened. In 2007, three of Purdue’s executives pled guilty to felony misbranding at the time of the release of OxyContin, and the company paid $600 million in fines. In 2010, Purdue brought out a reformulated OxyContin that was harder to tamper with. Most of Purdue’s revenues still come from OxyContin. In 2015, the Sackler family, the company’s sole owners,

suddenly appeared at number sixteen on Forbes magazine’s list of America’s richest families.

Today’s opioid epidemic is, in part, an unintended consequence of the Reagan era. America in the 1980s and 1990s was guided by a coalition of profit-seeking corporations and concerned traditional communities, both of which had felt oppressed by a high-handed government. But whereas Reaganism gave real power to corporations, it gave only rhetorical power to communities. Eventually, when the interests of corporations and communities clashed, the former were in a position to wipe the latter out. The politics of the 1980s wound up enlisting the American middle class in the project of its own dispossession.

OxyContin was only the most commercially successful of many new opioids. At the time, the whole pharmaceutical industry was engaged in a lobbying and public relations effort to restore opioids to the average middle-class family’s pharmacopeia, where they had not been found since before World War I. The American Pain Foundation, which presented itself as an advocate for patients suffering chronic conditions, was revealed by the Washington Post in 2011 to have received 90 percent of its funding from medical companies.

“Pain centers” were endowed. “Chronic pain” became a condition, not just a symptom. The American Pain Society led an advertising campaign calling pain the “fifth vital sign” (after pulse, respiration, blood pressure, and temperature). Certain doctors, notoriously the anaesthesiologist Russell Portenoy of the Beth Israel Medical Center, called for more aggressive pain treatment. “We had to destigmatize these drugs,” he later told the Wall Street Journal. A whole generation of doctors was schooled in the new understanding of pain. Patients threatened malpractice suits against doctors who did not prescribe pain medications liberally, and gave them bad marks on the “patient satisfaction” surveys that, in some insurance programs, determine doctor compensation. Today, more than a third of Americans are prescribed painkillers every year.

Very few of them go on to a full-blown addiction. The calamity of the 1990s opioid revolution is not so much that it turned real pain patients into junkies—although that did happen. The calamity is that a broad regulatory and cultural shift released a massive quantity of addictive drugs into the public at large. Once widely available, the supply “found” people susceptible to addiction. A suburban teenager with a lot of curiosity might discover that Grandpa, who just had his knee replaced, kept a bottle of hydrocodone on the bedside table. A construction boss might hand out Vicodin at the beginning of the workday, whether as a remedy for back pain or a perquisite of the job. Pills are doseable—and they don’t require you to use needles and run the risk of getting AIDS. So a person who would never have become a heroin addict in the old days of the opioid taboo could now become the equivalent of one, in a more antiseptic way.

But a shocking number of people wound up with a classic heroin problem anyway. Relaxed taboos and ready supply created a much wider appetite for opioids. Once that happened, heroin turned out to be very competitively priced. Not only that, it is harder to crack down on heavily armed drug gangs that sell it than on the unscrupulous doctors who turned their practices into “pill mills.” Addicts in Maine complain about the rising price of black-market pharmaceutical pills: They have risen far above the dollar-a-milligram that used to constitute a kind of “par” in the drug market. An Oxy 30 will now run you forty-five bucks. But you can shoot heroin when the pills run out, and it will save you money. A lot of money. Heroin started pouring into the eastern United States a decade ago, even before the price of pills began to climb. Since then, its price

has fallen further, its purity has risen—and, lately, the number of heroin deaths is rising sharply everywhere. That is because, when we say heroin, we increasingly mean fentanyl.

Fentanyl is an opioid invented in 1959. Its primary use is in transdermal patches given to people for end-of-life care. If you steal a bunch of these, you can make good money with them on the street. Addicts like to suck on them—an extremely dangerous way to get a high. Fentanyl in its usual form is about fifty times as strong as street heroin. But there are many different kinds of fentanyl, so the wallop it packs is not just strong but unpredictable. There is butyrfentanyl, which is about a quarter the strength of ordinary fentanyl. There is acetylfentanyl, which is also somewhat weaker. There is carfentanil, which is 10,000 times as strong as morphine. It is usually used as an animal tranquilizer, although Russian soldiers used an aerosol version to knock out Chechen hostage-takers before their raid on a Moscow theater in 2002. A Chinese laboratory makes its own fentanyl-based animal tranquilizer, W-18, which finds its way into Maine through Canada.

China manufactures a good deal of the fentanyl that comes to the U.S., one of those unanticipated consequences of globalization. The dealers responsible for cutting it by a factor of fifty are unlikely to be trained pharmacists. The cutting lab may consist of one teenager flown up from the Dominican Republic alone in a room with a Cuisinart and a box of starch or paracetamol. It takes considerable skill to distribute the chemicals evenly throughout a package of drugs. Since a shot of heroin involves only the tiniest little pinch of the substance, you might tap into a part of the baggie that is all cutting agent, no drug—in which case you won’t get high. On the other hand, you could get a fentanyl-intensive pinch—in which case you will be found dead soon thereafter with the needle still sticking out of your arm. This is why fentanyl-linked deaths are, in some states, multiplying year on year. The federal CDC has lagged in reporting in recent years, but we can get a hint of the nationwide toll by looking at fentanyl deaths state by state. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.

Sometimes arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl. But there are addicts who swear they can tell what’s in the barrel of their needles. One in Rhode Island, whom we’ll call Gilberto, says heroin has a pleasant caramel brown tint, like the last sip of Coca-Cola in a glass. Fentanyl is clear. And many addicts claim they can recognize the high. “Fentanyl just hits you. Hard,” Gilberto says. “But it’s got no legs on it. It lasts about two hours. Heroin will hold you.” This makes fentanyl a distinctly inconvenient drug, but many addicts prefer it. All dealers, at least around Rhode Island, describe their heroin as “the fire,” in the same way all chefs describe their ribs as so tender they just fall off the bone.

“I knew we were screwed, as a state and as a country,” Jonathan Goyer says, “when I had a conversation with a kid who was going through withdrawals.” Although he had enough money to get safer drugs, the kid was going to wait through the sweats and the diarrhea and the nausea until his dealer came in at 5 p.m. That would allow him to risk his life on fentanyl.

Those in heroin’s grip often say: “There are only two kinds of people—the ones I get money from and the ones I give money to.” A man who is dead to his wife and his children may be desperate to make a connection with his dealer. They don’t buy much besides heroin—perhaps a plastic cup of someone else’s drug-free urine on a day when they need to take a drug test for a hospital or employer. This will set them back twenty or thirty dollars. In addiction, as in more mainstream endeavors, the lords of hedonism

are the slaves of money. Gilberto in Rhode Island claims to have put a million dollars into each of his needle-pocked arms, at the rate of three fifty-bag “bricks” of heroin a day.

Dealers are businessmen and behave like businessmen, albeit heavily armed ones. They may “throw something” to a particularly reliable customer—that is, give him enough heroin from time to time to allow him to deal a bit on his own account and stay solvent. An addict who discovers that the 10mg pills he is paying $18 each for in Maine are available for $10 in Boston, a three-hour drive away, may be tempted to sell them to support his own habit. The line between users and pushers blurs, rendering impractical the policy that most people prefer—be merciful to drug users, but come down hard on dealers.

Addicts wake up “sick,” which is the word they use for the tremulous, damp, and terrifying experience of withdrawal. They need to “make money,” which is their expression for doing something illegal. Some neighborhood bodegas—the addicts know which ones—will pay 50 cents on the dollar for anything stolen from CVS. That is why razor blades, printer cartridges, and other expensive portable items are now kept under lock and key where you shop. Addicts shoplift from Home Depot and drag things from the loading docks. They pull off scams. They will scavenge for thrown-out receipts in trash cans outside an appliance store, enter the store, find the receipted item, and try to return it for cash. On the edge of the White Mountains in Maine, word spread that the policy at Hannaford, the dominant supermarket chain, was not to dispute returns of under $25. For a while, there was a run on the big cans of extra virgin olive oil that sold for $24.99, which were brought to the cash registers every day by a succession of men and women who did not, at first sight, look like connoisseurs of Mediterranean cuisine. Women prostitute themselves on Internet sites. Others go into hospital emergency rooms, claiming a desperately painful toothache that can be fixed only with some opioid. (Because if pain is a “fifth vital sign,” it is the only one that requires a patient’s own testimony to measure.) This is generally repeated until the pain-sufferer grows familiar enough to the triage nurses to get “red-flagged.”

The population of addicts is like the population of deer. It is highest in rustic places with access to urban supplies. Missouri’s heroin problem is worst in the rural counties near St. Louis. New Hampshire’s is worst in the small cities and towns an hour or so away from the drug markets of Massachusetts: Lawrence, Lowell, and Boston. But the opioid epidemic of the past decade is unusually diverse. Anchor’s emergency room clients are 82 percent white, 9 percent Hispanic, and 6 percent black. The state of Rhode Island is 85 percent white, 9 percent Hispanic, and 5 percent black. “I try to target outreach,” Goyer says, “but the demographics are too random for that.”

Drug addiction used to be a ghetto thing. Now Oxycodone has joined shuttered factories and Donald Trump as a symbol of white working-class desperation and fecklessness. The reaction has been unsympathetic. Writes Nadja Popovich in The Guardian: “Some point to this change in racial and economic demographics as one reason many politicians have re-evaluated the tough ‘war on drugs’ rhetoric of the past 30 years.”

The implicit accusation is that only now that whites are involved have racist authorities been roused to act. This is false in two ways. First, authorities have not been roused to act. Second, when they do, they will have epidemiological, and not just tribal, grounds for doing so. A plague afflicting an entire country, across ethnic groups, is by definition more devastating than a plague afflicting only part of it. A heroin scourge in America’s housing projects coincided with a wave of heroin-addicted soldiers brought back from Vietnam, with a cost peaking between 1973 and 1975 at 1.5 overdose deaths per 100,000. The Nixon White House panicked. Curtis Mayfield wrote his soul ballad

“Freddie’s Dead.” The crack epidemic of the mid- to late 1980s was worse, with a death rate reaching almost two per 100,000. George H. W. Bush declared war on drugs. The present opioid epidemic is killing 10.3 people per 100,000, and that is without the fentanyl-impacted statistics from 2016. In some states it is far worse: over thirty per 100,000 in New Hampshire and over forty in West Virginia.

In 2015, the Princeton economists Angus Deaton and Anne Case released a paper showing that the life expectancy of middle-aged white people was falling. Prominent among the causes cited were “the increased availability of opioid prescriptions for pain” and the falling price and rising potency of heroin. Census figures show that Case and Deaton had put the case mildly: Life expectancy was falling for all whites. Although they are the only racial group to have experienced a decline in longevity—other races enjoyed steep increases—there are still enough whites in the United States that this meant longevity fell for the country as a whole.

Bill Clinton alluded to the Case-Deaton study often during his wife’s presidential campaign. He would say that poor white people are “dying of a broken heart.” Heroin has become a symbol of both working-class depravity and ruling-class neglect—an explosive combination in today’s political climate.

Maine’s politicians have taken the opioid epidemic as seriously as any in the country. Various new laws have capped the maximum daily strength of prescribed opioids and limited prescriptions to seven days. The levels are so low that they have led some doctors to warn that patients will go onto the street to get their dosages topped off. “We were sad,” State Representative Phyllis Ginzler said in January, “to have to come between doctor and patient.” She felt the deadly stakes of Maine’s problem gave her little alternative.

Paul LePage, the state’s garrulous governor, has been even more direct. Speaking of drug dealers at a town hall in rural Bridgton in early 2016, he said: “These are guys with the name D-Money, Smoothie, Shifty, these types of guys. They come from Connecticut and New York, they come up here, they sell their heroin, they go back home. Incidentally, half the time they impregnate a young white girl before they leave.” This is what the politics of heroin threatens to become nationwide: To break the bureaucratic inertia, one side will go to any rhetorical length, even invoking race. To protect governing norms, the other side will invoke decency, even as the damage mounts. It is what the politics of everything is becoming nationwide. From town to town across the country, the correlation of drug overdoses and the Trump vote is high.

The drug problem is already political. It is being reframed by establishment voices as a problem of minority rights and stigmatization. A documentary called The Anonymous People casts the country’s 20 million addicts as a subculture or “community” who have been denied resources and self-respect. In it, Patrick Kennedy, who was Rhode Island’s congressman until 2011 and who was treated for OxyContin addiction in 2006, says: “If we can ever tap those 20 million people in long-term recovery, you’ve changed this overnight.” What’s needed is empowerment. Another interviewee says, “I refuse to be ashamed of what I am.”

This marks a big change in attitudes. Difficult though recovery from addiction has always been, it has always had this on its side: It is a rigorously truth-focused and euphemism-free endeavor, something increasingly rare in our era of weasel words. The face of addiction a generation ago was that of the working-class or upper-middle-class man, probably long and intimately known to his neighbors, who stood up at an AA meeting in a church basement and bluntly said, “Hi, I’m X, and I’m an alcoholic.”

The culture of addiction treatment that prevails today is losing touch with such candour. It is marked by an extraordinary level of political correctness. Several of the addiction professionals interviewed for this article sent lists of the proper terminology to use when writing about opioid addiction, and instructions on how to write about it in a caring way. These people are mostly generous, hard-working, and devoted. But their codes are neither scientific nor explanatory; they are political.

The director of a Midwestern state’s mental health programs emailed a chart called “‘Watch What You Call Me’: The Changing Language of Addiction and Mental Illness,” compiled by the Boston University doctor Richard Saltz. It is a document so Orwellian that one’s first reaction is to suspect it is a parody, or some kind of “fake news” dreamed up on a cynical website. We are not supposed to say “drug abuse”; use “substance use disorder” instead. To say that an addict’s urine sample is “clean” is to use “words that wound”; better to say he had a “negative drug test.” “Binge drinking” is out—“heavy alcohol use” is what you should say. Bizarrely, “attempted suicide” is deemed unacceptable; we need to call it an “unsuccessful suicide.” These terms are periphrastic and antiscientific. Imprecision is their goal. Some of them (like the concept of a “successful suicide”) are downright insane. This habit of euphemism and propaganda is not merely widespread. It is official. In January 2017, less than two weeks before the end of the last presidential administration, drug office head Michael Botticelli issued a memo called “Changing the Language of Addiction,” a similarly fussy list of officially approved euphemisms.

Residents of the upper-middle-class town of Marblehead, Massachusetts, were shocked in January when a beautiful twenty-four-year-old woman who had excelled at the local high school gave an interview to the New York Times in which she described her heroin addiction. They were perhaps more shocked by her description of the things she had done to get drugs. A week later, the police chief announced that the town had had twenty-six overdoses and four deaths in the past year. One of these, the son of a fireman, died over Labor Day. At the burial, a friend of the dead man overdosed and was rushed to the hospital. One fireman there said to a mourner that this was not uncommon: Sometimes, at the scene of an overdose, they will find a healthy- and alert-looking companion and bring him along to the hospital too, assuming he might be standing up only because the drug hasn’t hit him yet. In communities like this, concerns about “hurtful” words and stigma can seem beside the point.

Former Bush administration drug czar John Walters and two other scholars wrote last fall, “There is another type of ‘stigma’ afflicting drug users—that their crisis is somehow undeserving of the full resources necessary for their rescue.” Walters is talking largely about law enforcement. As he said more recently: “If someone were getting food poisoning from cans of tuna, the whole way we’re doing this would be more aggressive.”

Which is not the direction we’re going. In state after state, voters have chosen to liberalize drug laws regarding marijuana. If you want an example of mass media–induced groupthink, Google the phrase “We cannot arrest our way out of the drug problem” and count the number of politicians who parrot it. It is true that we cannot arrest our way out of a drug problem. But we cannot medicate and counsel our way out of it, either, and that is what we have been trying to do for almost a decade.

Calling addiction a disease usefully describes certain measurable aspects of the problem—particularly tolerance and withdrawal. It fails to capture what is special and dangerous about the way drugs bind with people’s minds. Almost every known disease is something people wish to be rid of. Addiction is different. Addicts resist known cures—even to the point of death. If you do not reckon with why addicts go to such

lengths to continue suffering, you are unlikely to figure out how to treat them. This turns out to be an intensely personal matter.

Medical treatment plays an obvious role in addressing the heroin epidemic, especially in the efforts to save those who have overdosed or helping addicts manage their addictions. But as an overall approach, it partakes of some of the same fallacies as its supposed opposite, “heartless” incarceration. Both leave out the addict and his drama. Medicalizing the heroin crisis may not stigmatize him, but it belittles him. Moral condemnation is an incomplete response to the addict. But it has its place, because it does the addict the compliment of assuming he has a conscience, a set of thought processes. Those thought processes are what led him into his artificial hell. They are his best shot at finding a way out.

In 1993, Francis F. Seeburger, a professor of philosophy at the University of Denver, wrote a profound book on the thought processes of addicts called Addiction and Responsibility. We tend to focus on the damage addiction does. A cliché among empathetic therapists, eager to describe addiction as a standard-issue disease, is that “no one ever decides to become an addict.” But that is not exactly true, Seeburger shows. “Something like an addiction to addiction plays a role in all addiction,” he writes. “Addiction itself . . . is tempting; it has many attractive features.” In an empty world, people have a need to need. Addiction supplies it. “Addiction involves the addict. It does not present itself as some externally imposed condition. Instead, it comes toward the addict as the addict’s very self.” Addiction plays on our strengths, not just our failings. It simplifies things. It relieves us of certain responsibilities. It gives life a meaning. It is a “perversely clever copy of that transcendent peace of God.”

The founders of Alcoholics Anonymous thought there was something satanic about addiction. The mightiest sentence in the book of Alcoholics Anonymous is this: “Remember that we deal with alcohol—cunning, baffling, powerful!” The addict is, in his own, life-damaged way, rational. He’s too rational. He is a dedicated person—an oblate of sorts, as Seeburger puts it. He has commitments in another, nether world.

That makes addiction a special problem. The addict is unlikely ever to take seriously the counsel of someone who has not heard the call of that netherworld. Why should he? The counsel of such a person will be, measured against what the addict knows about pleasure and pain, uninformed. That is why Twelve Step programs and peer-to-peer counselling, of the sort offered by Goyer and his colleagues, have been an indispensable element in dragging people out of addiction. They have authority. They are, to use the street expression, legit.

The deeper problem, however, is at once metaphysical and practical, and we’re going to have a very hard time confronting it. We in the sober world have, for about half a century, been renouncing our allegiance to anything that forbids or commands. Perhaps this is why, as this drug epidemic has spread, our efforts have been so unavailing and we have struggled even to describe it. Addicts, in their own short-circuited, reductive, and destructive way, are armed with a sense of purpose. We aren’t. It is not a coincidence that the claims of political correctness have found their way into the culture of addiction treatment just now. This sometimes appears to be the only grounds for compulsion that the non-addicted part of our culture has left.

Christopher Caldwell is a senior editor at the Weekly Standard.


Meet Ryan Hampton, 36, recovery advocate, political activist and recovering heroin addict igniting America’s social media feeds with stories of hope, recovery and activism. From his advocacy that led Sephora to take their eyeshadow branded “druggie” off the shelves to the activism that urged an Arizona politician to apologize for a statement stigmatizing addiction, he’s certainly become a social media powerhouse for all things addiction, recovery and policy. And with an estimated 7 out of 10 people on social media platforms, it’s no coincidence he’s found success taking the addiction advocacy fight digital.

Today, more than 22 million people are struggling with addiction, and it’s estimated that as a result, more than 45 million people are affected. But what many people don’t realize is that there are more than 23 million people living in active, long-term recovery today. Yet, because of shame and stigma, many stay silent. To fight this often-lethal silence, Hampton has urged the public to speak up and share personal stories of recovery through his recently launched Voices Project. The project, a collaborative effort to encourage people across the nation to share their story, exists to put real faces and names behind the addiction epidemic.

A Personal Struggle

Before becoming a national recovery advocate and social media powerhouse, Hampton himself faced a personal struggle with addiction. A former staffer in the Clinton White House, Hampton did not appear to be a likely candidate for heroin addiction, or so stigma would say. But after an injury and subsequent prescription for pain medication, Hampton found himself addicted to opiates, eventually leading to a heroin addiction that would span more than a decade.  After a long struggle, Hampton decided to get help.

It was the phone call that started his recovery journey that changed everything – his life and his view on the power of his phone. After getting sober, he began connecting with others in recovery, amazed at the magnitude of the digital community. But still, while uncovering these online stories of recovery, Hampton lost four friends to opioid addiction.

It was a breaking point for Hampton – one that led to the beginning of a movement that would someday reach and impact millions.

A Notable Partner

Hampton began reaching out to others in recovery and started realizing the power of digital tools to connect and build an online recovery community. And as he was slowly networking and meeting others in recovery, on October 4, 2015, Hampton’s advocacy met its catalyst: Facing Addiction.   The non-profit organization hosted a concert at the National Mall in Washington, D.C., an event that drew thousands to the capitol with celebrities, musicians and other well-known names willing to publicly celebrate the reality of recovery and call for reform in the addiction industry. Hampton, a Los Angeles resident, tuned into the event from across the country through Facebook Live and was again inspired by the content delivered through his mobile phone.

After meeting co-founders of Facing Addiction, Jim Hood and Greg Williams, Hampton plugged in, partnered and even joined the Facing Addiction team as a recovery advocate.

The importance of online advocacy aligns with Facing Addictions’ national priorities, shares CEO Jim Hood, “When enough people tell enough stories and the people who are impacted by addiction look like all of us and our kids and neighbors and relatives, the stigma has to start going away. And then we can get to work.”

After partnering with Facing Addiction, Hampton understood the priorities, the strategy and the mechanism. Said by Hampton, “I stand on the shoulders of giants”.

Leveraging the power of the algorithms at his fingertips every day, Hampton has grown his online presence to be one of the most influential in the recovery movement. Digital communication helped him get to treatment, connected him with Facing Addiction, and now is the platform in which he is sharing recovery stories from across the nation.

In just one week, more than 200 stories were submitted to the Voices Project and over 500 people sent in personal messages to express their support. Among those speaking up are notable voices such as pro skateboarder and former Jackass member Brandon Novak;   Grammy Award-winning musician Sirah;  rapper Royce da 5’9’’;   American politician and mental health advocate Patrick Kennedy;  former child actress and now-addiction counselor Mackenzie Phillips, and more.

According to Royce da 5’9’’, “Addiction is a problem that we all have to deal with. It affects us all in one way or another, and having someone giving it a voice, a name and a face not only helps get rid of the stigma regarding addiction, but he’s [Ryan] on the forefront letting people know there are solutions out there and recovery is real.”

Patrick Kennedy shares the importance of building a digital recovery movement to influence and support political reform in the addiction recovery space. “With the push of a button we’ll be able to have others show up to support communities across the nation,” says Kennedy, “because their fight is our fight.”

“The face of addiction is everyone,” Sirah shares. “The Voices Project gives people a voice and a connection to hope.”

The hope offered through open dialogue about addiction and recovery has now grown into a digital movement.

The pages that Hampton started with $20 and an old computer have gained more than 200,000 followers across platforms, reaching nearly 1 million people each week. “We’re the fastest-growing social movement in history – and the funny thing is, we’re a community that nobody ever wanted to be a part of,” Novak says.

“This is the one space where we cannot be ignored. The time has come for us to speak out, and we’re a community that speaks loudly. With addiction, we’re dealing with imminent death every day,” Hampton says. “Through social media, we’ve found an innovative way to communicate with each other and connect with people we haven’t met, and now, we’re having this conversation with the rest of the world.”

Perhaps the most intriguing impact of Hampton’s work is the paradoxical ability to bring the work of addiction recovery advocacy online – only to take it back offline through real-world change in communities across the country. According to Hampton, the work he’s doing shouldn’t stay digital – it should impact community laws, help new non-profits emerge and influence real people to seek treatment and find it.

“No matter if you have social media or not – your way of doing this is talking about addiction at the dinner table, to a parent or a friend or an employer. You should not be afraid to tell your story of recovery or loss and, most importantly, your story of struggle and how you need help. It may not just change your life, it may change someone else’s life,” Hampton says.

At the crux of digital advocacy in the addiction recovery realm are real lives being saved – people finding treatment, families finding hope and those in recovery being freed of stigma that can keep them in shame and silence.  This is the mission that has fuelled Hampton’s work since the beginning. And Hampton’s reason is hard to refute: “My story is powerful, but our stories are powerful beyond measure.”


‘What can we do?’ This was the question that dominated the weekend’s news and current affairs in the aftermath of the Westminster ‘terror’ attack. We still do not know if it was organised by so-called Islamic State or, as seems increasingly likely, was the savage work of a ‘lone wolf’.

The discussion I heard on Any Questions centred on rooting out radicalisation, smartening up security, or accepting ‘the new normal’ that the likes of Sadiq Khan and Dominic Grieve (the security services have done well and something was bound to happen at some point) seem resigned to – a world where increasingly frequent human sacrifices are subliminally accepted as a price worth paying to protect our democracy and ‘our way of life’.

Two factors were not considered. One, the role of family dysfunction and two, the role of drugs, in catalysing the sort of violence perpetrated in Westminster last Wednesday.

From the moment he was born to a 17-year-old lone mother, Adrian Ajao was statistically at risk. Newspapers referred to his ‘well to do’ Home Counties upbringing but of far more significance for this baby’s future life path was a birth certificate that listed only his mother. I am not asking you to weep but to accept, statistically, that Adrian didn’t get off to a very good start. The hard statistical fact is that children who live continuously with lone mothers have poorer cognitive and socio-emotional outcomes compared to children who have biological fathers as a stable part of the household and family life.

Any idea that the presence of a stepfather helps can be forgotten. It doesn’t stack up statistically either – children are no less at risk of poor outcomes in step households. Adrian adopted his stepfather’s name only symbolically to abandon it later.

While some children in Africa are named after the unfortunate circumstances they are born to, in the modern West the unfortunate circumstance is not to have a biological father to name you.

Here is where the trajectory from pain to violence begins. As the young Adrian hit his late teens, his chances of his hitting drugs too were high. From the graphic descriptions volunteered by former friends it was to prove disastrous. Cannabis, it seems likely, triggered the psychosis that was a key factor in his increasingly psychotic and violent behaviour.

Before his final horrific killing spree in Westminster last week, Khalid Masood (as he became) had gone from troubled teen to terror of his neighbourhood; once he tried to run a neighbour down and the wife he married in 2004 fled for her life. He would be jailed twice for slashing people with knives.

For anyone in a culture of denial about cannabis, schizophrenia and violence let me refer them to the epidemiological evidence in the public domain. It not only identifies cannabis use as a risk factor for schizophrenia, but in individuals with a predisposition for schizophrenia, it results in an exacerbation of symptoms and worsening of the schizophrenic prognosis (Simona A. Stilo,MD; Robin M. Murray RM. Translational Research 2010: The epidemiology of schizophrenia: replacing dogma with knowledge. Dialogues Clin Neurosci. 2010 Sep;12(3):305–315). A recently published Cambridge Study in Delinquent Development – a 50-year cohort study – has categorically found that cannabis caused a seven-fold increase in a violent behaviour and that continued use of cannabis over the lifetime of the study was strongest predictor of violent convictions, even when all other factors that contributed to violent behaviour were accounted for. A study of Norwegian youths similarly found an association between cannabis use and violence and that frequency of cannabis use relates to frequency of incidents of violent behaviour. The preliminary findings of another study have found the changes in brain function that suggest the mechanism for cannabis-induced violence.

Ajao is not the only young British drug user to become prone to sudden bursts of violence, to dream about killing someone or to harbour a blood lust. Our NHS psychiatric wards are full of them on anti-psychotic medication to stop them hearing voices while they yet still abuse cannabis.

An analysis of hospital episode statistics I investigated a few years ago revealed the extent of the cannabis mental health crisis in the UK, despite an overall fall in use. Between 1998 and 2011, mental and behavioural disorders due to cannabis use increased overall by 54 per cent. This included an 108 per cent increase in harmful use episodes, a 51 per cent increase in dependence, a 61.8 per cent increase in psychotic disorders, and a 450 per cent increase in ‘other mental and behavioural disorders. Drug-related hospital admissions have reached record highs too in recent years. Most, 70 per cent are men and most of these are young men. The science is there for the behavioural unit in the Home Office to investigate, as Amber Rudd promised would be the case last year when she was asked.

Since Wednesday police have been searching for explanations for Khalid Masood’s violence. They are checking all possible contacts with ISIL cells and the influence of Islamist radicals, quite rightly. Masood, I have no doubt, was ripe for radicalisation in his own unhappy quest for personal ‘justice’.

Like Lee Rigby’s killers before him, I suspect the drugs came first and the conversion followed, giving a purpose to the violent impulses lurking within. Newspaper columnist Peter Hitchens has been right to ask what violent killers have in common and to ask whether it is dope that may be the real mind-blowing terror threat in our midst and where dysfunctional families abound. For the fact is that mental illness, triggered by cannabis, increases the risk of aggressive behaviour, crime and violence.

British longitudinal data on cannabis use and schizophrenia shows that the incidence of schizophrenia in South London doubled between 1965 and 1999. The study uniquely allowed for the examination of trends in cannabis use prior to first presentation with schizophrenia. The greatest increase was found in people under 35. Its author Professor Sir Robin Murray has suggested that up to 20 per cent of schizophrenia cases could be cannabis attributable.

Despite all this, the Government in the UK has kept its head in the sand over this public health and safety time bomb. It has never fulfilled its pledge to run a major public health education campaign.

The evidence should tell Amber Rudd’s Home Office ‘behaviour unit’ that it is overdue, as is committed policing to protect young men at risk.  This has to be part of any prevention strategy in response to the carnage in Westminster last week. The link between cannabis and violence, as I argued before, can no longer be ignored.

Source:   28th March 2017 

The Director of the NDPA, Peter Stoker, visited Vancouver East Side in 1999.  It was tragic to see drug dependent men and women living rough on the streets – in the alleys behind the main road – injecting in public.  A team of police officers called The Odd Squad worked the area and did everything they could to help these people – producing a great video called ‘Through the Blue Lens’ – we took this video into schools and it was the most powerful drug prevention message we had ever used.  We would urgently ask you to see this video on You Tube –

The article below is covering the same story – 19 years later.  Isn’t it about time that Canada began to promote good drug prevention instead of relaxing their drug laws? 

As overdose deaths spike, provincial health officials say more overdose prevention sites will soon open across the province.

The number of overdose deaths related to illicit drugs in British Columbia leapt to 755 by the end of November, a more than 70-per-cent jump over the number of fatalities recorded during the same time period last year.

In August, 50 people died of drug overdoses in British Columbia.  In September, 57 died. In October, the number jumped to 67 — an increase that worried health officials, who had thought that increasing the supply and training for administering the overdose reversal drug naloxone was making a difference.

In November, drug overdoses caused 128 deaths — 61 more than the previous month, and nearly double the October total. That spike has brought the total number of deaths between January and November to 755, the highest number ever recorded by the BC Coroner and a 70 per cent increase over this time last year

“We’re quite fearful that the drug supply is increasingly toxic, it’s increasingly unpredictable, and it’s very, very difficult to manage,” said Lisa Lapointe, B.C.’s chief coroner, referring to the increasing prevalence of the synthetic opioid fentanyl being added to many illicit drugs.  “Those who…attempt to use drugs safely, it’s almost impossible.”

With advance notice from the coroner that November numbers would be much higher, provincial health officials announced three weeks ago that several overdose prevention sites would open in Vancouver, Surrey and Victoria. People can go inside the sites to inject drugs, and are given first aid if they overdose.

An unofficial safe consumption site located in the alley behind the Downtown Eastside Market off East Hastings Street.

Health officials have insisted the sites are temporary and are not supervised injection sites, which are currently difficult to open because of a strict Conservative-era law that current federal health minister Jane Philpott has promised to change.

If there is any good news to be found within the grim statistics, it is that no deaths have occurred at any of those overdose prevention sites. And no one has died at a volunteer-run tent that has been operating since September, without official permission or government funding, out of an alley in the heart of the Downtown Eastside. People can smoke or snort drugs at that site, not just inject.

“We’re pretty steady, we get about 100 people a day,” said Sarah Blyth, the Downtown Eastside market coordinator and one of the organizers of the tent. “We’re coming up to welfare (day)…it’s happening this Wednesday, so I imagine up until Christmas it’s going to be pretty busy.”

A sign on the front door of VANDU’s storefront at 380 E. Hastings advertises that the location is an overdose prevention site, with volunteers trained in first aid

“A lot of people use during Christmas,” Blyth added. “Not everybody’s Christmas is as happy as others.”  At the Vancouver Area Network of Drug Users storefront further down East Hastings Street, Linda Bird confirmed the overdose prevention site located there has been busy, with around 60 people a day passing through. Volunteers, who are paid a small stipend by Vancouver Coastal Health, work two to four hour shifts. Overdoses are common, small stipend by Vancouver Coastal Health, work two to four hour shifts. Overdoses are a small stipend by Vancouver Coastal Health, work two to four hour shifts. Overdoses are common, Bird said.

“A lot of them are taking this very, very seriously,” Bird said of the volunteers. “It’s a crisis and a lot of them have seen their friends dropping.”

Vancouver Coastal Health has announced a fourth overdose prevention site in Vancouver, while Fraser Health has added more sites in Langley, Abbotsford and Maple Ridge.

Overdose deaths in November were nearly double the number seen in October

Health authorities in the Interior, Vancouver Island and the north are also planning to open sites in the future, said Perry Kendall, B.C.’s health officer.  “We’re still struggling in many communities with the idea of having these (overdose prevention) sites open,” Kendall said. “That doesn’t help.”

He urged the federal government to introduce the new legislation as soon as possible.

“You must use (drugs) in the presence of somebody who can help you,” Lapointe emphasized. “We are seeing people die with a naloxone kit open beside them, but they haven’t even had time to use it. We are seeing people die with a needle in their arm or a tablet nearby…You must go somewhere where someone is able to give you immediate medical assistance.”


As part of the ongoing efforts of the International Narcotics Control Board (INCB) to raise awareness of key issues relevant to international drug control, I have the pleasure to share with you three short texts:

* Application of principle of proportionality for drug-related offences

* Ensuring availability of narcotic drugs for medical purposes

* Carrying by international travellers of small quantities of preparations containing controlled substances

Application of principle of proportionality for drug-related offences

  1. The application of the principle of proportionality in the context of drug offences is a key aspect of a sound and effective drug policy. Some States have made extensive use of incarceration of low-level drug offenders, despite the fact that this approach is not mandated by the international drug control treaties, and some have even applied extrajudicial responses to drug-related offences, notwithstanding the fact that such actions are contrary to the treaties. It is essential to distinguish between the criminal justice provisions contained within the Conventions1,2,3, and the criminal justice policy measures which have been taken by some Governments.
  2. Implementation of the international treaties is subject to the internationally recognized principle of proportionality, which requires that a State’s treatment of illegal behaviour to be proportionate and that a punishment in response to criminal offences should be proportionate to the seriousness of the crime.
  3. The INCB has repeatedly called upon States to give due regard to the principle of proportionality in the elaboration and implementation of criminal justice policy in their efforts to address drug-related crime.
  4. While the choice of legislative or policy measures to address drug-related crime, including the determination of sanctions is the prerogative of States, the international drug control treaties require that these sanctions should be adequate and proportionate, taking into account the gravity of the offence and the degree of responsibility of the alleged offender.
  5. The international drug control treaties do not automatically require the imposition of conviction and punishment for drug-related offences, including those involving the possession, purchase or cultivation of illicit drugs, in appropriate cases of minor nature or when committed by drug users. While “serious offences shall be liable to adequate punishment, particularly by imprisonment or other penalties of deprivation of liberty”, offences of a minor or lesser gravity need not necessarily be subject to harsh criminal sanctions, such as incarceration. The Conventions afford discretion for Parties to provide, either as an alternative to conviction and punishment or in addition to conviction and punishment, that drug users undergo measures of treatment, education, after-care, rehabilitation and social reintegration.


Ensuring availability of narcotic drugs for medical purposes

  1. Some decades ago the international community made a solemn commitment with the SingleConvention on Narcotic Drugs of 1961 and the Convention on Psychotropic Substances of 1971: to ensure the availability, to make adequate provision and not to unduly restrict the availability of drugs that were considered indispensable for medical and scientific purposes. Over the past decades that promise has not been fully met. . Too many people suffer or die in pain or do not have access to the medications they need. Unnecessary suffering because of the lack of appropriate medication due to the inaction, lack of know-how or unnecessary administrative requirements is a scandal that shames us all.
  2. Around 5.5 billion people still have limited or no access to medicines containing narcotic drugs such as codeine or morphine, leaving 75 per cent of the world population without access to proper pain relief treatment. Around 92 per cent of morphine used worldwide is consumed by only 17 per cent of the world population, primarily living in the United States, Canada, Western Europe, Australia and New Zealand. Inadequate access violates the notion of article 25 of the Universal Declaration of Human Rights, including the Right to medical care, which also encompasses palliative care.
    1. This situation is caused by a variety of factors, including health care professionals, that meansThe imbalance in the availability of opioid analgesics is particularly worrying as the latest data show that many of the conditions requiring pain management, particularly cancer, are prevalent and increasing in low- and middle-income countries.doctors and nurses, not receiving adequate education and training as part of their professional education, lack of know-how and capacity of government authorities, concerns about overprescribing and addiction and overly onerous regulatory and administrative requirements. Many patients in most of the countries in Africa, Central America and the Caribbean, and South Asia are affected, but patients in other parts of the world are also affected.
    2. Concrete steps and rapid action by Member States, the international community and the pharmaceutical industry can go a long way to remedy the situation. The most important and urgent actions would involve providing specialised training for health care professionals enabling them to prescribe and administer pain medication as well as training for the competent national authorities.
    3. Governments must bring about partnerships with the pharmaceutical industry, which has a duty to act in a socially responsible manner, to ensure access to and availability of affordable medications, placing emphasis on generics.
    4. Governments need also ensure that the training curricula of doctors and nurses contain, ab initio, content on the prescribing and rational use of medicines containing controlled substances.
    5. At the same time, where necessary, legislation and regulations should be revised, prescribing practices brought up to day and the capacity of national agencies involved strengthened.
    6. If Governments, together with the relevant international agencies, were to put together a sufficiently well-resourced plan of action, Member States would be on their way to significantly contributing towards achieving a major element of Sustainable Development Goal 3 on Ensuring healthy lives and promote wellbeing for all at all ages.


Carrying by international travellers of small quantities of preparations containing narcotic drugs and psychotropic substances for personal medical use

  1. The Board’s continuing endeavour to assist travellers carrying small quantities of controlled substances for personal medical use across international borders gained, both, high visibility and prominent usefulness.
  2. An ever increasing inflow of queries from individual travellers and organizations on the aforementioned subject has been observed. The secretariat regularly receives requests for assistance and/or clarification of the applicable national rules and regulations. The requests come from organizations and individual travellers residing in various countries. In 2016, requests came from Australia, France, Italy, United Kingdom, and the United States; their countries of interest included Cambodia, Canada, Colombia, France, Germany, Guinea Bissau, Malaysia, Saudi Arabia, Thailand, Turkey and the USA.
  3. Several requests relate to common rules and regulations of the European Union and the Schengen area. The substances referenced in the queries included psychotropic substances listed in Schedules II, III and IV such as amfetamine, alprazolam, buprenorphine, dextroamphetamine, diazepam, methylphenidate, nitrazepam, tramadol, zolpidem and others that are not under international control.
  4. Since 2013, the information furnished by Governments on national requirements for travellers under medical treatment carrying preparations containing narcotic drugs or psychotropic substances under international control has been summarized in a standardized table format and made available in six official UN languages on INCB website.
  5. To date, such information is available for 109 Governments (up from 79 in May 2014)and is uploaded to the Board’s webpage, more than half are already available in the form of standardized tables translated into six official UN languages:
  6. In September 2016, given the increasing interest in this pertinent information, inparticular the international guidelines for national regulations concerning travellers under treatment with internationally controlled drugs, and the compilation of standardized summary tables of regulations by country, the secretariat sent out a reminder letter to all countries and territories, requesting all Governments to visit the above website and to inform the Board if the information pertaining to their countries accurately reflects current provisions of their national laws and regulations.
    1. The Governments that have not yet furnished any information were requested to

    provide the requisite description of all relevant legal/regulatory or administrative measures

    adopted to allow travellers entering/leaving the country to carry medical preparations

    containing controlled substances for personal medical use. In addition to full texts of relevant

    pieces of information, these Governments were also requested to fill in and to submit to the

    Board the standardized summary tables that were attached to the circular letter.

    1. The secretariat will continue to augment the list of national rules and regulations

    pertaining to travellers carrying internationally controlled substances for personal medical use,

    provide requisite assistance and attend to all inquiries in this regard.


    INCB is the independent, quasi-judicial body charged with promoting and monitoring Government compliance with the three international drug control conventions: the 1961 Single Convention on Narcotic Drugs, the 1971 Convention on Psychotropic Substances, and the 1988 Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances.






I was just a year old when I had my first experience with opioids. I was born with a hiatal hernia, which constricted my esophagus and caused me to reflux like crazy. I couldn’t keep breast milk down and I became malnourished, tiny and weak. One night, my parents, Gayle and Morty Gebien, rushed me to the hospital. I was dehydrated and spitting up everything they tried to get me to eat or drink. The doctors told my parents to prepare themselves for the possibility that I wouldn’t live through the night. They brought me into surgery and gave me morphine for the pain. Maybe that’s where it all began.

I’ve always had a difficult time coping with stress. I sucked my thumb until I was eight years old. I started smoking at age 14 and never stopped. In high school, I was a pothead, and so were most of my friends. I dropped acid and did ecstasy a handful of times. Academically, I was apathetic, skipping class often and bringing home terrible report cards. One day, when I was 17, I went golfing with friends. When I got home, my back began to ache, a dull pain like a hand wrapping around my spine and squeezing it tight. I didn’t know it then, but I had a herniated disc. I lay down on the floor of my bedroom, and it felt like my vertebrae were shifting beneath me. Eventually, the sensation passed, and I got up.

The next year, I started volunteering at a hospital in Richmond Hill, folding blankets, mopping floors and stocking shelves. That’s when I first considered becoming a doctor. I studied science at the University of Toronto Scarborough, but my grades weren’t strong enough to get me into medical school, so I moved to Montreal and did a master’s in molecular biology at McGill. After that, I went to med school at the University of Queensland in Australia and did my residency in emergency medicine in Michigan.

In 2007, I visited my parents on vacation in Florida. I slept on the couch and, during the night, I displaced the disc in my back. The pain was much stronger than what I’d experienced in high school. My mother, who had prescriptions for her own back issues—she’d slipped on wet stairs a few years before I was born—gave me a powerful opioid called Dilaudid to soothe it. I knew I liked it too much. The back pain melted away, but so did everything else. It was like taking a happy pill. I immediately felt calm, relaxed, brighter and more wakeful than usual. Later that month, I sprained my thumb playing hockey. I went to the hospital, where the doctor asked me if I wanted codeine-based Tylenol 3s or oxycodone-based Percocet. I chose the latter. I knew Percs were the stronger of the two and I wanted to know just how strong. The feeling was great—similar to how I’d felt on Dilaudid that morning in Florida. My first bottle of Percocets—30 tiny white pills—lasted about a year.

In 2008, following stints as a cruise-ship doctor and an air-ambulance physician, I landed an ER job in Saint John, New Brunswick. At the bar one night, I met a blond girl named Katie, a personal support worker at a pain clinic. I was taken by her eyes, a light bluish-grey I’d never seen before. It took me a couple of tries, but, eventually, she agreed to go out with me. In February 2009, I moved back to Toronto to take a job as an ER doctor at the York Central Hospital, and Katie and her two-year-old daughter soon followed. They rented an apartment at Bathurst and Steeles, and began settling into a routine.

I found a new doctor in Toronto who prescribed me another 30 Percocets for my back, and I started taking them more often. After a few weeks, the pain subsided, and I stopped using them, but I stashed the extras, maybe half the bottle, in my medicine cabinet. One Friday night, some buddies came over for a few beers and some PlayStation golf, and I popped a few Percocets. It wasn’t some big decision, but, in hindsight, I realize that was the moment I crossed the line. It was the first time I took them purely recreationally. They gave me a fuzzy, happy feeling I couldn’t access any other way. Soon, I was dipping into my bottle once every few weeks—if Katie and I were going camping with friends or if I needed a boost of energy to play with Katie’s daughter after a long shift. She couldn’t tell when I was high and, at first, neither could Katie. The following year, in early 2011, we learned that Katie was pregnant with a boy and we bought a five-bedroom stone house at Bathurst and Sheppard.

My parents lived a short drive away and were proud grandparents. They were over at least once a week, but my mom and Katie didn’t get along. Katie felt they were too involved in her daughter’s life—they weren’t biologically related, after all. My mom would get upset if Katie’s daughter didn’t call her on her birthday. A series of slights, real and imagined, between my mother and Katie culminated in an exchange of profanity-laden emails. I became the rope in a vicious tug-of-war. My mother would tell me to assert myself and “be a man.” Katie would say I wasn’t standing up for her. Eventually, Katie asked me to choose between her and my parents. I was dedicated to making my life with Katie work, so I told my parents that they weren’t welcome at the house anymore. Shortly after that, Katie and I flew to Las Vegas to get married. A little more than a year later, she gave birth to our second child together, a girl. My parents weren’t there for the birth, which broke my heart.

Over time, I began to rely on the pills not just to help my back pain but also to cope emotionally. Initially, I went to my doctor every couple of months, then once a month and then every couple of weeks. He recommended that I exercise, lose weight and see a physiotherapist, but he always filled my prescription. He never told me it was too much.

In August 2012, I got a job as an emergency room doctor at the Royal Victoria Regional Health Centre in Barrie. Katie and I bought a spectacular five-bedroom house on the waterfront, at the end of a cul-de-sac. We had a dock and a boat. I was making roughly $300,000 a year. I bought Katie a Lexus SUV, which we eventually traded in for an Audi Q7. But our marriage was deteriorating. We were arguing all the time—about my family, about my parenting. I’d reprimand her daughter for misbehaving, and Katie would undermine me, saying, “Daddy’s just had a bad day.” Katie had also noticed my drug use, which had gone from two pills a day to as many as eight. We fought about it at least once a week.

She wanted me to get help, but I always refused. Seeking help would have meant two things: one, admitting that I had a problem; and two, admitting that I was no longer in control. The pills helped me get through my days, and I wasn’t ready to let that go. Sometimes I slept in my car to avoid another fight.

The first time it occurred to me that I might have a drug problem, I was standing next to a lumber pile in Rona, waiting for my contractor to pick out aluminum framing for our basement renovation. I felt irritation wash over me, totally unprovoked. I couldn’t figure out what was wrong, but I popped a Percocet and immediately felt relieved. I wondered if I had been experiencing withdrawal symptoms, but I felt ashamed even considering it. I dealt with patients every day and didn’t see myself as one. Throughout my career as a doctor, I was trained to believe I was infallible. As far back as medical school, we were told that, no matter what, you don’t call in sick; you show up. So, even though I knew I was in trouble, I didn’t ask for help.

As the months went on, I continued using. That May, I was visiting my folks when I started having withdrawal symptoms. I asked my mom for a few fentanyl patches and she obliged, thinking that I just needed relief for my back pain. She had a prescription for the opioid, which is up to a hundred times more powerful than morphine. The intensely potent drug is usually doled out in surgery or given to patients with chronic pain who have built up a tolerance to other opioids. The transparent squares, which at the time looked a little like clear Band-Aids, contained two layers: one with the slow-release drug and one that’s skin adhesive. I slapped one on my back and stashed the others for later.

About a week later, I got home after a long shift and typed, “How to smoke fentanyl” into Google. My kids were with their nanny at the park near our house. I went to the garage and cut a patch into one-centimetre squares. I lined each piece up on a larger square of tin foil, then I held the lighter under the first piece, watched the puff of smoke come up and inhaled. The sweet smell of burnt plastic filled my nose and travelled deep into my lungs. It was as if I were being pushed by a powerful but gentle wave. Calm washed over me. My anxiety and fear were gone. I slowly lowered myself backward into a chair. I was higher than I’d ever been. Imagine a surge of confidence kicking in, a worldly reassurance that all of your problems will just dissolve. A soft happiness sets in, then a creativity spike. You feel totally alert, more awake and sharper than ever. Everything around you feels warmer. Now, imagine those sensations happening within a few milliseconds of each other. And that’s what it’s like to smoke fentanyl. I sat there, eyes glazed, staring out at the street for 20 minutes. I was in heaven.

Gayle Gebien, above, gave her son a few fentanyl patches for his back pain. He took them home and Googled “How to smoke fentanyl”

A drug like fentanyl doesn’t inject your body with new feelings; it borrows from the ones you already have. When the high starts to wear off, the positive sensations retreat and the negative ones become amplified. And addicts have no shortage of negative emotions. A dark cloud descends upon your brain. You become scared, anxious, agitated. The warmth rolls away and leaves you in cold sweats, shivering. Self-loathing kicks in, followed by guilt, fear, sadness, paranoia. Coming down off that first rush, my body began to ache. All I could focus on was escaping those feelings as quickly as possible, and the only solution was to smoke again. And again—each iteration sinking me deeper into dependency. From that day on, I smoked fentanyl at least six times a day and sometimes as many as 15 times.

The scariest part was that, as a doctor, I knew exactly what I was getting into, and I didn’t care. Fentanyl is one of the most dangerous opioids on the market. It can be smoked, injected or dissolved under your tongue. The federal health minister, Jane Philpott, has called Canada’s opioid problem a national public health crisis. In Ontario, 162 people died of fentanyl overdoses in 2015. In B.C., 332 people died in the first nine months of 2016.

Doctors are part of the problem. One of the most common complaints we get from patients is that we under-treat chronic pain. And, because pain is subjective and difficult to diagnose, we tend to take patients’ word for it when they say they’re in pain. Late last year, the College of Physicians and Surgeons announced it was investigating 86 doctors for prescribing daily opioid dosages that wildly exceeded national guidelines. One patient was prescribed the equivalent of 150 Tylenol 3s per day. Some of those cases occur because patients undergoing cancer treatment or living with multiple sclerosis may need very high dosages. But, in other cases, like mine, there’s rampant abuse of the system.

When I think about it now, I’m disgusted that I kept drugs in the same house as my children. At first, I locked up my patches in my toolbox in the garage. Later, I would smoke in the shower stall in our basement and hide my fentanyl under the sink behind the pipes. I convinced myself that, by taking those precautions, I was being a responsible father. I was high-functioning, but, still, my kids were getting a stoned daddy, even if they were too young to realize it. I wanted to believe that I was like any other doting dad—I took my kids to the beach in the summer, dunking the little ones in the water and wading hand in hand with the eldest. I took them apple-picking in the fall and tobogganing in the winter. The only difference was that, 15 times a day, I’d head to the basement to smoke up. That I was high around my kids is one of the hardest things for me to forgive of myself.

That summer, my cravings were ruthless, and I had no legitimate access to patches. I knew I couldn’t write prescriptions in my own name, so I came up with a plan: I began to write prescriptions for Katie, then I’d go to the pharmacy to pick them up. But I didn’t want pharmacists getting suspicious of Katie, so I began to recruit other pretend patients. I had become friendly with one of the contractors renovating our basement. At one point, I asked him: “Can you do me a favour?” I explained that I needed someone to pick up my fentanyl and that I could supply him with Percocet if he agreed, which he did. I’d write two prescriptions in his name: one for fentanyl and one for Percocet. He’d get them both filled and keep the Percs. One night, my supply was dry and I was going through withdrawal. Katie and I were arguing, and I left the house. I got in a taxi and went into town. I was so desperate that I began going from taxi to taxi, knocking on windows and asking strangers, “Are you interested in doing a swap? I can get you Percocet, but I need you to pick up some fentanyl for me.” The first three weren’t interested. The fourth was.

From August to October, I also cajoled two assistants and a nurse into giving me painkillers from the hospital. I never offered to pay them; I just told them I was in a lot of pain and couldn’t write prescriptions in my own name. I put them in a terrible position and I minimized the stakes. “Oh, it’s not a big deal,” I said. They saw I was hurting and agreed. (They were later fired for it.) Over 16 months, I acquired 445 patches of fentanyl with fraudulent prescriptions, smoking about a patch a day.

At home, my relationship with Katie was in tatters. Instead of offering support, Katie would yell at me, and I would yell back or retreat in silence. “You’re smoking again,” she would shout when she caught me going downstairs. She threatened to leave. She called me a junkie.

I never smoked before work. But I did wear a patch to stave off withdrawal symptoms. Twice I had to leave work because my cravings were too intense to keep going. I lost more than 30 pounds, my cheeks were sunken and I became irritable and jittery. Once, a colleague asked me if I was okay. I told her there were problems at home and left it at that. She didn’t ask again.

My mom had noticed my ragged state and, unbeknownst to me, called and told the hospital I might have a drug problem. My supervisor and the hospital’s chief of staff called me into a meeting and asked me if I had any problems they should be aware of. I lied. I said that things were rocky with Katie but, otherwise, no. They gave me pamphlets on addiction and mental health, and I went back to work.

I decided to change tactics. For the next four months, I forged prescriptions from other doctors in my own name. I’d go to the pharmacy and sweet-talk the staff—it was usually the same guy—into not faxing my prescription over to the hospital. Pharmacists hate to bother busy doctors, and I played on that. Every time I went to get one filled, I threatened everything: my job, my family, my freedom. I didn’t care.

One Sunday in November 2014, the pharmacist was too busy administering flu shots to speak to me and faxed the prescription. I could have tried harder to intervene, but, for some reason, I didn’t. My endless scheming had worn me down. The doctor who happened to pick it up in the ER was the same doctor whose signature I’d forged on the script, which requested a dozen patches. I didn’t know it then, but the doctor reported me to my supervisor. After 20 minutes of nervously waiting, I was waved over by the pharmacist. “We’ve run out of supplies, actually,” she said. She gave me what she claimed were her last few patches, and I went home none the wiser. Two days later, the chief of emergency and the chief of staff greeted me in the doctors’ change room. They told me that they knew about the false prescriptions, that the pharmacy had called the police and that I couldn’t work—I’d be going on unofficial leave without pay, and my medical licence would be suspended. I was scared shitless. The shame of being caught in a tangle of lies was overwhelming. I was afraid for my family, afraid I’d lose my job, afraid of what other people would say. I should have felt lucky to be alive—at that point I was a bag of skin and bones—but I just felt dizzying fear for the future. And yet, on top of all that was an unexpected wave of relief. My life had just come crashing down; at least I couldn’t deny it anymore.

I was arrested at home. Police charged me with three counts of forgery and gave me a notice to appear in court. Three days later, I went to Homewood Health Centre in Guelph, a facility recommended to me by a psychiatrist at my hospital, for five weeks. My parents covered the $10,000 bill. There, the doctors decided I should go into a rapid wean, a process intended to produce intense withdrawal and, with it, a deterrent to using drugs again. First, doctors gave me Suboxone, a pill used to get addicts off opiates. The drug satisfies some of the body’s narcotic cravings but doesn’t get you high. Coming off the Suboxone was vicious, as my endorphin levels plummeted and my brain began to rewire itself. I thought I was going to die. When I tried to walk, my body curled inward, neck down, arms tight to my chest, in a position known in rehab as the Suboxone shuffle. My ears were ringing. My body temperature began to swing like crazy: one moment I’d soothe my chills in a hot shower and the next I’d be running aimlessly outside, rubbing snow on my face. I remember telling the doctor that I couldn’t handle the pain. He agreed to give me another two milligrams of Suboxone to stave off my withdrawal. I knew that would only delay the inevitable, but, at that point, I didn’t care—I was so desperate I considered throwing myself in front of a bus. My body felt like it was disintegrating. Lifting a spoon to my mouth was tiring; walking up a ramp left me winded. The next day, I thought I was progressing, but, 32 hours later, I was still in the throes of withdrawal. I lay down on the hospital bed in my room to take a nap. When I woke up four hours later, the weakness was gone, my limbs had uncurled and my gait returned to normal. The week from hell was over.

On my 14th day in rehab, Katie brought the kids to visit. She told them that I was sick, and they assumed Homewood was a regular hospital. I’ll never forget my son asking why I wasn’t coming home with them that day.

My return from rehab was strange. Katie was exhausted from caring for the kids by herself for five weeks, and we were soon back to our bickering. I was sleeping on the couch and I was still on leave from my job, so my days were empty.

There’s a grieving process that comes with addiction, and I was grieving the loss of my drug of choice. The cycles of shame, self-loathing, rationalization and apathy returned. So I did what I always did to cope: I wrote a prescription for fentanyl using one of my old prescription pads. I didn’t realize the police were monitoring me.

Within a week, I was back to getting high 15 times a day. On the morning of January 4, I lost track of how much I’d smoked. I overdosed and collapsed in my basement shower stall. My face was a putrid shade of green, drool was dribbling down my chin and my dry tongue was hanging from my open mouth. I was barely breathing when Katie walked in. She had seen me high many times before, and she could spot the telltale bursts of energy, hoarse voice and constricted pupils, but that day was different. I’d been downstairs for longer than usual, and she hadn’t seen my face like that before. I remember her screams tearing through the fog in my head. “I’m calling an ambulance,” she cried. I jolted awake, flailing my arms as my paraphernalia went flying. I gasped for breath a few times, head lolling, then lunged for the toilet and vomited. “I thought you were dead,” she said. I told her I didn’t need an ambulance and, eventually, she stopped insisting, worn down from so many arguments. A few hours later, I was back in the stall lighting up another patch.

At 7 a.m. on January 19, 2015, 10 officers from the Barrie drug crimes unit showed up at my front door. If I have a rock bottom, I hit it that day. I woke to my three dogs barking and peered out the window to see the cops on the front steps. I opened the door in my underwear. “Sorry to do this, but your life is never going to be the same,” one of them said to me. I asked for a minute to put the dogs out in the backyard, and the officer

agreed. Another went upstairs to tell Katie she would be arrested, too, wrongly thinking she was involved. They let me put my clothes on and have a cigarette in the garage. They handcuffed me as we were walking outside, so that my kids wouldn’t see if they came downstairs. I was taken to the police station and charged with 72 counts of trafficking—for compelling the pharmacist to supply drugs under false pretences—plus six counts of forging prescriptions.

From January 19 to February 5, I was in jail at the North Correctional Centre in Penetanguishene awaiting my bail hearing. I was despondent. There was a stairwell on the second storey that overlooked the unit’s concrete floor, and I figured that if I jumped headfirst I would die. I told one guy I’d made friends with about my plan, and he pulled me aside. “Wait a second, motherfucker,” he said. “You’ve got your wife, your kids. That’s the most selfish thing you could do.” I went back to my cell. I hadn’t been using long enough after my first stint in rehab to go through acute withdrawal again, but I had the munchies like crazy, a sign of early recovery. I had an appetite so ferocious I’d chug the syrup that came with our French toast in the morning. My cellmate let me eat some of his snacks, too—Rice Krispies Treats, ketchup chips, Twix bars.

With the help of my parents, I made the $80,000 bail, but one of the conditions was that I live with my mom and dad at their Yonge and Sheppard condo. I went home briefly to collect my things. Katie wanted a stable environment for the kids, so she moved them back to New Brunswick 10 days later. I was devastated but didn’t have a choice. In April, I enrolled in Renascent, a clinic at Spadina and Bloor, for my second stint in rehab. I stayed for four weeks. During my daily walks in the neighbourhood, every time I saw a homeless person, I’d think to myself that I was closer to becoming one of them than I was prepared to admit. I was nearly out of money, my marriage was probably over and my network of friends had dwindled. I was initially represented by Marie Henein and Danielle Robitaille, the lawyers who represented former attorney general Michael Bryant and CBC host Jian Ghomeshi. I put the first payment of $35,000 on a line of credit but changed lawyers shortly after. I was still paying the mortgage on our home in Barrie and couldn’t keep up with their retainer.

In August, I walked into the Vitanova Foundation recovery centre in Woodbridge, another government-funded facility, not knowing how long I would be there. The centre offered a free rehab program and dorm-style residence, and, as the weeks passed, I felt my strength and clarity returning.

Three months later, on November 2, 2015, my 45th birthday, I got a call from my dad telling me that my mom had died. He’d found her in bed, non-responsive, wearing three 50-milligram fentanyl patches that we think she applied by accident. Her usual dose was a 25-milligram patch. It was the worst day of my life. I redoubled my efforts to stay clean. I checked out of Vitanova and moved back into my father’s condo. I slept on the couch and have continued to for the past two years. I FaceTime with my kids every couple of days, but it feels like no way to be a father. I’m on social assistance and help my dad with rent when I can—his pension isn’t enough to support both of us. Our Barrie home sold shortly after my mom’s death, and I gave most of the money to Katie, knowing that I might not be working much in the next few years. I run a flooring company with an old friend to make extra cash. And I’m still drug-free.

But my body hasn’t fully recovered: my short-term memory is spotty, I have hearing loss in my right ear and, for the first time in my life, I suffer from panic attacks. I apologized to the City of Barrie for betraying the trust of its residents. And I’ve done some outreach work, speaking to officials at the Ontario Ministry of Health and Toronto Public Health about how to tackle the opioid epidemic.

In April 2016, I filed for bankruptcy. Katie sent divorce papers a few months later. I had been hoping we’d find a way to make it as a couple, but I understood. In February, my biological kids came to stay with me for a week. I got to see my son—now five years old—skate for the first time; my little girl, who’s four, was so excited with the Hatchimal we picked out at Toys’R’Us that she carried the box around with her everywhere and showered me with hugs. I didn’t explain what was going on—I just said I’d talk to them soon. They’re too young to understand what happened. I worry about what they’ll think of me when they do find out. I hope they can be proud of my recovery, but that day is a long way away.

In December 2016, I pleaded guilty, and, as part of the deal, Katie’s charges were finally dropped. I’m awaiting my sentence. The Crown wants me locked up for eight years; my lawyer is arguing for house arrest. Most likely, the judge will settle on a multi-year prison term. My dad has early-stage Alzheimer’s, and I’m concerned about how he’ll cope while I’m gone. I worry constantly about Katie and our kids, too. I’m embarrassed that my life has become a cautionary tale, but I’m thankful that I got caught. Had I not been arrested, I’m certain I’d be dead right now.

When I get out, I will have to face the College of Physicians and Surgeons’ discipline committee, as is standard in cases like mine. My medical licence is currently suspended, and they’ll probably revoke it entirely. If they don’t, I plan to practise again, ideally in the area of addiction. I became a doctor so that I could help people. I messed up my life, but I can still help others avoid the same fate.

Correction  March 30, 2017

An earlier version of this story indicated that Darryl Gebien’s stay at Renascent was covered by OHIP, when in fact the fees there are covered by the Ministry of Health, as well as the centre’s foundation.


Outdoor cannabis cultivation in northern California has damaged forestlands and their inhabitants. Will legalization of recreational marijuana make things worse or better?

A visit to a marijuana farm in Willow Creek, the heart of northern California’s so-called Emerald Triangle feels like strolling through an orchard. At 16 feet high and eight feet around, its 99 plants are too overloaded with cannabis buds to stand on their own. Instead each plant has an aluminium cage for support.

Welcome to America’s “pot basket.” The U.S. Drug Enforcement Administration estimates 60 percent of cannabis consumed nationwide is grown in California. According to the Department of Justice, the bulk of that comes from the three upstate counties of the Emerald Triangle: Mendocino, Humboldt and Trinity. Conditions here are said to be perfect for outdoor marijuana cultivation. But that has proved to be a very mixed blessing for the region, bringing with it a litany of environmental disturbances to local waterways and wildlife. Creek diversions threaten fish habitat and spur toxic algal blooms. Road building and clear-cuts erode soil and cloud streams. Deep within, illegal “guerilla grows” pepper forestlands with banned rodent poisons that are intended to eradicate crop pests but are also fatal to other mammals.

On November 8 voters in four states—Massachusetts, Maine, California and Nevada—legalized recreational marijuana. These states join Colorado, Washington, Oregon and Alaska, along with the District of Columbia, where one can already legally buy the drug for recreational use. Will this expanded market mean more environmental damage? Or will legalization pave the way for sounder regulation?

In 1996 California legalized marijuana for medical use, providing the first legal space for pot cultivation since the federal government’s blanket ban on the crop some 60 years before. As grow operations in the state flourished, California Department of Fish and Wildlife biologist Scott Bauer analyzed satellite imagery to examine the impact of cultivation on water levels in four Emerald Triangle watersheds. His study, published in PLoS ONE in 2015, found that in three of the four watersheds, “water demand for marijuana cultivation exceeds stream flow during the low-flow [summer] periods.”

The real problem is not marijuana’s overall water consumption, which still falls far short of California staples like walnuts or almonds, explains environmental scientist Van Butsic of the University of California, Berkeley. Rather it is an issue of where and when pot is

grown. Analyzing aerial imagery of 4,428 grow sites in 60 Humboldt county watersheds, Butsic found that one in 20 grow sites sat within 100 meters of fish habitat and one in five were located on steep land with a slope of 17 degrees or more. “The problem is that cannabis is being grown in the headwaters, and much of the watering is happening in the summer,” Butsic says.

If that arrangement goes on unchecked, U.C. Berkeley ecologist Mary Powers warns, summer plantations could transform local rivers from cool and “salmon-sustaining” to systems full of toxic cyanobacteria. Over eons of evolution native salmon species have adapted to “deluge or drought” conditions, she says. But the double whammy of climate change and water extraction could prove to be a game-changer.

Powers spelled out the unprecedented stresses in a 2015 conference paper focused on the Eel River that flows through Mendocino and southern Humboldt. She and her team found riverbed-scouring floods in winter, followed by dry, low-flow conditions in summer, led to warm, stagnant, barely connected pools of water. That is bad news for salmon, but ideal for early summer algal blooms. The algae then rot, creating an oxygen-deficient paradise for toxic cyanobacteria, which have been implicated in the poisoning deaths of 11 dogs along the Eel River since 2002.

Dogs are not the only terrestrial creatures endangered by the grow operations. Between 2008 and 2013 Mourad Gabriel, then a doctoral candidate at the University of California, Davis, Veterinary Genetics Lab, carried out a study of the American fisher, a small carnivorous mammal that is a candidate for the endangered species list. He wanted to suss out the threats to fisher populations in northern California. So he radio-tagged fishers from Trinity County’s Hoopa Valley Reservation and public lands near Yosemite National Park to track their movements. Between 2006 and 2011, 58 of the fishers Gabriel and his team tracked turned up dead. Gabriel studied the necropsies and found that 46 of the animals had been exposed to anticoagulant rodenticides—rat poisons that block liver enzymes, which enable blood clotting. Without the enzyme the exposed mammals bled to death from flesh wounds.

The finding puzzled Gabriel at first, because rat poison is more common in agricultural and urban settings than in remote forests. But then he started visiting the remnants of guerilla grows that had been busted under the guidance of lawmen such as Omar Brown, head of the Narcotics Division at the Trinity County Sheriff’s Office. “We have found [anticoagulant rodenticides] carbofuron on grows in the national forest,” Brown reports. “These are neurotoxin-laced pesticides that have been banned in the U.S. since 2011. And even for allowed pesticides, we’ve found instances where trespass grows are using them in illegally large quantities.” The poisons hit female fishers particularly hard, because the early, pest-prone phase of marijuana cultivation coincides with the fishers’ nesting season, when pregnant females are actively foraging.

Gabriel, now director of the Integral Ecology Research Center based in Humboldt County, says other states may be dealing with rodenticides, water diversions and other problems from guerilla grows, too. “The climate in Colorado, Oregon and Washington is conducive for marijuana cultivation,” he observes. But “there just isn’t the scientific data to prove whether other states have these problems because there has not been research funding put towards answering these questions.”

In California headwater ecosystems could get a reprieve if a greatly expanded legalized pot industry moves to the Central Valley, where production could take place indoors and costs would be less. In pot-growing pioneer states like Colorado or Washington much of the production has moved indoors, where temperatures can be more closely managed. But other factors may hinder that move. “Bud and pest problems are always worse indoors, which biases farmers toward a chemically intensive regime,” says Marie

Peterson of Downriver Consulting, a Weaverville, Calif.–based firm that helps growers fill out the paperwork for state and county permits as well as assesses water management plans for their plantations. And besides, the Central Valley already suffers from prolonged drought.

Of the eight states that legalized the cultivation of recreational marijuana, only Oregon and California allow outdoor grows. But regulating open-air pot plantations in these states remains challenging, even though legal operations for medical marijuana have been around since 1998 and 1996, respectively. In 2015 California passed the Medical Marijuana Regulation and Safety Act, which calls on the state’s departments of Food and Agriculture, Pesticide Regulation, and Fish and Wildlife, along with the state’s Water Board—to oversee environmental impacts of the industry. The board came up with a list of requirements for a marijuana plantation water permit, which in turn became a necessary condition for a license to grow medical pot in any of the three Emerald Triangle counties. Counties have until January 2018 to decide whether to create similar stipulations for recreational marijuana growing permits.

Butsic is optimistic about a more regulated future for the marijuana industry in California. “I think five years from now things will be more sustainable. Permitting shows growers that the state is interested in water use and their crop.”

Source:  2nd Feb. 2017

This Report reviews what we know about substance use and health and how we can use that knowledge to address substance misuse and related health consequences.

First, a general Introduction and Overview of the Report (PDF | 1.5 MB) describes the extent of the substance use problem in the United States. Then it lays a foundation for readers by explaining what happens in the brain of a person with an addiction to these substances.

Chapter 2 – The Neurobiology of Substance Use, Misuse, and Addiction (PDF | 6.0 MB) describes the three main circuits in the brain involved in addiction, and how substance use can “hijack” the normal function of these circuits. Understanding this transformation in the brain is critical to understanding why addiction is a health condition, not a moral failing or character flaw.  Few would disagree with the notion that preventing substance use disorders from developing in the first place is ideal. Prevention programs and policies are available that have been proven to do just that.

Chapter 3 – Prevention Programs and Policies (PDF | 1.5 MB) describes a range of programs focused on preventing substance misuse including universal prevention programs that target the whole community as well as programs that are tailored to high-risk populations. It also describes population-level policies that are effective for reducing underage drinking, drinking and driving, spread of infectious disease, and other consequences of alcohol and drug misuse.

If a person does develop a substance use disorder, treatment is critical. Substance use disorders share some important characteristics with other chronic illnesses, like diabetes. Both are chronic conditions that can be effectively managed with medications and other treatments that focus on behavior and lifestyle.

Chapter 4 – Early Intervention, Treatment, and Management of Substance Use Disorders (PDF | 629 KB) describes the clinical activities that are used to identify people who have a substance use disorder and engage them in treatment. It also describes the range of medications and behavioral treatments that can help people successfully address their substance use disorder.

As with other chronic conditions, people with substance use disorders need support through the long and often difficult process of returning to a healthy and productive life.

Chapter 5 – Recovery: The Many Paths to Wellness (PDF | 335 KB) describes the growing array of services and systems that provide this essential function and the many pathways that make recovery possible.  Responsive and coordinated systems are needed to provide prevention, treatment, and recovery services. Traditionally, general health care and substance use disorder treatment have been provided through distinct and separate systems, but that is now changing.

Chapter 6 – Health Care Systems and Substance Use Disorders (PDF | 1.3 MB) explains why integrating general health care and substance use services can result in better outcomes and describes policies and activities underway to achieve that goal.

The final chapter, Chapter 7 – Vision for the Future: A Public Health Approach (PDF | 255 KB), provides concrete recommendations on how to reduce substance misuse and related harms in communities across the United States.


NIH Monitoring the Future survey shows use of most illicit substances down, but past year marijuana use relatively stable

December 13, 2016

The 2016 Monitoring the Future (MTF) annual survey results released today from the National Institutes of Health (NIH) reflect changing teen behaviors and choices in a social media-infused world. The results show a continued long-term decline in the use of many illicit substances, including marijuana, as well as alcohol, tobacco, and misuse of some prescription medications, among the nation’s teens. The MTF survey measures drug use and attitudes among eighth, 10th, and 12th graders, and is funded by the National Institute on Drug Abuse (NIDA), part of the NIH.

Findings from the survey indicate that past year use of any illicit drug was the lowest in the survey’s history for eighth graders, while past year use of illicit drugs other than marijuana is down from recent peaks in all three grades.

Marijuana use in the past month among eighth graders dropped significantly in 2016 to 5.4 percent, from 6.5 percent in 2015. Daily use among eighth graders dropped in 2016 to 0.7 percent from 1.1 percent in 2015. However, among high school seniors, 22.5 percent report past month marijuana use and 6 percent report daily use; both measures remained relatively stable from last year. Similarly, rates of marijuana use in the past year among 10th graders also remained stable compared to 2015, but are at their lowest levels in over two decades.

The survey also shows that there continues to be a higher rate of marijuana use among 12th graders in states with medical marijuana laws, compared to states without them. For example, in 2016, 38.3 percent of high school seniors in states with medical marijuana laws reported past year marijuana use, compared to 33.3 percent in non-medical marijuana states, reflecting previous research that has suggested that these differences precede enactment of medical marijuana laws.

Further, some 40.2 percent of seniors in so-called medical marijuana (MMJ) states are using edibles—foods infused with marijuana concentrates—compared to 28.1 percent of seniors in states that have not medicalized pot. High school seniors are in the healthiest part of the life span. One wonders why so many young people need so much “medicine.”

The survey indicates that marijuana and e-cigarettes are more popular than regular tobacco cigarettes. The past month rates among 12th graders are 12.4 percent for e-cigarettes and 10.5 percent for cigarettes. A large drop in the use of tobacco cigarettes was seen in all three grades, with a long-term decline from their peak use more than two decades ago. For example, in 1991, when MTF first measured cigarette smoking, 10.7 percent of high school seniors smoked a half pack or more a day. Twenty-five years later, that rate has dropped to only 1.8 percent, reflecting the success of widespread public health anti-smoking campaigns and policy changes.

There has been a similar decline in the use of alcohol, with the rate of teens reporting they have “been drunk” in the past year at the survey’s lowest rates ever. For example, 37.3 percent of 12th graders reported they have been drunk at least once, down from a peak of 53.2 percent in 2001.

Although non-medical use of prescription opioids remains a serious issue in the adult population, teen use of prescription opioid pain relievers is trending downwards among 12th graders with a 45 percent drop in past year use compared to five years ago. For example, only 2.9 percent of high school seniors reported past year misuse of the pain reliever Vicodin in 2016, compared to nearly 10 percent a decade ago.

“Clearly our public health prevention efforts, as well as policy changes to reduce availability, are working to reduce teen drug use, especially among eighth graders,” said Nora D. Volkow, M.D., director of NIDA. “However, when 6 percent of high school seniors are using marijuana daily, and new synthetics are continually flooding the illegal marketplace, we cannot be complacent. We also need to learn more about how teens interact with each other in this social media era, and how those behaviors affect substance use rates.”

“It is encouraging to see more young people making healthy choices not to use illicit substances,” said National Drug Control Policy Director Michael Botticelli. “We must continue to do all we can to support young people through evidence-based prevention efforts as well as treatment for those who may develop substance use disorders. And now that Congress has acted on the President’s request to provide $1 billion in new funding for prevention and treatment, we will have significant new resources to do this.”

The MTF survey, the only large-scale federal youth survey on substance use that releases findings the same year the data is collected, has been conducted by researchers at the University of Michigan at Ann Arbor since 1975.

Other highlights from the 2016 survey:

Illegal and Illicit Drugs

* Illicit Drugs other than Marijuana: Past year rates are the lowest in the history of the survey in all three grades. For example, 14.3 percent of 12th graders say they used an illicit drug (other than marijuana) compared to its recent peak of 17.8 percent in 2013.

* Marijuana-Past year use: Past year marijuana use among eighth graders dropped significantly to 9.4 percent in 2016, from 11.8 percent last year. Past year rates were somewhat stable for sophomores at 23.9 percent, and for seniors at 35.6 percent when compared to last year. However, past year marijuana use has dropped in the last five years among eighth and 10th graders.

* Marijuana-Daily use: Daily rates among 10th and 12th graders remained relatively stable at 2.5 percent and 6 percent for the past few years.

* Marijuana Edibles: Teens who live in states where medical marijuana is legal report a higher use of marijuana edibles. For example, among 12th graders reporting marijuana use in the past year, 40.2 percent consumed marijuana in food in states with medical marijuana laws compared to 28.1 percent in states without such laws.

* Synthetic Cannabinoids: Past year “synthetic marijuana” (K2/Spice) use among 10th and 12th graders dropped significantly from last year. For example, the rate for seniors fell to 3.5 percent compared to 5.2 percent in 2015, with a dramatic drop from its peak of 11.4 percent the first year it was measured in 2011.

* Cocaine: Past year cocaine use was down among 10th graders to 1.3 percent from 1.8 percent last year. Cocaine use hit its peak in this measure at 4.9 percent in 1999.

* Inhalants: Inhalant use, usually the only category of drugs used more by younger teens than their older counterparts, was down significantly among eighth graders compared to last year, with past year use at 3.8 percent, compared to 4.6 percent in 2015. Past year inhalant use peaked among eighth graders in 1995 at 12.8 percent.

* MDMA (Ecstasy or “Molly”): Past year use is down among eighth graders to 1 percent, from last year’s 1.4 percent. MDMA use is at its lowest point for all three grades in the history of the MTF survey.

* Heroin: Heroin rates remain low with teens still in school. High school seniors report past year use of heroin (with a needle) at 0.3 percent, which remains unchanged from last year. In the history of the survey, heroin (with a needle) rates have never been higher than 0.7 percent among 12th graders, as seen in 2010.

* Cold and Cough Medicine: Eighth graders alone reported an increase in misuse of over-the-counter cough medicine at 2.6 percent, up from 1.6 percent in 2015, but still lower than the peak of 4.2 percent when first measured in 2006.

* Attitudes and Availability: Attitudes towards marijuana use have softened, but perception of harm is not necessarily linked to rates of use. For example, 44 percent of 10th graders perceive regular marijuana smoking as harmful (“great risk”), but only 2.5 percent of them used marijuana daily in 2016. This compares to a decade ago (2006) when 64.9 percent of 10th graders perceived marijuana as harmful and 2.8 percent of them used it daily. The number of eighth graders who say marijuana is easy to get is at its lowest in the history of the survey, at 34.6 percent.

Prescription Drugs

* Opioid Pain relievers (described as “Narcotics other than Heroin” in the survey):  The  past year rate for non-medical use of all opioid pain relievers among 12th graders is at 4.8 percent, down significantly from its peak of 9.5 percent in 2004.

* Vicodin/OxyContin: The past year non-medical use of Vicodin among high school seniors is now lower than misuse of OxyContin (2.9 percent compared to 3.4 percent). The past year data for 12th graders 10 years ago was 9.7 percent for Vicodin and 4.3 percent for OxyContin.

* ADHD Medicines: Past year non-medical use of Adderall is relatively stable at 6.2 percent for 12th graders; however, non-medical use of Ritalin dropped to 1.2 percent, compared to 2 percent last year, and a peak of 5.1 percent in 2004.

* Tranquilizers: Non-medical use of this drug category, which includes benzodiazepines, has seen a general decline. For example, among 12th graders the 2016 past year rate is 4.9 percent, compared to its peak in 2002 at 7.7 percent.

* Attitudes and Availability: The majority of teens continue to say they get most of their opioid pain relievers (for non-medical use) from friends or relatives,

either taken, bought or given. The only prescription drugs seen as easier to get in 2016 than last year are tranquilizers, with 11.4 percent of eighth graders reporting they would be “fairly easy” or “very easy” to get, up from 9.8 percent in 2015. Also, when eighth graders were asked if occasional non-medical use of Adderall is harmful (“great risk”), 35.8 percent said yes, compared to 32 percent last year.


* Daily Smoking: The 2016 daily smoking rates for high school seniors was 4.8 percent compared to 22.2 percent two decades ago (1996). For 10th graders, the 2016 daily smoking rate is 1.9 percent, compared to 18.3 percent in 1996.

* Hookah Use: For past year tobacco use with a hookah, the 2016 rate dropped to 13 percent among high school seniors, from 22.9 percent two years ago, its peak year since the survey began measuring hookah use in 2010.

* E-Cigarettes (Vaporizers): The rate for e-cigarettes among high school seniors dropped to 12.4 percent from last year’s 16.2 percent. Of note: only 24.9 percent of 12th graders report that their e-cigarettes contained nicotine (the addictive ingredient in tobacco) the last time they used, with 62.8 percent claiming they contain “just flavoring.”

* Little Cigars: The 2016 past year rate dropped to 15.6 percent among 12th graders, from a peak of 23.1 percent in 2010, when first included in the survey.

* Attitudes and Availability: This year, more 10th graders disapprove of regular use of e-cigarettes than last year. For example, 65 percent of 10th graders say they disapprove, up from last year’s 59.9 percent. In addition, more 10th graders think it is harder to get regular cigarettes than last year; 62.9 percent said they are easy to get, compared to 66.6 percent last year. This represents a dramatic shift from survey findings two decades ago, when 91.3 percent of 10th graders thought it was easy to get cigarettes.


* Past year use: More than half (55.6 percent) of 12th graders report having used alcohol in the past year, compared to the peak rate of about 75 percent in 1997. Thirty-eight percent of 10th graders and 17.6 percent of eighth graders report past year use, compared to the peaks of 65.3 percent in 2000 among 10th graders and 46.8 percent in 1994 among eighth graders.

* Binge drinking: Among eighth graders, binge drinking (described as five or more drinks in a row in the last two weeks) continues to significantly decline, now

at only 3.4 percent, the lowest rate since the survey began asking about it in 1991, down from a peak of 13.3 percent in 1996. Binge drinking among high school seniors is down to 15.5 percent, half its peak of 31.5 percent in 1998.

* Been drunk: Representing a long-term downward trend, 37.3 percent of 12th graders say they have been drunk in the past year; 20.5 percent of 10th graders say they have been drunk, down from a peak of 41.6 percent in 2000. Eighth graders reported a rate of 5.7 percent, down from a peak of 19.8 percent in 1996.

* Attitudes: Just over 71 percent of 10th graders think it is easy to get alcohol, compared to last year’s rate of 74.9 percent, and down from 90.4 percent two decades ago.

Overall, 45,473 students from 372 public and private schools participated in this year’s MTF survey. Since 1975, the survey has measured drug, alcohol, and cigarette use and related attitudes in 12th graders nationwide. Eighth and 10th graders were added to the survey in 1991. Lloyd D. Johnston, Ph.D., who has been the principal investigator at the University of Michigan’s Institute for Social Research for all 42 years, is retiring from that position this year, but the survey of teens will continue under the leadership of Richard A. Miech, Ph.D., who is currently a member of the MTF scientific team.

“The declining use of many drugs by youth is certainly encouraging and important,” said Dr. Johnston. “But we need to remember that future cohorts of young people entering adolescence also will need to know why using drugs is not a smart choice. Otherwise we risk having another resurgence of use as was seen in the 90s.”

“We want to thank Dr. Johnston for his lifetime of work building this survey into the important public health tool it is today,” added Dr. Volkow.

Source:  National Families in Action’s The Marijuana Report  12th Dec.2016

Please share this post with every concerned parent you know! Spread the Word about Pop Pot!

Pew Research released a new poll from late August and early September that shows 57% of American voters favor marijuana legalization.  Based on the question and the article, the poll probably means that 57% of the voters favor marijuana decriminalization.   Next time the poll should be more specific in its meaning.  The same day this poll was released, a headline from the Cape Cod News in supposedly “liberal” Massachusetts read Support Scarce for Legal Pot.   There could not be a bigger difference in meaning  between these headlines.  Why the difference?

Despite this poll, all 5 states with ballots for marijuana legalization this November poll at less than 57% in favor of legalization.  There is a disparity between the survey question and legalization in practice. Legalization creates a new industry expected to make a lot of money for investors.   It is the reason that Weed Maps, ArcView group  and Soros-funded groups contribute to the ballots.  There’s a big difference between legalization and decriminalization.  Did those conducting the survey explain what legalization means?


Since the Sacramento Bee made this chart, at least $10 million more has been raised by  California’s Yes on 64 campaign. With the business Weed Maps, MJ Freeway and George Soros funding so much, it’s obviously a good business venture.  George Soros gave at least $4 million.

Legalization creates commercial marijuana stores regulated by the state .   Administering and implementing it is very difficult to do.   Pot sales are taxed at various levels and earn some money.  But as Colorado marijuana director, Andrew Freedman said, it’s not worth legalizing for the benefit of tax revenues.

When presented with facts, voters are  sceptical of commercialization and don’t want more impaired drivers.  The cost of regulation is  high.   On October 1 in Colorado, new rules began,  and the packaging must make it more difficult for children to access. Gummy candies in the shape of animals are now forbidden. The number of hospitalizations and overdose deaths from marijuana edibles which make up nearly 50% of the market necessitated these changes.

Opting out of commercial pot is very tough, too.  Dealing with inconsiderate neighbors who grow a lot of pot plants is difficult.  In Colorado, city governments are often greedy for tax money while residents say no to pot.  When voters want to ban dispensaries, other forces such as the marijuana industry fight them.   It’s one of the reasons Colorado now has buyer’s remorse


Why Marijuana Decriminalization ?

Decriminalization means that marijuana is not treated as a crime but as a mistake; offenders are charged with a small fine, like a speeding ticket.   In legal terms, it’s the difference between a misdemeanor and a felony.  The marijuana lobbyists have successfully convinced Americans that large numbers of people go to jail for marijuana possession only.

The only people who go to jail for marijuana possession charges have committed other crimes and have plea bargained to get convicted of lesser charges.   Other crimes include drug dealing, transportation of drugs or possession of a large amount of drugs that indicates intent to sell.  Selling drugs is not a victimless crime.

Marijuana lobbyists omit information about drug courts which allows users an alternative and provides addiction treatment.

The reason that marijuana possession is a felony crime in some states is so that it can be used as evidence to convict when there are more serious crimes.  Drugs and drug paraphernalia become supporting evidence when other crimes may be harder to prove.

How are Minorities Really Affected by Drug Laws?

Minorities have the most to lose by using marijuana.  Daily or near daily use of marijuana by teens nearly doubles the risk of dropping out of high school.   Dropping out of high school makes future education and job prospects dim.  Furthermore, a study of long-term marijuana users in New Zealand over a 25-year period found an average 7-point drop in IQ by age 38.   People who complain that this study did not adjust for IQ differences as reflected by socio-economic class should realize that IQ differences resulting from socio-economic factors are in play seen before age 13, when participants first entered the study.

A recent study from UC Davis showed how chronic marijuana users faced more downward mobility than chronic alcohol users.  In the US, the disproportionate arrest of minorities may reflect concern about dropping out of school and what that means for the future. The higher conviction rate for minorities is probably a reflection of income disparity and poverty.  A disproportionate number of black and Hispanic drug dealers go to jail.   Minorities are less likely to be able to afford the legal fees that allow wealthy white drug dealers to get less time in jail or wiggle their way out of going to jail.  Justice reform should not be centered on legalizing drugs, but on giving minorities better legal representation. Retired Judge Arthur Burnett, National Executive Director of the  National African-American Drug Policy Coalition, says that  African-American communities already suffer from a liquor store on every corner. Black voters know commercial marijuana would prey on their communities at a much higher rate.  “Do we really want to substitute mass incapacitation for mass incarceration?” he asked.

There’s a strong misconception that people go to jail just for having a joint.   (The threat of jail is not the reason to tell kids not to use pot, but defense of your brain is!)   There’s also a misconception that inequities in the justice system would be solved by legalization.

Maybe next time Pew Research present the polls with a bunch of different options between decriminalization, allowing home grows only or commercialization.   Or Pew Research should a better job at explaining what they mean by legalization.

Source:   OCTOBER 13, 2016 EDITOR

September 27, 2016 |   By Renato D. Alarcón, MD, MPH

That the world is currently going through a complex and critical phase in its history is an understatement. The background is multifaceted: violence of all types with a different kind of war (but war anyway) at its peak, large migrations in all regions, religion transformed in terrorist codes and strategies with tragically massive sequelae, and politics in many countries (starting with the US) reaching levels of cheap TV shows or grotesque deformity by the words and actions of some of its protagonists. And the main victim, in addition to all the innocent lives of those who died or were injured (physically and emotionally) is humanity itself, the essence of its raison d’etre—culture—as both the repository of history and the expression of our human identity.

Culture is being demolished by grenades, guns, and incendiary speeches. And the world’s mental health is being threatened as never before by viruses of hatred, fanaticism, frivolousness, and a technology-based infectious chain. The challenges to psychiatry as the clinical armour of mental health, and to cultural psychiatry as its vanguard platoon, are indeed enormous in these dramatic and confusing times.

The preceding may sound exaggerated but an objective and close examination of worldwide events these days, conveyed by the media, social networks, or word-of-mouth, confirm the seriousness of the situation. Almost daily attacks by unknown assailants in malls, train stations, bars, churches, or in the streets reflect the contagious nature of violence—be that the result of dysmorphic preaching or the action of “lonely wolves.” Religious and even ethical principles used as reasons to kill, dressed up by coward anonymity, have used European and American cities as worldwide stages. A re-invigorated racism and its mixed-up dialectics play with fear, apprehension, or sheer ignorance to make public places or dark neighborhoods scenarios of death, invoking at times the name of the law. Homicide and suicide-related deaths have increased as a consequence.

The cultural and mental implications of all these behaviors cannot be neglected. Migration within countries or regions has been a phenomenon present for centuries around the world. To mostly socio-economic and occupational needs as main causes of migration, others have been added in the last several decades: prolonged internal political conflicts, religious wars, cruel political persecutions, bloody massive expulsions, or voluntary exile.

Psychiatry can help to alleviate, contain, and eventually prevent demolition of culture and health. That’s how powerful it is.

The other big differences are the size and frequency of the migratory waves, particularly between the Middle East and European countries, in the African continent, and the ever-present flow of Hispanics into the US.

International bureaucratic and professional organizations (World Health Organization, World Psychiatric Association, World Association of Cultural Psychiatry) have made strong pronouncements, urging governments and other agencies to study, plan, and intervene in the alleviation and prevention of the health and mental health consequences of migrations, clinical pictures of which fragilities, rejection, resentment, and uncertainties are substantial ingredients.

Moreover, we cannot deny that the political picture of the most powerful country in the world presents evidences of circus and polarization, showmanship and distrust, that make it “different.” The problem is that the “difference” now is not ideological or doctrinal; particularly on one side of the current campaign, it is the accentuation of hate,

the use of stereotypes and insults as arguments, the not-too-disguised lies or the not-too-subtle incitements to overt violence. And this fact, violence, is precisely where all the occurrences in today’s world (war, terrorism, migrations, politics) converge and show their shared umbrella.

Violence, without distinctions of age, gender, ethnicity, civil status, socio-economic level, nationality, religious or cultural features, permeates these processes. Violence—be it domestic, collective, verbal, physical, sexual, emotional, or political—is one of the most demonstrative manifestations of social as well as psychological/mental instability.

It corrodes the spaces of tolerance and reason, the roots of dialogue and communication, the capacity to judge and opine. It takes away the visions of future and progress converting them into weak presentism and facile demagoguery. Violence kills people, demolishes buildings, cities, monuments . . . and the whole of culture.

In clinical terms, the mental health consequences of this global socio-political climate affect individuals, groups, communities and the society at large. To the well-known posttraumatic stress manifestations per se, those of depression, anxiety, psychosis, substance use, as well as dissociative, somatic, conversion, and personality disorders, can be triggered or exacerbated by violence, making it the final common pathway of a variety of conditions, the overcrowded catalogue of disorganization, fright, and confusion.

It is also fed by denial, the oldest of what are known as “defense mechanisms;” by duplicities, sophisticated versions of multiplied lying, rationalism, or sloganized justifications. In the cultural realm, again, individual and group/community/ethnic identities are deformed; beliefs and traditions are betrayed or simply set aside; faith is lost. Contagiousness is, many times, an atypical collateral of violence.

In short, violence engenders more violence.

What to do under these circumstances? What can psychiatry and its allied disciplines do to alleviate, contain, and eventually prevent or avoid the demolition of culture and health? A systematic, consistent, tireless call to reason that must include an honest assessment of history and its changes, should constitute the core of a public education campaign.

An analysis of the roots of each problem, the public health/mental health response to the realities of the situation, direct invitations to and active participation in civilized dialogues with government authorities, public citizens, and political groups and academic institutions; an unequivocal protection of civil liberties and human rights, and fostering of preparedness and preventive vigilance from and for all population segments. Concomitant tasks of teaching, learning and training at all levels—students, professionals and public—strengthened by available mental health care infrastructure.

Most importantly, the restoration of cultural consciousness, of the texture of identity and genuine faith (respecting differences and welcoming coincidences), of the force of ideas and practices carrying out genuine understanding, solidarity, and teamwork. The ultimate objective is, of course, the elimination of violence as a resource, the reconstruction of culture as a unifying force, a chalice of diversity.

Globalization is far from being a comprehensive concept, in spite of its etymology. Global health and global mental health are still at the beginning of their conceptual articulation, their presence felt as undeniably strong but their entities still uncertain. Culture is being threatened worldwide, but its perpetual, basic configuration throughout millennia becomes the basis of the most important factor against its destruction: hope, the same quality that Jerome Frank intuited as the most powerful ingredient of all psychotherapies. Hope as a source of action and positive responses, as a pillar of protection and resilience for individuals and nations. Hope as a tool for the survival of human culture.


I was born in Arequipa, the second largest city in Perú, and graduated from medical school in Lima. My parents were both high school teachers and always voiced their wish to have “a doctor” among their 3 children. I confess I liked letters and humanities but, in the end, I “compromised” by choosing psychiatry as my specialty: I am very happy because I know psychiatry is the last bastion of Humanism in medicine, and because I enjoyed the work and wisdom of great teachers. Let me just mention two: Honorio Delgado (1892-1969), a Peruvian philosopher and researcher who met and worked with giants like Freud; Jaspers; the Schneiders; Gregorio Marañón or Pedro Lain-Entralgo, who is considered the greatest Latin American psychiatrist of the 20th century; and Jerome Frank (1909-2005), an accomplished, compassionate and inspiring Hopkins academician, the first and most solid psychotherapy researcher in the world.

Trained in the US, I worked back in Lima for 8 years before returning in 1980 to work at the University of Alabama in Birmingham, Emory and, finally, the Mayo Clinic. I have always kept in close touch with Latin American psychiatry and have its visibility around the world as, perhaps, the fundamental objective of my career. In a globalized world, it is only fair to recognize the contributions of developing countries and continents. I am gratified for having helped a number of Latin American young colleagues, medical students, and residents to come to the US and enjoy learning experiences in American academic centers. I have also assisted in the organization of international events where experience-sharing, teaching, and learning from each other are substantial didactic resources. And, certainly, I plan to continue doing so for as many years as possible.

I love classical music, Latin boleros, and Peruvian waltzes. I used to play soccer and was an adolescent sports anchorman and journalist in my hometown. I lost my brother Javier, an idealist of the left, one of the 80,000 desaparecidos or victims of the “dirty war” of the 1980s in Perú; in his memory, social and political reconciliation are frequent themes of my reflections from the cultural and social psychiatry perspectives. I feel moved by Cesar Vallejo’s poetry; Hemingway’s life and novels; Bertrand Russell’s thinking; Elie Wiesel’s, M.L. King’s, or Octavio Paz’s social militancy. And count The Room, Schindler’s List, and To Kill a Mockingbird among my favorite movies.


Dr. Alarcón is Emeritus Professor and Consultant in the department of psychiatry and psychology at Mayo Clinic College of Medicine in Rochester, MN,


Peter @ Sun, 2016-10-02 19:11

Is psychiatry really so powerful in order “to help alleviate, contain, and eventually prevent demolition of culture and health”? If that is so, how can we really measure, evaluate or discern this kind of helpfulness without incurring in another romantic case of

irremediable wishful thinking? Call me pessimist or disenchanted, but after four decades working as a clinical psychiatrist in my beloved and violent Mexico, my guess is as Paul Auster declared during the Príncipe of Asturias Award Ceremony “A book has never put food in the stomach of a hungry child. A book has never stopped a bullet from entering a murder victim’s body. A book has never prevented a bomb from falling on innocent civilians in the midst of war” (not even a psychiatry textbook or article). Nevertheless, I still do think that Dr. Alarcón words are beautiful, thoughtful and even inspiring.

Dr. Moisés Rozanes

The concept of culture is very important especially because culture and race have been misused as concepts. Most of what people call ‘race’ is culture. We live in a time of huge cultural change including the globalization of music, art, sports, and fashion. Language which communicates culture is globalizing. The internet has brought about these changes and the internet is being fought over as to which global player will control this agent of change. The danger for psychiatry is that psychiatry has too often been on the wrong side of cultural change and has supported the insider powerful over the people in past issues such as psychiatry’s shameful support of Eugenics and psychiatry’s calling being gay illness. The Populist Movement as shown by the Brexit and the Trump campaign must not be demonized by organized psychiatry and instead , need to be seen as the People culturally taking power and rejecting the mostly self-appointed ruling elite. Psychiatry needs to accept it does not have a mandate to call culture illness. Psychiatry must carefully separate culture and illness and clearly demonstrate that psychiatry can be trusted to be a medical specialty and that psychiatry will never again abuse people in the name of the powerful political elites.

Alan @ Fri, 2016-09-30 17:15

Excellent article but I wonder what is the role of culture triggering the contemporary situation? We are conditioned by our culture and use it as a reference against other social groups. I am not free from my conditioning although I can be aware of it, then a transformation takes place and I become compassionate and less violent. The other social group see my attitude and now (they seems to) listen opening the door for communication. The role of psychiatry is tainted by the damage done by it; our pseudo-diagnostic manual, Pharma and the psychotropic drugs. We are part of the problem and only after we see it there will be hope…and compassion and healing.

Manuel @ Fri, 2016-09-30 10:34

This portrayal of current cultural situation in the world is excellent, but please don’t tell me the answer is “hope”.

Psychiatry’s role should be EDUCATION, secular/Scientific education and in a good many number of years this “cultural demolition” would start to respond to treatment, I believe.

Dr. Pistone, MD Psychiatrist

Daniel @ Fri, 2016-09-30 00:04

It takes quite a bit of hubris, or delusion, to think that the times in which we live are unique or somehow special or especially threatening to culture or civilization. The world and civilization have endured fascism, the Holocaust, “Mongol hordes”, the Fall of the Roman Empire, extermination of native peoples, colonization, the Black Death, the Opium Wars, slavery, the Inquisition, ad nauseam throughout recorded history, and most certainly before. ISIS, Hillary Clinton, and Donald Trump are hardly the worst things that might “demolish” world culture.

Quentin @ Thu, 2016-09-29 10:32

My thoughts exactly. There is nothing new under the sun. The Middle Ages were far worse, especially for women and children. The Crusaders put us to shame when it comes to violent murder in the name of God. There is less violence in the streets today than in the past. Civil rights are stronger today than in the past. This is not to say, of course, that we should not be horrified about the tenor of the political climate, or the divide between those fearful who lean toward xenophobia and those who envision an open, multicultural society where every person who wants one is given a fair shot to live a safe, authentic life. “Give me your tired, your poor, your huddled masses…the wretched refuse of your teeming shore” should not be just words on a statue.

Dana @ Thu, 2016-09-29 11:23

Is not the comparison with the tranquil (civilized?) peace of America’s (e.g.) 50’s against current events in the USA? I may get eaten alive for being simple but the “world” (America) seems much more violent than even the 70’s and 80’s. I don’t believe the author was comparing today’s society against the holocaust, etc. I found the article to be interesting and a provider of Hope.

Dana @ Thu, 2016-09-29 11:12

I think the 50’s were really great for straight white folks. Otherwise, not so much.

Dana @ Thu, 2016-09-29 12:57

I think the key word is “seems” In fact, there is less violence today than in those decades. It is simply that we have access 24/7 to the sensationalized news reports about the violence that is being perpetrated today, so we are left with the impression that there is more violence when in fact there is less. It is safer to walk on city streets today than in the 70’s and 80’s. There are studies that show this.

Denise @ Thu, 2016-09-29 11:31

I think of that intermittently but not consistently enough. That’s an excellent point. Thank you for your response. I would be interesting in finding a study to reinforce my thinking. * reply

Dana @ Thu, 2016-09-29 12:59

I’m not sure I understand the context of your post. I interpreted the essay to be a commentary on current affairs and identified social trends not a look backward comparing today’s events with all recorded events since the mass extinction of mammoth and giant sloth.

If the argument is that reporting by news media is so pellucid and unreliable that current events are virtually unknowable being disinformation but that written histories are a reliable and superior source of knowledge about the world today, then I would lean toward assurance that finished and complete knowledge is enough.

Societies are being transformed. No one can argue that the world is not changing in ways unique to our times. How the people of the world interpret the transformation may not be determinative in the end, but it is important for the curious-furious to develop perspective on forces and powers influencing the future of all cultures. It’s an unusual opportunity for scholars; those with a focus on psychiatry or no.

Richard Anthony @ Thu, 2016-09-29 21:19

Reading this article reminded me the vision outlined by Jerome D. Frank in his book “Sanity and Survival”. Truly wonderful essay. John M. de Figueiredo

John @ Thu, 2016-09-29 10:23

I do not recall who said that “civilization was started by the first man who used word instead of a club to work out a disagreement.” it was well said.

Melvin @ Thu, 2016-09-29 10:21

Your words speak volumes. Working at the public school level I see first hand the “trickle down” effect the issues of this world are having on children. We must be vigilant, in continuing to address the issues you discussed, for the future of society as a whole. Thank you.

Cheryl @ Thu, 2016-09-29 10:17

Well said! Eloquent and on target.

Jennifer @ Thu, 2016-09-29 10:03

I couldn’t agree more. Listening to the political and event news feels like a daily assault to my mental health, which is generally good. I try to stay informed, but I am not allowing myself to be involved in the 24 hour / day news cycle. Quiet walks alone seems to be a good respite for me from the daily stressors of life (job, family…), but more importantly the political and global stressors (politics of hate / division, terrorism, economics, wars, climate change with devasting weather events…). It is no wonder that there is an increase in mental health issues and a growing need for medications to assist people with coping with life.

Filed under: Social Affairs (Papers) :

Imagine for a minute a world in which marijuana is available in a vending machine or corner grocery store near you — like any other snack machine — pot-infused lollipops, gummy candies, baked goods and beverages available at the push of a button.

As futuristic as this farfetched tale sounds, this is Colorado’s reality, a state with the dubious distinction of becoming the first to legalize marijuana, which has helped spawn legalization efforts across the U.S., including in New Jersey.   And while Colorado’s experiment has sparked heated debate over drug legalization, a critical and unbiased look at the data clearly shows that marijuana legalization has serious and far-reaching consequences that far outweigh any of its alleged benefits.

Strong emotions on both sides of this issue should not obscure the facts. Marijuana is an addictive substance that is harmful to users, especially to its younger users. As a teen’s brain development is disturbed by chronic marijuana use, the risk for physical and psychological dependency grows exponentially.

In addition to permanently affecting brain functioning, marijuana use can lead to a wide array of negative consequences, ranging from lower grades and isolation from family to an increased risk of psychotic symptoms, depression and suicide.

According to the Office of National Drug Control Policy, legalization will cause a substantial increase in economic and social costs.  The expansion of drug use will increase crime committed under the influence of drugs, as well as family violence, vehicular crashes, work-related injuries and a variety of health-related problems. These new costs will far outweigh any income from taxes on drugs.

Few would argue that a drug that can cause such destruction is something that we should counsel people to avoid. However, legalization efforts do just the opposite. In fact, experience has shown that when drugs are legalized, drug use increases because the perception of harm is reduced.

Moreover, the Drug Enforcement Agency has estimated that legalization could double or even triple the amount of marijuana users.

While it is hard to fathom the societal impact of an additional 17 million to 34 million marijuana users, it is safe to assume that those who profit from legalization have calculated the impact on their bottom line.

Those in favor of legalization often fail to tell you that levels of drug use have gone down substantially since the 1970s when the “war” on drugs began. This is not to say that our drug laws, including those governing marijuana, are not in need of reform.

For instance, the effort to place more drug users into treatment instead of prison is a positive development, both for those struggling with addiction and for taxpayers.

However, reforming and improving our drug laws does not mean we should abandon our fight against the use of illegal drugs like marijuana.

On the contrary, the more we learn about effective methods of combating drug use, the more we learn that legalization is not the answer, and is, in fact, very much part of the problem.

Source:  Source:  Daily Record 13 Apr 2014


At one point a few days ago I feared to turn on the radio or TV because of the ceaseless accounts of blood, death and screams, one outrage after another, which would pour out of screen or loudspeaker if I did so.

And I thought that one of the most important questions we face is this: How can we prevent or at least reduce the horrifying number of rampage murders across the world?

Let me suggest that we might best do so by thinking, and studying. A strange new sort of violence is abroad in the world. From Japan to Florida to Texas to France to Germany, Norway and Finland, we learn almost weekly of wild massacres, in which the weapon is sometimes a gun, sometimes a knife, or even a lorry. In one case the pilot of an airliner deliberately flew his craft into a hillside and slaughtered everyone on board. But the victims are always wholly innocent – and could have been us.

The culprits of the Charlie Hebdo murders, all had drugs records or connections. The same was true of the Bataclan gang, of the Tunis beach killer and of the Thalys train terrorist

I absolutely do not claim to know the answer to this. But I have, with the limited resources at my disposal, been following up as many of these cases as I can, way beyond the original headlines.

* Those easiest to follow are the major tragedies, such as the Oklahoma City bombing, the Nice, Orlando, Munich and Paris killings, the Anders Breivik affair and the awful care-home massacre in Japan last week. These are covered in depth. Facts emerge that do not emerge in more routine crimes, even if they are present.

Let me tell you what I have found. Timothy McVeigh, the 1995 Oklahoma bomber, used cannabis and methamphetamine. Anders Breivik took the steroid Stanozolol and the quasi-amphetamine ephedrine. Omar Mateen, culprit of the more recent Orlando massacre, also took steroids, as did Raoul Moat, who a few years ago terrorised the North East of England. So did the remorseless David Bieber, who killed a policeman and nearly murdered two others on a rampage in Leeds in 2003.

Eric Harris, one of the culprits of the Columbine school shooting, took the SSRI antidepressant Luvox. His accomplice Dylan Klebold’s medical records remain sealed, as do those of several other school killers. But we know for sure that Patrick Purdy, culprit of the 1989 Cleveland school shooting, and Jeff Weise, culprit of the 2005 Red Lake Senior High School shootings, had been taking ‘antidepressants’.

So had Michael McDermott, culprit of the 2000 Wakefield massacre in Massachusetts. So had Kip Kinkel, responsible for a 1998 murder spree in Oregon. So had John Hinckley, who tried to murder US President Ronald Reagan in 1981 and is now being prepared for release. So had Andreas Lubitz, the German wings pilot who murdered all his passengers last year. The San Bernardino killers had been taking the benzodiazepine Xanax and the amphetamine Adderall.

The killers of Lee Rigby were (like McVeigh) cannabis users. So was the killer of Canadian soldier Nathan Cirillo in 2014 in Ottawa (and the separate killer of another Canadian soldier elsewhere in the same year). So was Jared Loughner, culprit of a 2011 mass shooting in Tucson, Arizona. So was the Leytonstone Tube station knife attacker last year. So is Satoshi Uematsu, filmed grinning at Japanese TV cameras after being accused of a horrible knife rampage in a home for the disabled in Sagamihara.

I know that many wish to accept the simple explanation that recent violence is solely explained by Islamic fanaticism. No doubt it’s involved. Please understand that I am not trying to excuse or exonerate terrorism when I say what follows.

But when I checked the culprits of the Charlie Hebdo murders, all had drugs records or connections. The same was true of the Bataclan gang, of the Tunis beach killer and of the Thalys train terrorist.

It is also true of the two young men who murdered a defenceless and aged priest near Rouen last week. One of them had also been hospitalised as a teenager for mental disorders and so almost certainly prescribed powerful psychiatric drugs.

The Nice killer had been smoking marijuana and taking mind-altering prescription drugs, almost certainly ‘antidepressants’.

As an experienced Paris journalist said to me on Friday: ‘After covering all of the recent terrorist attacks here, I’d conclude that the hit-and-die killers involved all spent the vast majority of their miserable lives smoking cannabis while playing hugely violent video games.’

The Munich shopping mall killer had spent months in a mental hospital being treated (almost certainly with drugs) for depression and anxiety

Now look at the German events, eclipsed by Rouen. The Ansbach suicide bomber had a string of drug offences. So did the machete killer who murdered a woman on a train in Stuttgart. The Munich shopping mall killer had spent months in a mental hospital being treated (almost certainly with drugs) for depression and anxiety.

Here is my point. We know far more about these highly publicised cases than we do about most crimes. Given that mind-altering drugs, legal or illegal, are present in so many of them, shouldn’t we be enquiring into the possibility that the link might be significant in a much wider number of violent killings? And, if it turns out that it is, we might be able to save many lives in future.

Isn’t that worth a little thought and effort?


PUBLISHED: 00:55, 31 July 2016 | UPDATED: 18:36, 31 July 2016


Pot for the poor! That could be the new slogan of marijuana legalization advocates.

In 1996, California became the first state to legalize the use of medical marijuana. There are now 25 states that permit the use of marijuana, including four as well as the District of Columbia that permit it for purely recreational use.

Colorado and Washington were the first to pass those laws in 2012. At least five states have measures on the ballot this fall that would legalize recreational use. And that number is only likely to rise with an all-time high (no pun intended) of 58 percent of Americans (according to a Gallup poll last year) favoring legalization.

The effects of these new laws have been immediate. One study, which collected data from 2011-12 and 2012-13, showed a 22 percent increase in monthly use in Colorado. The percentage of people there who used daily or almost daily also went up. So have marijuana-related driving fatalities. And so have incidents of children being hospitalized for accidentally ingesting edible marijuana products.

But legalization and our growing cultural acceptance of marijuana have disproportionately affected one group in particular: the lower class.

A recent study by Steven Davenport of RAND and Jonathan Caulkins of Carnegie Mellon notes that “despite the popular stereotype of marijuana users as well-off and well-educated . . . they lag behind national averages” on both income and schooling.

For instance, people who have a household income of less than $20,000 a year comprise 19 percent of the population but make up 28 percent of marijuana users. And even though those who earn more than $75,000 make up 33 percent of the population, 25 percent of them are marijuana users. Having more education also seems to make it less likely that you are a user. College graduates make up 27 percent of the population but only 19 percent of marijuana users.

The middle and upper classes have been the ones out there pushing for decriminalization and legalization measures, and they have also tried to demolish the cultural taboo against smoking pot. But they themselves have chosen not to partake very much. Which is not surprising. Middle-class men and women who have jobs and families know that this is not a habit they want to take up with any regularity because it will interfere with their ability to do their jobs and take care of their families.

But the poor, who already have a hard time holding down jobs and taking care of their families, are more frequently using a drug that makes it harder for them to focus, to remember things and to behave responsibly.

Legalization and our growing cultural acceptance of marijuana have disproportionately affected one group in particular: the lower class.

The new study, which looked at use rates between 1992 and 2013, also found that the intensity of use had increased in this time. The proportion of users who smoke daily or near daily has increased from 1 in 9 to 1 in 3. As Davenport tells me, “This dispels the idea that the typical user is someone on weekends who has a casual habit.”

Sally Satel, a psychiatrist and lecturer at Yale, says that “it is ironic that the people lobbying for liberalized marijuana access do not appear to be the group that is consuming the bulk of it.” Instead, it’s “daily and near-daily users, who are less educated, less affluent and less in control of their use.”

In fact, the typical user is much more likely to be someone at the bottom of the socioeconomic ladder, whose daily life is driven, at least in part, by the question of how and where to get more marijuana. Just consider the cost. Almost a third of users are spending a tenth of their income on marijuana. And 15 percent of users spend nearly a quarter of their income to purchase the drug. The poor have not only become the heaviest users, but their use is making them poorer.

To all the middle-class professionals out there reading this: Do you know anyone who spends a quarter of their income on pot? Of course not. But these are the people our policies and attitudes are affecting.

As the authors of the study note, marijuana use today actually more closely resembles tobacco use than alcohol use. Cigarette smoking has completely fallen off among the educated and well-off, while the poor and working class have continued their habits. Even as far back as 2008, a Gallup poll found that the rate of smoking among people making less than $24,000 a year was more than double that of those making $90,000 or more.

But at least the rates have been going down for everyone. Thanks to a cultural shift on the acceptability of smoking, awareness campaigns about its dangers and a variety of legal measures regarding smoking in public facilities, smoking is significantly less popular. You could object to some of these public policies on the grounds that the government should mind its own business. But the truth is that Americans across all incomes are now less likely to suffer from the harmful effects of smoking.

Maybe the upper classes in this country have some romantic notion of what marijuana can do to the mind (though we once thought cigarettes were terribly classy too). But it is time to get over such silliness and consider the real effects of our attitudes.

As Manhattan Institute fellow and psychiatrist Theodore Dalrymple says, this is like the 1960s all over again. He tells me, “I’m afraid I can’t hear all that stuff about ‘tune in, drop out’ without being infuriated because the people affected really deleteriously [are] people at the bottom.”


Hard-partying Baby Boomer parents are more tolerant of drugs and alcohol, and their liberal attitudes may be paying off in an unexpected way.

There’s something terribly wrong with kids these days: a series of major surveys, conducted by the government every two years, suggest that they might just be the most well-behaved generation in recent memory. Teens are increasingly swearing off alcohol, cigarettes, drugs likesynthetic marijuana, and prescription painkillers, according to the latest survey of of more than 50,000 8th, 10th, and 12th graders from the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey. For some illicit substances, such as cocaine and heroin, consumption has dropped to its lowest point since the MTF’s inception in 1975 (fading stigmas around marijuana consumption may be responsible for its relatively consistent popularity amid this decline). The most recent Youth Risk Behavior Survey (YRBS) shows that cigarette smoking is at its lowest level in 24 years—11 percent in 2015, down from 28 percent in 1991. Rates of underage sex, teen pregnancy, HIV, and other sexually transmitted diseases have also declined according to a survey of 16,000 students by the Centers for Disease Control and Prevention (CDC). The kids, apparently, are all right.

But why? Conventional wisdom suggests this shouldn’t be the case. This is a generation that’s taking its cues from their Baby Boomer parents, those 76 million Americans born roughly between 1946 and 1964 who are veterans of the sexual and psychedelic revolutions of the 1960s and 70s and launched the modern trends in risky behaviors measured by surveys like the MTF and YRBS. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Baby Boomers havemaintained their hard-partying ways more than any other generation. Parental attitudes towards addiction matter. Research suggests that children of addicted parents are more likely to develop substance abuse problems themselves—due to both modeling and lax oversight. A recent longitudinal study of adolescents between 1994 and 2008 confirms that parents with permissive attitudes tend to breed self-destructive behaviors in their children; by contrast, the children of authoritative parents (or were even connected to authoritative adults through friends) were “40 percent less likely to drink to the point of drunkenness, 38 percent less likely to binge drink, 39 percent less likely to smoke cigarettes, and 43 percent less likely to use marijuana.”

So why are today’s young people resisting the allure of binge-drinking and illicit drugs that ensnared their Boomer parents? Perhaps it is precisely due to Baby Boomers’ libertine drug experiences that their children are inclined to avoid substance abuse. This may not just be out of disgust with their parental cautionary tales. Thanks to theirenthusiastic embrace of coddling- and self-esteem-focused helicopter parenting—Boomer parents may actually be better equipped to preemptively (and subsequently) engage their children in the type of interventions that help inoculate their kids against the risks of substance abuse.

Part of that progress is due to our increased knowledge about just what kind of interventions are effective in deterring drug use. Nancy Reagan’s famous “Just Say No” campaign in the 1980s catalyzed concern around adolescent drug use, but interventions that focused purely on abstinence or punishment (like, say, the armed police officer at the front of a D.A.R.E. session) tended to be ineffective. Programs centered on the threat of discipline — you’re going to get arrested, suspended or labeled a criminal in some other way — tend to alienate young people from seeking help from authority figures by perpetuating the stigma surrounding drug addiction, creating a gulf between young people and their parents. A 2014 examination of “just say no” programs by Scientific American found that the most effective substance abuse regimes focused on positive interactions between instructors and students that worked on developing social skills and behavioral norms. Skill development, including communication, goal setting, and negotiation, are the most important tools young people can learn regarding substance abuse, says Dr. Stephanie Zaza, the director of the CDC’s Division of Adolescent and School Health (DASH) which oversees the YRBS. “When students are confronted with an environment that has a lot of temptations, they need to be able to ask questions, talk things through, and stand up for themselves,” she says.

In other words, the same impulse that inspired Baby Boomers’ enthusiastic rebellion—the desire to push back against the strict traditions and institutions of their parents—led to a shift in parenting styles that incorporated their relatively lax views of alcohol and drug consumption with a less authoritative mode of parenting than they experienced as children themselves. More productive interventions (think “talk to your kids about drugs)” emerged as parenting methods of choice. These were widely embraced among open-minded Boomer parents with first-hand experience in the risky behavior they want to prevent. After all, the Boomers have always been “less moralistic about drug use” and more likely to blame society for their ills than their parents, as sociologist Robert Putnam observed in 2001; drugs are a problem to be addressed, not a behavior to be punished. Hell, Boomer parents are more likely to worry about bullying and depression than drug abuse, according to 2015 data from the Pew Research Center. This change in approach seems to be paying off: A 2010 longitudinalexamination of parenting practices across three generations (Gen X and older Millennial children, their Boomer parents and their “Greatest Generation” grandparents) published in Developmental Psychologyfound that the harsh discipline and overbearing monitoring Boomers experienced tended to catalyze externalized behavior problems like “poor

impulse control and oppositional, aggressive, or delinquent behavior.” When harsh discipline was in turn handed down by Boomers, it also spurred bad behavior among their children. But Boomers, by contrast, also engaged in other forms parental monitoring (observing behavior, frank conversations and the like) that lacked harsh behavioral consequences. These more gentle interventions tended to have a mediating effect between Baby Boomers and their children, a unique relationship absent from Boomers and their own discipline-happy parents.

For Boomers, “parental monitoring” takes the form of openness and trust, a propensity to engage with their children rather than merely discipline or alienate them with the likes of D.A.R.E. or Scared Straight. According UC Berkeley psychologist Diana Baumrind’s landmark 1991 research published in The Journal of Early Adolescence, it’s this balance between being demanding (focused on discipline and control) and being responsive (focused on fostering individuality and self-regulation) that both deters children from substance abuse and engenders them with the important social skills that help them avoid risky behaviors without constant parental supervision. Though we often write off this type of engagement as intrusive helicopter parenting and debilitating condescension, this style also comes with a level of empathy, openness, and engagement that helps children fully absorb and comprehend the consequences of substance abuse.

“What [the CDC] knows about parental and school engagement is simple: the more you talk with children about these issues, the less likely they are to do things,” says Dr. Zaza.

It takes more than a bad trip (or a really, really good one) at college to induce parents to change how they communicate to their kids about youth attitudes about illicit substances. The high expectations of overachieving established by Boomer parents certainly help ward kids away from addiction. According to SAMHSA, fear of disappointing ones parents is an increasingly common disincentive to experiment with illicit substances. But those parents who were either less demanding (i.e. permissive parents) or less responsive (authoritarian parents) were less likely to keep their children drug-free. By ensuring interventions are staged by emotional peers and not merely authority figures, parents are more likely to impart the social skills designed to help their children avoid developing a drug problem.

Of course, not every Boomer parent is immediately equipped to stage an in-home intervention just because they smoked a few joints at Woodstock. While a 2001 study found that some 94 percent of parents claimed to have discussed the consequences of substance abuse with their kids, 39 percent of their teenagers said the conversations never actually took place. And too much leniency can be a serious problem: a lack of boundaries and rules in an overly-permissive parent can increase the risk of drug or alcohol abuse, a reminder that “letting kids drink in a safe space” like your home probably isn’t the best idea.

But as far as today’s kids are concerned, actually talking with their once-wild and crazy parents may be the best cure for the scourge of drug addiction. Growing up, I knew that no matter what I did in the way of drugs and alcohol, I could always turn to my own Boomer parents for help and support if I was in trouble, an unspoken agreement that was, in some ways, the foundation of our relationship during my turbulent teen years—all because I knew they would actually understand what I was talking about. While the Boomers have their own issues with illicit substances, they have the experience and compassion to help future generations prepare for the dangerous world of drugs and alcohol better than any previous one. It may have been a long strange trip for the Boomers, but it needn’t go on forever.

Source:     7th August 2016 

Filed under: Social Affairs (Papers) :

Knowing what to say or do can be tough, but your help can make a huge difference

Helping a friend or family member through an alcohol or drug addiction is by no means easy, but with the right help and knowledge it can be incredibly successful (and rewarding). First things first, there’s no perfect way to behave and it’s rare that the recovery process is understood by anyone except for the individual, but that doesn’t mean you shouldn’t try. Ian Young founder of Sober Services says,

“When someone begins (or even continues or returns to) their addiction recovery journey, the love and support of friends and family is often crucial to their success. This begins with their acceptance of the addictive illness and then continues with sensitivity around the recovery seeking addict’s requirements, such as not visiting bars initially and not socialising with friends who are still using.”

So here are some of the most helpful things you can do to help a loved one tackle addiction…

1. Speak up and offer support

Just the act of offering support alone goes a long way towards helping recovery (whether it’s taken up or not), says Deirdre Boyd, founder of DB Recovery Resources. And to know that people have offered it means a lot. There’s a few different ways you can do this, for example:

“If they attend Alcoholics or Narcotics Anonymous, ask them if they would like you to accompany them to an ‘open’ meeting.”

2. Focus on the replacement rather than sacrifice

Remember that recovery is not about sacrificing something but about replacing it with something healthier (and happier), advises Deirdre. Suggest meeting friends in a coffee bar or even a recovery café instead of the pub, or in a restaurant instead of a night club. There’s now a growing trend of recovery cafes and dry bars, with more people trying to curb their drinking completely. If you’re going out, arrange to meet in the company of ‘safe’ friends instead of old drinking companions, advises Deirdre.

“Don’t replace drinks only with water but with sparkling flavoured waters offered by many supermarkets and interesting drinks, such as those from Schloer. This is especially important on celebratory occasions where others might use champagne to toast, so that they don’t miss out on the ‘ritual’ and sense of belonging.”

You could also suggest a physical activity: perhaps go for a walk. The combination of the natural environment acts as a calming backdrop to any issues up for discussion. Events are also a good option.

“Music and comedy are also often the best anchors for this as they naturally offer a good time to the recovering addict without the requirement for alcohol or drugs, though maybe avoid rave parties or rock concerts,” advises Ian.

3. Be sure they know you’re not judging

Deirdre says:

“People that are in their active addiction can be ashamed of themselves, and they feel that everyone else feels that way. But it is not always the case. A lot of times, good friends and healthy friends are just worried about the person and want them to be the best they can be.”

Understand that an addict is not responsible for their addiction, but when they learn about recovery, they are accountable for their actions.

4. Listen

If you’re helping a friend, listening is the best thing you can do. Deirdre says,

“You can’t always fix someone but you can always say, ‘Have you gone to your meeting?’, ‘Have you spoken to your sponsor?’.”

5. Educate yourself on addiction

There are plenty of resources available for those that want to learn about addiction. The most important part of the family or friends role in the addict’s early recovery will be their own education to what’s appropriate and what isn’t, says Ian.

“For instance, the addict will know it’s not a good idea to visit a pub where their friends may be drinking. But if the family or friend is unaware of this then the simple invitation could be enough to trigger their obsession to drink. Or maybe the suggestion that the recovering addict visits an ex-girlfriend whom the family/friend thinks is a safe person for them to be around, could be bringing up deep emotions that could destabilise the newly recovering addict.”

7. Know that it’s not your job to ‘fix them’

If you notice that your friend is struggling or they tell you that they are, Deirdre says to listen and ‘echo’ what they have said – you don’t have to fix them, just be there for them and advise them to share also at an AA or NA meeting.

In most cases, if the recovering addict is serious about their recovery, they’ll inform the family and friends of their boundaries, but they may not think to speak of everything, or they may be more introverted or shy about specifics, and so sensitivity is encouraged here by the loved ones, says Ian.

Source:   17th June 2016

THE methadone programme has failed drug addicts in Clydebank, a leading addictions worker said this week.

methadone-is-a-monsterDonnie McGilveray is the manager of Alternatives, a West Dunbartonshire charity that helps reform drug addicts, many of them methadone users.

He told the Post the methadone programme used to treat heroin addicts has gone unregulated — and described the green liquid as a “monster” that keeps people hooked for good.

His comments come after shock statistics were released last week showing that Clydebank pharmacies claimed £153,000 for methadone prescriptions in 2014.

Donnie told the Post: “I think methadone is helpful for a small cohort of people, the five to ten per cent of people who are chaotic, suicidal or maybe sex workers being used and abused by people. There is a small group of people who need to be made safe.

But that’s not what is happening. We’ve got this monster, a jolly green giant, that many, many addicts are stuck on. And again, it’s not just them who are stuck in this it’s the doctors and nurses who have an obligation to keep them safe.”

National data obtained by BBC Scotland showed pharmacists were paid £17.8 million for handling nearly half a million prescriptions of methadone in 2014. In Clydebank, £153,000 was paid to eight pharmacies to deliver 3,165 prescriptions of the heroin substitute. In Dalmuir Lloyds, £31,671 was claimed for prescribing and supervising methadone to addicts in 2014. But topping the chart was Lloyds Pharmacy on 375 Kilbowie Road which received £38,207 in payments. Pharmacists are paid around £2.32 for dispensing every dose of methadone and about £1.33 for supervising addicts while they take it. Chemists pay the wholesale cost of buying methadone from the government money they claim.

Around 60 per cent of the cash they are paid is made up of their handling fee for the drug and their charges for dishing it out to addicts. In 2013, pharmacies claimed back more than £17.9 million from the Scottish Government for handling 470,256 prescriptions of methadone — 22,980 prescriptions more than in 2014.

Donnie also told the Post he believes West Dunbartonshire, which has a long history of drug problems, is making progress tackling addiction. He said: “At the end of the day, the statistics don’t tell you how many people are on methadone or any details of the prescription, but what we can tell is the drug companies are making a killing from it.”

Figures released by the NHS in 2012 revealed that methadone-implicated deaths increased dramatically in cases where the individual had been prescribed the drug for more than a year.

The addictions worker told the Post he believes methadone should be reserved for the chaotic drug users and other substitutes such as Buprenorphine, Subutex and Dihydrocodiene should be implemented. He continued: “Methadone is not just a medical or pharmaceutical matter but a human rights issue. “The dilemma is that if you reduce someone’s methadone they become unstable and could relapse. Some of the people we work with at Alternatives have relapsed, it’s a regular situation.

If you start to reduce this person they could relapse and relapse significantly, and they might think they can go back onto heroin and inevitably could end up overdosing.”

He added: “That’s my position and I don’t envy the medical side of it in trying to square this problem.”

Top researcher Dr Neil McKeganey, from the Centre for Drug Misuse Research, said the methadone programme “is literally a black hole into which people are disappearing”.

The statistics of methadone prescriptions can be viewed online at:

Alternatives is an organisation funded by West Dunbartonshire Council that helps bring recovering addicts back into society. The project has been around since January 1995, firstly covering Dumbarton and the Vale of Leven, latterly broadening out to Clydebank.

Source: 7th April 2015


Marijuana use for medical conditions is an issue of growing concern. Some Veterans use marijuana to relieve symptoms of PTSD and several states specifically approve the use of medical marijuana for PTSD. However, controlled studies have not been conducted to evaluate the safety or effectiveness of medical marijuana for PTSD. Thus, there is no evidence at this time that marijuana is an effective treatment for PTSD. In fact, research suggests that marijuana can be harmful to individuals with PTSD.


Marijuana use has increased over the past decade. In 2013, a study found that 19.8 million people reported using marijuana in the past month, with 8.1 million using almost every day (1). Daily use has increased 60% in the prior decade (1). A number of factors are associated with increased risk of marijuana use, including diagnosis of PTSD (2), social anxiety disorder (3), other substance use, particularly during youth (4), and peer substance use (5).

Cannabis Use Disorder among Veterans Using VA Health Care

There has been no study of marijuana use in the overall Veteran population. What we do know comes from looking at data of Veterans using VA health care, who may not be representative of Veterans overall. When considering the subset of Veterans seen in VA health care with co-occurring PTSD and substance use disorders (SUD), cannabis use disorder has been the most diagnosed SUD since 2009. The percentage of Veterans in VA with PTSD and SUD who were diagnosed with cannabis use disorder increased from 13.0% in fiscal year (FY) 2002 to 22.7% in FY 2014. As of FY 2014, there are more than 40,000 Veterans with PTSD and SUD seen in VA diagnosed with cannabis use disorder (6).



Problems Associated with Marijuana Use

Marijuana use is associated with medical and psychiatric problems. These problems may be caused by using, but they also may reflect the characteristics of the people who use marijuana. Medical problems include chronic bronchitis, abnormal brain development among early adolescent initiators, and impairment in short-term memory, motor coordination and the ability to perform complex psychomotor tasks such as driving. Psychiatric problems include psychosis and impairment in cognitive ability. Quality of life can also be affected through poor life satisfaction, decreased educational attainment, and increased sexual risk-taking behavior (7). Chronic marijuana use also can lead to addiction, with an established and clinically significant withdrawal syndrome (8).

Active Ingredients and Route of Administration

Marijuana contains a variety of components (cannabinoids), most notably delta-9-tetrahydrocannabinol (THC) the primary psychoactive compound in the marijuana plant. There are a number of other cannabinoids, such as cannabidiol (CBD), cannabinol (CBN), and cannabigerol (CBG). Marijuana can vary in cannabinoid concentration, such as in the ratio of THC to other cannabinoids (CBD in particular). Therefore, the effects of marijuana use (e.g., experience of a high, anxiety, sleep) vary as a function of the concentration of cannabinoids (e.g., THC/CBD). In addition, the potency of cannabinoids can vary. For example, the concentration of THC in the marijuana plant can range in strength from less than 1% to 30% based upon strain and cultivation methods. In general, the potency of THC in the marijuana plant has increased as much as 10-fold over the past 40 years (9,10). Recently, cannabis extract products, such as waxes and oils, have been produced and sold in which the concentration of THC can be as high as 90%. Thus, an individual could unknowingly consume a very high dose of THC in one administration, which increases the risk of an adverse reaction.

Marijuana can be consumed in many different forms (e.g., flower, hash, oil, wax, food products, tinctures). Administration of these forms also can take different routes: inhalation (smoking or vaporizing), ingestion, and topical application. Given the same concentration/ratio of marijuana, smoking or vaporizing marijuana produces similar effects (11); however, ingesting the same dose results in a delayed onset and longer duration of effect (12). Not all marijuana users may be aware of the delayed effect caused by ingestion, which may result in greater consumption and a stronger effect than intended.


Research has consistently demonstrated that the human endocannabinoid system plays a significant role in PTSD. People with PTSD have greater availability of cannabinoid type 1 (CB1) receptors as compared to trauma-exposed or healthy controls (13,14). As a result, marijuana use by individuals with PTSD may result in short-term reduction of PTSD symptoms. However, data suggest that continued use of marijuana among individuals with PTSD may lead to a number of negative consequences, including marijuana tolerance (via reductions in CB1 receptor density and/or efficiency) and addiction (15). Though recent work has shown that CB1 receptors may return after periods of marijuana abstinence (16), individuals with PTSD may have particular difficulty quitting (17).

Marijuana as a Treatment for PTSD

The belief that marijuana can be used to treat PTSD is limited to anecdotal reports from individuals with PTSD who say that the drug helps with their symptoms. There have been no randomized controlled trials, a necessary “gold standard” for determining efficacy. Administration of oral CBD has been shown to decrease anxiety in those with and without clinical anxiety (18). This work has led to the development and testing of CBD treatments for individuals with social anxiety (19), but not yet among individuals with PTSD. With respect to THC, one open trial of 10 participants with PTSD showed THC was safe and well tolerated and resulted in decreases in hyperarousal symptoms (20).

Treatment for Marijuana Addiction

People with PTSD have particular difficulty stopping their use of marijuana and responding to treatment for marijuana addiction. They have greater craving and withdrawal than those without PTSD (21), and greater likelihood of marijuana use during the six months following a quit attempt (17). However, these individuals can benefit from the many evidence-based treatments for marijuana addiction, including cognitive behavioral therapy, motivational enhancement, and contingency management (22). Thus, providers should still utilize these options to support reduction/abstinence.

Clinical Recommendations

Treatment providers should not ignore marijuana use in their PTSD patients. The VA/DoD PTSD Clinical Practice Guideline(2010) recommends providing evidence-based treatments for the individual disorders concurrently. PTSD providers should offer education about problems associated with long-term marijuana use and make a referral to a substance use disorder (SUD) specialist if they do not feel they have expertise in treating substance use.

Individuals with comorbid PTSD and SUD do not need to wait for a period of abstinence before addressing their PTSD. A growing number of studies demonstrate that that these patients can tolerate trauma-focused treatment and that these treatments do not worsen substance use outcomes. Therefore, providers have a range of options to help improve the lives of patients with the co-occurring disorders.

Marcel O. Bonn-Miller, Ph.D. and Glenna S. Rousseau, Ph.D.

For more information, see PTSD and Substance Use Disorders in Veterans.


  1. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings.(Vol. NSDUH Series H-48, HHS Publication No. (SMA) 13-4795). Rockville, MD: Substance Abuse and Mental Health Services Administration.
  2. Cougle, J.R., Bonn-Miller, M. O., Vujanovic, A. A., Zvolensky, M. J., & Hawkins, K. A. (2011). Posttraumatic stress disorder and cannabis use in a nationally representative sample. Psychology of Addictive Behaviors, 25,554-558. doi: 10.1037/a0023076
  3. Buckner, J.D., Schmidt, N. B., Lang, A. R., Small, J. W., Schluach, R. C., & Lewinsohn, P. M. (2008). Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence. Journal of Psychiatric Research, 42,230-239. doi: 10.1016/j.jpsychires.2007.01.002
  4. Butterworth, P., Slade, T. & Degenhardt, L. (2014). Factors associated with the timing and onset of cannabis use and cannabis use disorder: Results from the 2007 Australian National Survey of Mental Health and Well-Being. Drug and Alcohol Review, 33,555-564. doi: 10.1111/dar.12183
  5. von Sydow, K., Lieb, R., Pfister, H., Höefler, M., & Wittchen, H. U. (2002). What predicts incident use of cannabis and progression to abuse and dependence? A 4-year prospective examination of risk factors in a community sample of adolescents and young adults. Drug and Alcohol Dependence, 68,49-64.
  6. Program Evaluation and Resource Center, V.A., 2015.
  7. Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. B. (2014). Adverse health effects of marijuana use. New England Journal of Medicine, 370,2219-2227. doi: 10.1056/NEJMra1402309
  8. Budney, A. J., Hughes, J. R., Moore, B. A., & Vandrey, R. (2004). Review of the validity and significance of cannabis withdrawal syndrome. American Journal of Psychiatry, 161,1967-1977.
  9. Mehmedic, Z., Chandra, S., Slade, D., Denham, H., Foster, S., Patel, A. S., Ross, S. A., Khan, I. A., & ElSohly, M. A. (2010). Potency trends of Δ9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008.Journal of Forensic Sciences, 55,1209-1217. doi: 10.1111/j.1556-4029.2010.01441.x
  10. Sevigny, E. L., Pacula, R. L., & Heaton, P. (2014) The effects of medical marijuana laws on potency. International Journal of Drug Policy, 25,308-319. doi: 10.1016/j.drugpo.2014.01.003
  11. Abrams, D. I., Vizoso, H. P., Shade, S. B., Jay, C., Kelly, M. E., & Benowitz, N. L. (2007). Vaporization as a smokeless cannabis delivery system: A pilot study. Clinical Pharmacology & Therapeutics, 82,572-578.
  12. Grotenhermen, F. (2003). Pharmacokinetics and pharmacodynamics of cannabinoids. Clinical Pharmacokinetics, 42,327-360.
  13. Neumeister, A., Normandin, M. D., Pietrzak, R. H., Piomelli, D., Zheng, M. Q., Gujarro-Anton, A., Potenza, M. N., Bailey, C. R., Lin, S. F., Najafzaden, S., Ropchan, J., Henry, S., Corsi-Travali, S., Carson, R. E., & Huang, Y. (2013). Elevated brain cannabinoid CB1 receptor availability in post-traumatic stress disorder: A positron emission tomography study. Molecular Psychiatry, 18,1034-1040. doi: 10.1038/mp.2013.61
  14. Passie, T., Emrich, H. M., Brandt, S. D., & Halpern, J. H. (2012). Mitigation of post-traumatic stress symptoms by Cannabis resin: A review of the clinical and neurobiological evidence. Drug Testing and Analysis, 4,649-659. doi: 10.1002/dta.1377
  15. Kendall, D.A. & Alexander, S.P. H. (2009). Behavioral neurobiology of the endocannabinoid system.Current topics in behavioral neurosciences. Heidelberg: Springer-Verlag.
  16. Hirvonen, J., Goodwin, R. S., Li, C-T., Terry, G. E., Zoghbi, S. S., Morse, C., Pike, V. W., Volkow, N. D., Huestis, M. A., & Innis, R. B. (2012). Reversible and regionally selective downregulation of brain cannabinoid CB1 receptors in chronic daily cannabis smokers. Molecular Psychiatry, 17,642-649. doi: 10.1038/mp.2011.82
  17. Bonn-Miller, M. O., Moos, R. H., Boden, M. T., Long, W. R., Kimerling, R., & Trafton, J. A. (in press). The impact of posttraumatic stress disorder on cannabis quit success. The American Journal of Drug and Alcohol Abuse.
  18. Crippa, J. A., Zuardi, A. W., Martín-Santos, R., Bhattacharyya, S., Atakan, Z., McGuire, P., & Fusar-Poli, P. (2009). Cannabis and anxiety: a critical review of the evidence. Human Psychopharmacology, 24,515-523. doi: 10.1002/hup.1048
  19. Bergamaschi, M. M., Queiroz, R. H. C., Hortes, M., Chagas, N., de Oliveira, C. G., De Martinis, B. S., Kapczinski, F., Quevedo, J., Roesler, R., Schröder, N., Nardi, A. E., Martín-Santos, R., Hallak, J. E. C., Zuardi, A. W., & Crippa, J. A. S. (2011). Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology, 36,1219-1226. doi: 10.1038/npp.2011.6
  20. Roitman, P., Mechoulam, R., Cooper-Kazaz, R., & Shalev, A. (2014). Preliminary, open-label, pilot study of add-on oral Δ9-tetrahydrocannabinol in chronic post-traumatic stress disorder. Clinical Drug Investigation, 34,587-591. doi: 10.1007/s40261-014-0212-3
  21. Boden, M. T., Babson, K. A., Vujanovic, A. A., Short, N. A., & Bonn-Miller, M. (2013). Posttraumatic stress disorder and cannabis use characteristics among military Veterans with cannabis dependence. The American Journal on Addictions, 22,277-284. doi: 10.1111/j.1521-0391.2012.12018.x
  22. Roffman, R. A. & Stephens, R. S. (2006). Cannabis dependence: its nature, consequences, and treatment.International research monographs in the addictions. Cambridge, UK; New York: Cambridge University Pres

Source:   May 2015

An interactive mobile texting aftercare program has shown promise as a means to help teens and young adults engage with post-treatment recovery activities and avoid relapse, researchers report. In a NIDA-supported pilot study, the program, called ESQYIR (Educating & Supporting Inquisitive Youth in Recovery), reduced young people’s odds of relapsing by half compared with standard aftercare.

Dr. Rachel Gonzales and colleagues at the University of California, Los Angeles (UCLA), designed ESQYIR to teach and reinforce wellness self-management in a manner that fits young people’s attitudes and communication styles. The researchers cite numerous advantages of the mobile texting approach: It is inexpensive and features personalization of content, convenience of use, ease of assessment and monitoring, and flexibility in the time and location of delivery.

The Need

Many young people comply poorly with aftercare interventions and resist involvement in 12-step programs and other post-treatment recovery activities. Dr. Gonzales says, “Teens and young adults don’t want to be stigmatized as having a disease or as still being in recovery. In their minds, after the primary treatment, they are done.” Young people often don’t view addiction as a disease, she adds. Instead, they regard substance use as a matter of lifestyle and personal choice. As a result, as many as 85 percent of teens and young adults relapse within 1 year.

Dr. Gonzales and her research team reckoned that young people might engage more readily with aftercare built on text messaging. This mode of communication is ubiquitous among young people, surpassing most other forms of social interaction. Messages can be personalized and can be accessed and responded to privately, when and where youths find it convenient or feel a need for help. Text messaging interventions are already used to treat maladies including obesity, sexually transmitted diseases, and tobacco dependence in young adults.

“The most effective programs take into consideration the users, their needs, their desires, and their way of connecting,” Dr. Gonzales says. Accordingly, when she and her team composed the text messages for Project ESQYIR, they solicited input from young people in recovery from substance use disorders (SUDs). “The program’s text messages are based on their voices, parallel their views of recovery, and speak to their recovery needs,” Dr. Gonzales says.

Keeping Tabs With Texts

The participants in the ESQYIR pilot study were 80 volunteers, ages 14 to 26, who had been treated in outpatient and residential community treatment centers in the Los Angeles area. The drugs that had caused them problems included marijuana (55 percent), methamphetamine (30 percent), cocaine (15 percent), heroin (11 percent), prescription drug (6 percent), and other substances including alcohol (4 percent). Half of the participants received the mobile texting ESQYIR program, the other half received the standard aftercare offered by their treatment facilities, which consisted of referral to 12-step programs.

Figure 1. Daily Mobile Texts Prompt Self-Monitoring, Give Recovery Advice and Encouragement

The participants in the text messaging program received daily text messages with tips to self-monitor their recovery- and substance use–related behaviors and with alerts to aftercare services in their community.

Each weekday at 12 noon, the participants in the ESQYIR group received a text that reminded them about being in recovery and provided a wellness tip for the day. The reminder portion of the text said, “Today’s a new day in ur recovery! Think about the change ur working towards.” The wellness tip promoted personal, social, physical, or emotional health. For example, one message read, “Write down the top 3 stressors that u need to avoid or deal with for helping u not use.”

Weekdays at 4 p.m., the participants in the ESQYIR group received a text that prompted them to self-monitor and text back numerical ratings of their abstinence confidence, wellbeing, substance use, and recovery behaviors (see Figure 1). The participants then received a feedback text, automatically selected from more than 600 possible messages, which provided motivational/inspirational encouragement, coping advice, or positive appraisal tailored to the participants’ self-rating. For example, motivational feedback texts encouraged participants to keep on track with recovery and attend therapy or self-help meetings when needed.

Dr. Gonzales says, “The self-monitoring texts helped participants remain mindful and aware of potential relapse triggers, particularly in risky situations.” With that awareness and the feedback provided by the program, the young people were able to generate strategies for coping with such situations without drugs, the researchers suggest.

On weekends, the participants received personalized texts with educational information adapted from NIDA reference materials and resource information on local support services.

Less Relapse, More Engagement

Figure 2. Text-Based Delivery of Aftercare Content Decreases Relapse

Teens and young adults receiving daily text messages had lower relapse rates than peers receiving only standard aftercare.

The UCLA researchers monitored the participants’ urine for alcohol and drugs monthly during the program. The results indicated that with passing time, the text-based aftercare participants’ odds of relapsing to their primary substances rose only half as fast as those of the standard aftercare group. Compared with the participants in standard aftercare, those assigned to the ESQYIR group were less likely to have relapsed 1 month (8.6 percent vs. 30.3 percent), 2 months (3.6 percent vs. 39.3 percent), and 3 months (14.7 percent vs. 62.9 percent) after the end of their substance abuse treatment (see Figure 2).

The researchers followed up with 55 of the original 81 study participants 180 days after the end of treatment (90 days after the end of the aftercare programs). Those who had received the ESQYIR mobile wellness aftercare intervention were still less likely to have relapsed (21.4 percent vs. 59.3 percent).

The ESQYIR and standard aftercare participants both attended on average ten 12-step meetings per month during their last month in substance abuse treatment. Both groups reduced their 12-step attendance in the aftercare period, but the ESQYIR participants did so to a lesser degree (8.9 vs. 2.9 meetings in the final month). The two groups no longer differed significantly in 12-step attendance during the third month post-aftercare (7.0 vs. 4.6 days per month). However, during that month the ESQYIR participants were more involved in other recovery-related extracurricular activities (e.g., exercise, walking, and community/volunteer service) than those who received the standard aftercare.

Text and Thrive

Dr. Gonzales and colleagues are planning a larger, stage II efficacy trial of the mobile-based ESQYIR aftercare wellness intervention. For this trial, they are enhancing the program with new features, including text messages to foster HIV awareness and prevention.

“We look forward to further research in this line of work and to learning more about the efficacy of this intervention,” says Dr. Jessica Campbell Chambers, health science administrator at NIDA’sBehavioral and Integrative Treatment Branch. “This work is extremely important given the high rates of relapse among recovering adolescents.”

Dr. Campbell Chambers concurs with Dr. Gonzales that although the pilot nature of the study and its relatively small cohort size make its results only preliminary, the findings are very promising. The UCLA study team will soon publish a report on the ESQYIR program’s effects at 6- and 9-months post-participation.

This study was supported by NIH grant DA027754.


Gonzales, R.; Ang, A.; Murphy, D.A. et al. Substance use recovery outcomes among a cohort of youth participating in a mobile-based texting aftercare pilot program. Journal of Substance Abuse Treatment 47(1):20-26, 2014.

Marijuana Use: Detrimental to Youth

ABSTRACT: Although increasing legalization of marijuana has contributed to the growing belief that marijuana is harmless, research documents the risks of its use by youth are grave. Marijuana is addicting, has adverse effects upon the adolescent brain, is a risk for both cardio-respiratory disease and testicular cancer, and is associated with both psychiatric illness and negative social outcomes. Evidence indicates limited legalization of marijuana has already raised rates of unintended marijuana exposure among young children, and may increase adolescent use. Therefore, the American College of Pediatricians supports legislation that continues to restrict the availability of marijuana except in the context of well controlled scientific studies which demonstrate medicinal benefit together with evidence-based guidelines for optimal routes of delivery and dosing for specific medical conditions.


Federal Law has prohibited the manufacture, sale, and distribution of marijuana for more than 70 years. However, with the discovery of potential medicinal properties of marijuana and the increasing misperception that the drug is harmless, there have arisen increased efforts to achieve its broad legalization despite persistent problems of abuse. Medical use of marijuana has prompted many states to establish programs for sale of medically-prescribed marijuana. As public perception of marijuana’s safety has grown, some states have also passed voter-approved referenda legalizing recreational use of marijuana by adults. The result has been the same: limited legalization has led to greater availability of marijuana to youth.

How is Marijuana Used?

Whether used licitly or illicitly, marijuana is smoked or ingested. It may be smoked in hand-rolled cigarettes (joints), pipes or water pipes (bongs), and cigars that have been refilled with a mixture of marijuana and tobacco (blunts). Marijuana emits a distinctive pungent usually sweet-and-sour odour when it is smoked. Marijuana is not so easily detectable, however, when ingested in candy, other foods or as a tea.


Has Legalization Escalated Youth Exposure to Marijuana?

There is evidence legalization of marijuana limited to medical dispensaries and/or adult recreational use has led to increased unintended exposure to marijuana among young children. By 2011, rates of poison center calls for accidental paediatric marijuana ingestion more than tripled in states that decriminalized marijuana before 2005. In states which passed legislation between 2005 and 2011 call rates increased nearly 11.5% per year. There was no similar increase in states that had not decriminalized marijuana as of December 31, 2011. Additionally, exposures in decriminalized states where marijuana use was legalized were more likely than those in non-legal states to present with moderate to severe symptoms requiring admission to a paediatric intensive care unit. The median age of children involved was 18-24 months.1

Marijuana use by adolescents has grown steadily as more states enact various decriminalization laws.2 According to CDC data, more teens now smoke marijuana than cigarettes.3 It is unclear, however, whether this trend indicates a causal relationship or mere correlation. There is some evidence legalization may encourage more youth to experiment with the drug. A national study of 6116 high school seniors, prior to legalization of recreational use in any state, found 10% of nonusers said they would try marijuana if the drug were legal in their state. Significantly, this included large subgroups of students normally at low risk for drug experimentation, including non-cigarette smokers, those with strong religious affiliation, and those with peers who frown upon drug use. Among high school seniors already using marijuana, 18% said they would use more under legalization.

There is also evidence of medical marijuana diversion having a significant impact upon adolescents. For example, researchers in Colorado found that approximately 74% of adolescents in substance abuse treatment had used someone else’s medical marijuana. After adjusting for sex, race and ethnicity, those who used medical marijuana had an earlier age of regular marijuana use, and more marijuana abuse and dependence symptoms than those who did not use medical marijuana.4-5 Conclusions from this study may not apply to adolescents as a whole due to the select population surveyed. There are broader adolescent population studies suggesting no significant increase in use due to enactment of medical marijuana laws.6-10 These authors, however, caution that their results may not be definitive for five reasons: not all states with medical marijuana laws are represented in the various studies; the studies rely upon survey data from a voluntary survey (the Youth Risk Behavior Survey) which has the potential for reporting bias; there are gaps in the annual youth risk behavior data; the primary outcome measure was obtained from a single survey item; and the research is not long-term relative to when medical marijuana laws were implemented. Consequently, while all reported their data did not find medical marijuana laws to significantly increase teen use, they also advised continued long-term observation and research.


Is Marijuana Medicine?

A recent article in the Journal of the American Medical Association noted there is very little scientific evidence to support the use of medical marijuana. Authors Samuel Wilkinson and Deepak D’Souza explain that medical marijuana is considerably different from all other prescription medications in that “evidence supporting its efficacy varies substantially and in general falls short of the standards required for approval of other drugs by the US Food and Drug Administration (FDA).”11 The FDA requires carefully conducted studies consisting of hundreds to thousands of patients in order to accurately assess the benefits and risks of a potential medication.

Although some studies suggest marijuana may palliate chemotherapy-induced vomiting, cachexia in HIV/AIDS patients, spasticity associated with multiple sclerosis, and neuropathic pain, there is no significant evidence marijuana is superior to FDA approved medications currently available to treat these conditions. Additionally, support for use of marijuana in other conditions, including post-traumatic stress disorder, Crohn’s disease and Alzheimer’s, is not scientific, relying on emotion-laden anecdotes instead of adequately powered, double-blind, placebo-controlled randomized clinical trials.11

Also, to be considered a legitimate medicine, a substance must have well-defined and measurable ingredients that are consistent from one unit (such as a pill or injection) to the next. This consistency allows researchers to determine optimal dosing and frequency. Drs. Samuel Wilkinson and Deepak D’Souza state:

Prescription drugs are produced according to exacting standards to ensure uniformity and purity of active constituents … Because regulatory standards of the production process vary by state, the composition, purity, and concentration of the active constituents of marijuana are also likely to vary. This is especially problematic because unlike most other prescription medications that are single active compounds, marijuana contains more than 100 cannabinoids, terpenoids, and flavonoids that produce individual, interactive, and entourage effects.”11

 As a consequence, there are no dosing guidelines for marijuana for any of the conditions it has been approved to treat. And finally, there is no scientific evidence that the potential healthful effects of marijuana outweigh its documented adverse effects.11 Sound ethics demands that physicians “First do no harm.” This is why a dozen national health organizations, including the College, presently oppose further legalization of marijuana for medicinal purposes.12 If and when rigorous research delineates marijuana’s true benefits relative to its hazards, compares its efficacy with current medications on the market, determines its optimal routes of delivery and dosing, and standardizes its production and dispensing (to match that of schedule II medications like narcotics and opioids), then medical opposition will dissipate.


The Extent of Marijuana Abuse

In the United States, marijuana is the most frequently used illicit drug,13-14 with 23.9 million of those at least 12 years old having used an illegal drug within the past month in 2012.15 The National Institute on Drug Abuse (NIDA)-funded 2013 Monitoring the Future study of the year 2012 showed that 12.7 percent of 8th graders, 29.8 percent of 10th graders, and 36.4 percent of 12th graders had used marijuana at least once in the year prior to being surveyed. They also found that 7, 18 and 22.7 percent respectively for these groups used marijuana in the past month.13

Figure 1. Long-Term Trends in Annual Marijuana Use by Grade14

After a period of decline in the last decade, marijuana use has generally increased among young people since 2007, corresponding with both its increased availability through limited legalization and a diminishing perception of the drug’s risks. The number of current (past month) users aged 12 and up increased from 14.5 to 18.9 million.15

In 2010, 7.3 percent of all persons admitted to publicly funded treatment facilities were aged 12-17. Marijuana is the leading illicit substance mentioned in adolescent emergency department admissions and autopsy reports, and is considered one of the major contributing factors leading to violent deaths and accidents among adolescents.16

Figure 2.  Emergency Department Visits by Type of Substance Abuse16


Such data indicate that marijuana use in adolescents is a major and growing problem. Given the widespread availability and abuse of marijuana, and its increasing decriminalization, it is important to examine the adverse clinical consequences of marijuana use.

Marijuana and Addiction

Marijuana is addictive. While approximately 9 percent of users overall become addicted to marijuana, about 17 percent of those who start during adolescence and 25-50 percent of daily users become addicted. Thus, many of the nearly 6.5 percent of high school seniors who report smoking marijuana daily or almost daily are well on their way to addiction, if not already addicted.13 In fact, between 70-72% of 12-17 year olds who enter drug treatment programs, do so primarily because of marijuana addiction.18,13

Long-term marijuana users trying to quit report various withdrawal symptoms including irritability, sleeplessness, decreased appetite, anxiety, and drug craving, all of which can make it difficult to remain abstinent.  These withdrawal symptoms can begin within the first 24 hours following cessation, peak at two to three days, and subside within one or two weeks follow drug cessation. Behavioral interventions, including cognitive-behavioral therapy and motivational incentives (i.e., providing vouchers for goods or services to patients who remain abstinent) have proven to be effective in treating marijuana addiction.19 Although no medications are currently available, recent discoveries about the workings of the endocannabinoid system offer promise for the development of medications to ease withdrawal, block the intoxicating effects of marijuana, and prevent relapse.20

Is Marijuana a Gateway Leading to the Abuse of Other Illicit Drugs?

An additional danger associated with marijuana use observed in adolescents is a sequential pattern of involvement in other legal and illegal drugs. Marijuana is frequently a stepping stone that bridges the gap between cigarette and alcohol use and the use of other more powerful and dangerous substances like cocaine and heroin. This stage-like progression of substance abuse, known as the gateway phenomenon, is common among youth from all socioeconomic and racial backgrounds.19, 21 Additionally, marijuana is often intentionally used with other substances, including alcohol or crack cocaine, to magnify its effects. Phencyclidine (PCP), formaldehyde, crack cocaine, and codeine cough syrup are also often mixed with marijuana without the user’s knowledge.21


Other Effects of Marijuana on the Brain

The main active chemical in marijuana is delta-9-tetrahydrocannabinol (THC). When marijuana is smoked, THC rapidly passes from the lungs into the bloodstream, which carries the chemical to the brain and other organs throughout the body. It is absorbed more slowly when ingested in food or drink.13 In all cases, however, THC acts upon specific molecular targets on brain cells, called cannabinoid receptors. These receptors are ordinarily activated by chemicals similar to THC called endocannabinoids, such as anandamide. These receptors are naturally occurring in the body and are part of a neural communication network (the endocannabinoid system) that plays an important role in normal brain development and function. The highest density of cannabinoid receptors is found in parts of the brain that influence pleasure, memory, thinking, concentration, sensory and time perception, and coordinated movement. Marijuana over activates the endocannabinoid system, causing the high and other effects that users experience. These effects include distorted perceptions, psychotic symptoms, difficulty with thinking and problem solving, disrupted learning and memory, and impaired reaction time, attention span, judgment, balance and coordination.21 Chronic exposure to THC may also hasten the age-related loss of nerve cells.22

 Numerous mechanisms have been postulated to link cannabis use, attentional deficits, psychotic symptoms, and neural desynchronization.23 The hippocampus, a component of the brain’s limbic system, is necessary for memory, learning, and integrating sensory experiences with emotions and motivations. THC suppresses neurons in the information-processing system of the hippocampus, thus learned behaviors, dependent on the hippocampus, also deteriorate.24 Brain MRI studies now report that in young recreational marijuana users, structural abnormalities in gray matter density, volume, and shape occur in areas of the brain associated with drug craving and dependence. There also was significant abnormality measures associated with increasing drug use behavior. In addition to the regions of the nucleus accumbens and amygdala, the whole-brain gray matter density analysis revealed other brain regions that showed reduced density in marijuana users compared with control participants, including several regions in the prefrontal cortex: right/left frontal pole, right dorsolateral prefrontal cortex, and right middle frontal gyrus (although another small region in the right middle frontal gyrus showed higher gray matter density in marijuana users). Countless studies have also shown that prefrontal cortex dysfunction is involved with decision-making abnormalities and functional MRI and magnetic resonance spectroscopy studies have shown that cannabis use may affect the function of this region.25 Brain imaging with MRI was used to map areas of working memory in the brain and showed similar findings in normal and schizophrenic subjects who did not use marijuana, but decreases in the size of the working memory areas of the striatum and thalamus for those who had a history of cannabis use, that was more marked in those who used marijuana at a younger age and in users with schizophrenia.26

 In chronic adolescent users, marijuana’s adverse impact on learning and memory persists long after the acute effects of the drug wear off. A major study published in 2012 in Proceedings of the National Academy of Sciences provides objective evidence that marijuana is harmful to the adolescent brain. As part of this large-scale study of health and development, researchers in New Zealand administered IQ tests to over 1,000 individuals at age 13 (born in 1972 and 1973) and assessed their patterns of cannabis use at several points as they aged. Participants were again IQ tested at age 38, and their two scores were compared as a function of their marijuana use.

The results were striking: Participants who used cannabis heavily in their teens and continued through adulthood showed a significant drop in IQ between the ages of 13 and 38—an average of eight points for those who met criteria for cannabis dependence. Those who started using marijuana regularly or heavily after age 18 showed minor declines. By comparison, those who never used marijuana showed no declines in IQ.27 This is the first prospective study to test young people before their first use of marijuana and again after long-term use (as much as 20+ years later) thereby ruling out a pre-existing difference in IQ. This means the finding of a significant mental decline among those who used marijuana heavily before age 18, even after they quit taking the drug, is consistent with the theory that drug use during adolescence—when the brain is still rewiring, pruning, and organizing itself—has long-lasting negative effects on the brain.

Other studies have also shown a link between prolonged marijuana use and cognitive or neural impairment. A recent report in Brain, for example, reveals neural-connectivity impairment in some brain regions following prolonged cannabis use initiated in adolescence or young adulthood.28


Effects on Activities of Daily Living

Consistent with marijuana’s impact upon the brain, research demonstrates marijuana has the potential to cause difficulties in daily life and/or worsen a person’s existing problems. Heavy marijuana users generally report lower life satisfaction, reduced mental and physical health, more relationship problems, and less academic and career success compared to their peers who come from similar backgrounds. Marijuana use is also associated with a higher likelihood of dropping out of school, workplace tardiness and absence, more accidents on the job with concomitant workman compensation claims, and increased job turnover.29-30

A 2014 study combined the data of 3 investigations from Australia and New Zealand which compared a series of outcome measures of young adults according to their marijuana use at age 17. The researchers found a significant dose-response effect for each of these.  After adjusting for co-variables, compared to those who never used cannabis prior to age 17 (OR 1.0), the odds of graduating from high school by age 25 dropped to 0.78 (95% CI,0.67-0.90) for those who used cannabis less than monthly to 0.61 (95% CI,0.45-0.81) for those using it monthly or more to 0.47 (95% CI,0.30-0.73) for those using it weekly or more to 0.37 (95% CI,0.20-0.66) for daily users.  The decrease in attaining a university degree was almost identical.  The odds of dependence on cannabis between the ages of 17 and 25 rose progressively from 2.06 (95% CI,1.75-2.42) for less than monthly users to 17.95 (95% CI,9.44-34.12) for daily users, and the odds of other illicit drug use between the ages of 23-25 rose from 1.67 (95% CI,1.45-1.92) for less than monthly users to 7.80 (95% CI,4.46-13.63) for those who were daily users prior to age 17.  The odds of a making a suicide attempt between the ages of 17 and 25 were increased from 1.62 (95% CI,1.19-2.19) for less than monthly users to 6.83 (95% CI,2.04-22.9) for daily users.  While unadjusted odds ratios were progressively higher for progressively higher amounts of cannabis used before age 17 for both depression (between ages 17-25) and for welfare dependence (at ages 27-30 depending on the study), these differences were no longer significant after adjusting for co-variables.31Although the greatest harm was among heavier users, it is most concerning that even less than monthly usage prior to age 17 was associated with a significantly lower educational achievement, and significantly higher rates of drug dependence and suicide attempts.

 Marijuana and Mental Illness

Figure 3.  Mood and Anxiety Disorders Among Users and Non-Users of Marijuana32

 A number of studies have shown an association between chronic marijuana use and mental illness. People who are dependent on marijuana frequently have other comorbid mental disorders including but not limited to anxiety, depression, suicidal ideation, and personality disturbances, including amotivation and failure to engage in activities that are typically rewarding (see figure 3).13 Marijuana use is associated with a 7-fold increased risk of depression (OR 7.10, 95% CI,4.39-11.73) and a 5-fold increased risk of suicidal ideation (OR 5.38, 95% CI,3.31-8.73) when used alone, and with a 9-fold increased risk of depression (OR 9.15, 95% CI,4.58-18.29) and nearly 9 fold increased risk of suicidal ideation when marijuana plus other drugs are involved (OR 8.74, 95% CI 4.29-17.79).17 Daily marijuana use in young women has been associated with a five-fold increase in depression and anxiety.33

Population studies also reveal an association between cannabis use and increased risk of schizophrenia. In the short term, high doses of marijuana can produce a temporary psychotic reaction involving hallucinations and paranoia. There is also sufficient data indicating that chronic marijuana use may trigger the onset or relapse of schizophrenia in people predisposed to it, perhaps also intensifying their symptoms .13,34,32A series of large prospective studies showed a link between marijuana use and the later development of psychosis with genetic variables, the amount of drug used, and the younger the age at which use began increasing the risk of occurrence.13 Although it is possible that pre-existing mental illness may lead some individuals to self-medicate with (abuse) marijuana and other illicit drugs, further prospective studies similar to those examining psychosis, will more firmly establish marijuana as a causative factor for other forms of mental illness.

 Marijuana and Driving

Marijuana contributes to accidents while driving due to its significant impairment of judgment and motor coordination. Data from several studies was analyzed and documented that use of marijuana more than doubles a driver’s risk of involvement in an accident.13 Because they impede different driving functions, the combination of even low levels of marijuana and alcohol is worse than either substance alone.35 Studies have shown a statistically significant increase in non-alcohol drugs detected in fatally injured drivers in the past decade. The most commonly detected non-alcohol drug was cannabinol, the prevalence of which increased from 4.2% in 1999 to 12.2% in 2010 (Z = -13.63, P < 0.0001).  The increase in the prevalence of non-alcohol drugs was observed in all age groups and in both sexes. In this study, increases in the prevalence of narcotics and cannabinol detected in fatally injured drivers were particularly apparent.36

 Other Health Effects of Marijuana

Since marijuana contains many of the same compounds as tobacco, it has the same adverse effects on the respiratory system when smoked as tobacco. These include chronic cough, respiratory infections, and bronchitis.19 In the longer term emphysema and lung cancer are also among its effects.21In fact, smoking marijuana is more harmful than tobacco for two reasons: first, because it contains more tar and carcinogens than tobacco, and secondly, because marijuana smokers tend to inhale more deeply and for a longer period of time as compared to tobacco smokers.

Marijuana use also has a variety of adverse, short- and long-term effects, especially on the cardiopulmonary system. Marijuana raises the heart rate by 20-100 percent shortly after smoking; this effect can last up to three hours. In one study, it was estimated that marijuana users had a 4.8-fold increase in the risk of heart attack in the first hour after smoking the drug. This elevated risk may be due to increased heart rate as well as the effects of marijuana on heart rhythms, causing palpitations and arrhythmias. This risk may be greater in older individuals or in those with cardiac vulnerabilities. Marijuana use has been found to increase blood pressure and heart rate and to decrease the oxygen-carrying capacity of the blood.37

 Chronic smoking of marijuana and its active chemical THC has consistently been shown to increase the risk of developing testicular cancer, in particular a more aggressive form of the disease. One study compared 369 Seattle-area men aged 18-44 with testicular cancer, to 979 men in the same age bracket without the disease. The researchers found that current marijuana users were 1.7 times more likely to develop testicular cancer than nonusers, and that the younger the age of initiation (below 18) and the heavier the use, the greater the risk of developing testicular cancer.38,39,40 A similar study of 455 men in Los Angeles found that men with testicular germ cell tumors were twice as likely to have used marijuana as men without these tumors.41 THC can also cause endocrine disruption resulting in gynecomastia, decreased sperm count, and impotence.42


Effects of prenatal exposure to marijuana

The risk of using marijuana during pregnancy is unrecognized by the general public, but infants and children exposed prenatally to marijuana have a higher incidence of neurobehavioral problems. THC and other compounds in marijuana mimic the human brain’s cannabinoid-like chemicals, thus prenatal marijuana exposure may alter the developing endocannabinoid system in the fetal brain, which may result in attention deficit, difficulty with problem solving, and poorer memory.13 Evidence especially suggests an association between prenatal marijuana exposure and impaired executive functioning skills beyond the age of three. Specifically, children with a history of exposure are found to have an increased rate of impulsivity, attention deficits, and difficulty solving problems requiring the integration and manipulation of basic visuoperceptual skills.43


Rising Potency and Contaminants

The potency of marijuana has been increasing for decades, with THC concentrations rising from 4% in the 1980s to 14.5% in 2012 in samples confiscated by police.  Some strains now contain as much as 30% THC.19 For a new user, this may mean exposure to higher concentrations of THC, with a greater chance of an adverse or unpredictable reaction. Increases in potency may account for the rise in emergency department visits involving marijuana use. For experienced users, it may mean a greater risk for addiction if they are exposing themselves to high doses on a regular basis. However, the full range of consequences associated with marijuana’s higher potency is not well understood, nor is it known whether experienced marijuana users adjust for the increase in potency by using less. Since the legalization in Colorado, one certified lab there has reported that much of the marijuana they have studied and tested has been found to be laced with heavy metals, pesticides, fungus and bacteria.44


Health Risks Underestimated

 Health risks associated with marijuana use are often underestimated by adolescents, their parents, and health professionals. As explained above, there are newer, stronger forms of marijuana available than that which existed in 1960; current forms of marijuana are known to be three to five times more potent. Parents underestimate the availability of marijuana to teens, the extent of their use of the drug, and the risks associated with its use. In a 1995 survey, the Hazelden Foundation found that only 40 percent of parents advised their teenagers not to use marijuana, 20 percent emphasized its illegal status, and 19 percent communicated to their teenagers that it is addictive.45


Parental Monitoring Important

 Research shows that appropriate parental monitoring can reduce drug use, even among those adolescents who may be prone to marijuana use, such as those with conduct, anxiety, or affective mood disorders.45

Columbia University’s National Center on Addiction and Substance Abuse (CASA) found that adolescents were much less likely to use marijuana if their parents stated their disapproval. “Parents who do not want their kids getting drunk and using drugs should begin by sending a strong message to their kids about the importance of avoiding alcohol. Our survey results this year show how important it is for teens to get a clear anti-use message from their parents, especially from Dad. Teens who get drunk monthly are 18 times more likely to report marijuana use than teens who do not drink; those who believe their father is okay with them drinking are two and a half times more likely to get drunk in a typical month.  Therefore, parents who do not want their kids getting drunk and using drugs should begin by sending a strong message to their children about the importance of avoiding alcohol.”45


In 2011, past month use of illicit drugs, cigarettes, and binge alcohol use were lower among youth aged 12 to 17 who reported that their parents always or sometimes engaged in monitoring behaviors compared to youths whose parents seldom or never engaged in monitoring behaviors. The rate of past month use of any illicit drug was 8.2 percent for youths whose parents always or sometimes helped with homework compared with 18.7 percent among youth who indicated that their parents seldom or never helped.

Columbia Center for Alcohol and Substance Abuse found that teens who have frequent family dinners (five to seven per week) were less likely to have used marijuana.46

Compared to teens who had infrequent family dinners (2 or fewer per week), teens who had frequent family dinners were almost 1.5 times likelier to have said they had an excellent relationship with their mother and their father. The report also found that compared to teens who said they had an excellent relationship with their fathers, teens that had a less than very good relationship with their father were:

o    Almost 4 times likelier to have used marijuana

o    Twice as likely to have used alcohol

o    2.5 times as likely to have used tobacco


Compared to teens who said they had an excellent relationship with their mothers, teens who had a less than very good relationship with their mother were:

o    Almost 3 times likelier to have used marijuana

o    2.5 times as likely to have used alcohol

o    2.5 times likelier to have used tobacco


Consequently, the College encourages parents to take advantage of the “family table,” and to become involved in drug abuse prevention programs in the community or in the child’s school in order to minimize the risk of their children experimenting with drug use.

In Conclusion

In summary, marijuana use is harmful to children and adolescents.  For this reason, the American College of Pediatricians opposes its legalization for recreational use and urges extreme caution in legalizing it for medicinal use.  Likewise, the American Academy of Child and Adolescent Psychiatry (AACAP) recently offered their own policy statement opposing efforts to legalize marijuana. They similarly pointed out that “marijuana’s deleterious effects on adolescent brain development, cognition, and social functioning may have immediate and long-term implications, including increased risk of motor vehicle accidents, sexual victimization, academic failure, lasting decline in intelligence measures, psychopathology, addiction, and psychosocial and occupational impairment.”

Thus the AACAP (a) opposes efforts to legalize marijuana, (b) supports initiatives to increase awareness of marijuana’s harmful effects on adolescents, (c) supports improved access to evidence-based treatment, rather than emphasis on criminal charges, for adolescents with cannabis use disorder, and (d) supports careful monitoring of the effects of marijuana-related policy changes on child and adolescent mental health.47  The College agrees with this position on marijuana.


The College urges parents to do all they can to oppose the legalization of marijuana, such as working with elected officials against the drug’s legalization and scrutinizing a candidate’s positions on this important children’s issue when making voting decisions. The College encourages legislators to consider the establishment and generous funding of more facilities to treat marijuana addiction. Children look to their parents for help and guidance in working out problems and in making decisions, including the decision to not use drugs. Therefore, parents should be role models, and not use marijuana or other illicit drugs. Finally, these reports strikingly emphasize the need for parents to recognize and discuss these serious health consequences of marijuana use with their children and adolescents. They also point to the requirement for medical experts and legislators to seriously discuss and review these observations prior to promoting any state or federal effort considering legalization.

For more information on this topic, the National Clearinghouse for Alcohol and Drug Information (NCADI) offers an extensive collection of publications, videotapes, and educational materials to help parents talk to their children about drug use. For more information on marijuana and other drugs, contact: National Clearinghouse for Alcohol and Drug Information, P. O. Box 2345, Rockville, MD 20847; 1-800-729-6686. Additional helpful information is provided at the following websites:,, and

Primary Author: Donald Hagler, MD, FCP

Original: January 2007

Revised March 2015

Revised September 2015


ADDENDUM added September 2015:

The Legalization of Marijuana in Colorado: The Impact”48 is a compilation of data by the Rocky Mountain High Intensity Drug Trafficking Area that analyzes the effects of marijuana legalization in the state. This third volume allows readers to compare and contrast statistics observed from 2006 – 2009 during Colorado’s early medical marijuana era with those from 2009 to 2013 as medical marijuana commercialization grew, and also with those from the current legalized recreational marijuana era from 2013 to the present. The statistics reveal that between 2013 and 2014 there was a 45% increase in marijuana-associated impaired driving, a 32% increase in marijuana-related motor vehicle deaths (with a 92% increase from 2010 to 2014), as well as 29% and 38% increases in emergency room visits and hospital admissions secondary to marijuana use. By 2013, marijuana use in Colorado was 55% above the national average among teens and young adults, and 86% higher among those over age 25. Diversion of marijuana from Colorado to other states has also increased several fold. This new data further supports the College Position Statement above emphasizing concerns that marijuana legalization will result in increased adolescent usage, addiction and its associated risks for them.

 A downloadable web source for parents can be found at this link, Marijuana Talk Kit, from Partnership for Drug-free Kids.

The American College of Pediatricians is a national medical association of licensed physicians and healthcare professionals who specialize in the care of infants, children, and adolescents. The mission of the College is to enable all children to reach their optimal physical and emotional health and well-being.

A PDF copy of this statement is available here: Marijuana Use Detrimental to Youth


Source:  Sept.2015


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4. Palamar JJ, Omapad DC, and Petkova E, “Correlates of Intentions to Use Cannabis Among U.S. High School Seniors in the Case of Cannabis Legalization,”International Journal of Drug Policy. 2014 May;25(3):424-35.


5. Salomonsen-Sautel S, Sakai J, Thurston C, et. al. “Medical Marijuana Use Among Adolescents in Substance Abuse Treatment.” J Am Acad Child Adolescent Psychiatry. July 2012; 51(7):694-702.


6. Anderson DM, Hansen B, Rees DI. “Medical Marijuana Laws and Teen Marijuana Use” A working paper IZA DP No. 6592 May 2012 (Accessed September 6, 2014 from:


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Posh Spectator and Sunday Times journalist James Delingpole has got his Y-fronts in a twist over outing the PM as former closet stoner. His former mates in the PM’s inner circle don’t approve and have been letting him have it. I can imagine why he’s felt such an urgent need to justify breaking this public school ‘omerta’. He hadn’t anticipated the fall out, he says, in a mea culpa in the Sunday Times. He hadn’t anticipated the impact his revelation to Cameron biographer Isabel Oakeshott would have because he thought that ‘puffing on a reefer’ at Oxford  was no big deal. It was barmy that it was ever a criminal act, he argues in self defence. And he still thinks so.

So since the law’s an ass, what was wrong with putting up two fingers to it? Nor does he see any reason to change his mind about dope now, thirty years later:

“Marijuana is being decriminalised across the world. Quite soon we’ll find the idea that (it) was ever a criminal act about as barmy and illiberal as the notion, that, not so long ago, a man could be imprisoned for sleeping with another man.”

So ‘me lud’, he effectively argued in mitigation, under the impression that we all (not least Dave and his inner sanctum) share liberal views about dope smoking, his and the future PM’s casual disregard for the law (then) was OK.

And besides what was the worst that could have happened as a result of his revelation in today’s modern and progressive world? Dave looking a hypocrite if he ever votes against the decriminalisation of cannabis or Barack Obama cracking a few retro Cheech and Chong jokes next time he meets our PM for a hamburger/baseball love in?

Ho, ho – all very amusing and just about how flippant Mr Delingpole perceives drug use. He really didn’t need to tell us of the state of arrested adolescence he says he is in.

The irony of this self observation is that arrested development is indeed one of the effects of cannabis on the brain. It affects normal maturity (as any drug counsellor will tell you) and specifically the brain development of adolescents. It affects attention, memory and executive functions in the brain. Its use risks worse effects  – from psychotic episodes to full blown schizophrenia for those with a genetic vulnerability. Its victims often do not know until it too late.

Delingpole, although a journalist, seems blissfully unaware of these research findings. It is also hard to believe he is unaware of cases where this apparently ‘innocent’ activity has destroyed the lives of children from affluent families similar to those he and his former friend Dave hail from.

It is hard too to believe as a journalist he’s remained oblivious to the crisis of NHS mental health and psychiatric units, which are bursting at the seams with young male psychotic cannabis addicts –  many incurable.

Maybe it’s a matter of I’m all right Jack. Maybe, he has no children of his own to worry about. Maybe, he’s naive enough to think by some magic of making cannabis freely available these cases would not exist. I have no idea.

As a journalist he should, at the very least, acknowledge that cannabis is a dangerous and for young people, in particular, a very undesirable and addictive drug.

His self-serving attempt to claim the moral high ground (he is not a slave to anyone you’ll be pleased to hear; he does not ingratiate himself with the powerful and he deplores those who do and have compromised themselves to benefit from the Cameron regime) is no substitute for responsible  journalism.

Before he so blithely downplays this drug again and so casually assumes its eventual legalisation is a world wide done deal, I suggest he first acquaint himself with a few more facts and then attend this debate where Dr Kevin Sabet, author of Reefer Sanity: Seven Great Myths About Marijuana, President of Smart Approaches to Marihuana (SAM) and a former advisor on drug policy to President Obama will be speaking.

Source: By Kathy Gyngell  Sept.2015

The lobby calling to decriminalise drugs focuses too much on gang violence. This overlooks death and health destruction among drug users. Photograph: Lawrence Lawry/Science Photo Library
The real horror of drugs stems not from gangs selling them, but from their effects on users, writes Chris Luke.

The wonderfully mischievous Mae West memorably skewered the perennial dilemma surrounding illicit intoxication when she quipped, “To err is human, but it feels divine!” And of course, it is a truth – almost universally acknowledged – that humans love to self-medicate, to seek oblivion and respite from the “grim predicament of existence”, with whatever mind-altering substance they can get hold of, be it 21st century psychotropic or ancient herbal concoction.
It seems equally likely that a debate has raged for ever between those who fret about the effects of such intoxicants on humanity, and those who see them as divine anaesthetics, soporifics and tonics.

The problem with contemporary substance misuse is mainly to do with its sheer scale and unnatural geography. These can be attributed to the global trading which took off in the 17th century, and to modern chemistry which led in the mid-19th century to the refining of organic produce into powders and liquids. These could be conveniently consumed by wealthy Europeans and Americans in a variety of oral, smoke-able and injectable formulations.

The acceleration, since Victorian times, of mechanised global trading and the dissemination of simplified chemistry kits now means that all sorts of chemical contraband are routinely transported thousands of miles from their source, and are easily and universally available for a small sum.

The illicit drug trade is arguably the most successfully globalised of all. Unfortunately, this enormous commercial success for “drug barons” (and sometimes the difference between life and death for dirt-poor drug-cultivators) has created a global pandemic of substance misuse with immensely problematic consequences.

For the most part, these tend to be viewed through the prisms of crime control and drug addiction treatment, and a remarkable number of commentators are now arguing – as did Dr Paul O’Mahony recently in these pages – for “decriminalisation” as the solution. Their central thesis is that it is the violent drug gangs which cause the main problems associated with substance misuse, and that legalisation would squeeze these menacing middlemen out of the equation.

Sadly, I think that this is extraordinarily naive and completely misses the point.
As a doctor who has been on the “receiving end” of industrial levels of substance misuse for many years (in inner-city hospital emergency departments in Dublin, Edinburgh, Liverpool, and now Cork), I am convinced that the question of “legality” of drugs is largely irrelevant in terms of the hazards of drugs to society in general and people’s health in particular.

Putting it very simply, the criminality of users is almost never an issue. It is the deaths, destruction of health and communities and the distraction from the primary function of the emergency department, due to substance misuse, that are of interest to me.

And as for Fintan O’Toole’s recent assertion, in The Irish Times, that “there is no great evidence that the demand is actually higher now . . . than it was a century ago”, I would point out that there is no funding for research into the healthcare frontline workload. So he will have to take my word that, while the appetite for them may not vary much over time, the intoxicants du jour in Ireland are much more worrisome than they were, say, in the post-war period, adding incalculably as they do, in terms of complexity and labour-intensity, to the existing tobacco and alcohol burdens.

The notions of “legalising”, “purifying” and “controlling” once-illegal drugs are frankly laughable in today’s risk-averse society. But drug users (including those who consume alcohol and tobacco) are prone to utter hypocrisy and self-delusion when it comes to their own prescriptions.

The fact is that people are no longer prepared to accept even minimal levels of risk when it comes to existing, legal and fastidiously purified pharmaceuticals (thalidomide is notorious but all medicines carry a risk of occasionally tragic adverse effects) and patients eagerly litigate, even after rare and unpredictable complications from the medications they have been prescribed.

The same would immediately apply to consumers of (hypothetically) legalised “hard drugs” like cocaine and heroin – and even cannabis – whose natural (ie “pure”) effects will always be unpredictably catastrophic for some individuals and inevitably disastrous for society, as dysphoric or delirious people interact with their hazard-ridden environment, as well as with other individuals who may often be less than sympathetic to their drug-addled fellow citizens. In addition, just because a commodity is legal doesn’t mean that it won’t be of interest to criminal gangs: think petrol, tobacco and alcohol and simply look North, after all.

Setting aside such specious reasons for “decriminalising” drugs, it is vital that people grasp the pivotal reality about drug misuse: the hideous and worsening global epidemic of violence – be it in British and Irish cities or Caribbean hotel rooms – is primarily fuelled by the effects of alcohol, cannabis and cocaine on the human psyche, and not by the illegality of the drugs. Drugs (including drink) derange. That is the whole point of taking them, and those who are easily or already deranged will do terrible things to the people around them as a direct result.

Sadly, “anti-prohibitionists” continue wilfully to forget that before drugs (like cocaine, cannabis or opium) were illegal, they were legal – with violent, woeful consequences. My greatest fear is that the ignorance of this seems invincible.

Chris Luke is consultant in emergency medicine in Cork University Hospital and Mercy University Hospital, Cork.

Source 2008 The Irish Times Monday, August 4, 2008


Putnam County Circuit Court Judge Joeseph K. Reeder and Putnam County Adult Drug Court Probation Officer LaKeisha Barron-Brown applaud the accomplishment/graduation of Stacy Casto Wednesday at the Putnam County Judicial Building in Winfield. Casto was quoted by Judge Reeder as she was being introduced saying, “Judge, I’m gonna graduate and I want my picture in the paper with you.”


Putnam County Drug Court Graduates Lindsey Eddy and Stacy Casto sit relieved and all smiles at their accomplishemnt Wednesday at the Putnam County Judicail Building in Winfield. Bob Wojcieszak/Daily


With a picture of his mug shot on the screen before him, Putnam County Drug Court Graduate Craig Owens goes through the circumstances in his life that forced him to take a long look at where he was going and what made him seek out Putnam County Circuit Judge Joeseph K. Reeder to sign up for drug court and change. Having been arrested twenty one times in his past, Owens used the Putnam County Drug Court to change his life. Behind him is Judge Reeder. Bob Wojcieszak/Daily Mail


Having been involved with drugs since the age of twelve, twenty-year-old Putnam County Drug Court Graduate Lindsey Eddy looks at a composity picture of who she was when she was arrested and what she looks like clean and sober during Putnam County Drug Court Graduation ceremonies Wednesday at the Putnam County Judicial Building.

A drug addict of more than 30 years, Stacy Casto was facing felony drug charges when she was given a second chance in Putnam County’s new adult drug court program.

Putnam Circuit Court Judge Joseph K. Reeder met with the first class of offenders more than a year ago to explain how intensive drug court would be; constant drug testing, home visits, counselling and curfews.

“(Casto) was the first person who spoke up, and when she did, she said ‘Judge, I’m going to graduate and when I do I want my picture in the paper with you,’” Reeder said.

Casto, of Hometown, was among the first five graduates of Putnam County’s adult drug court program. Casto, Lori Hodges, Craig Owens, Lindsey Eddy and Jacob Pauley were honored during a graduation ceremony Wednesday at the Putnam County Courthouse in Winfield.

Family and friends packed a courtroom as Reeder spoke about each graduate’s transformation. Many admitted they believed they would have been dead today if it weren’t for drug court.

Lindsey Eddy, 21, of Hurricane, starting using heroin when she was 12 years old. She had been through the juvenile court system and was most recently arrested for violating her probation order from felony drug charges she received when she was 18 years old.

As of Wednesday, Eddy had been drug-free for 221 days.

“Before, my life was hectic,” Eddy said. “I was always worried about my next high or what I was going to do for my next high. I never really imagined life without drugs. I tried rehabs and regular probation and I failed at that, and until I was entered into the drug court problem, this was the only thing that’s worked for me and it’s helped me out tremendously. I’m responsible now and I have a full time job, and I’ve been sober.”

Putnam adult drug court probation officer Lakeside Barron-Brown said Putnam’s program began in November 2013. She said candidates for the program have had drug-related charges or convictions, and must be willing to work toward a drug-free life.

“Once accepted into our program, they then come into a very intensive, therapeutic setting within our court system,” Barron-Brown said. “They are placed on home confinement, and the judge determines when they should be released.”

Offenders go through three phases, each lasting at least four months. During the first phase, they’re subjected to multiple drug tests and home visits a week. They attend group and individual counselling, put in community service hours and abide by a curfew.

During the second phase, drug court offenders receive help looking for and obtaining a job. In the third phase, Barron-Brown said offenders are given “a little more room” to become stabilized for society.

Barron-Brown said all five graduates had obtained jobs during the program and are still working those jobs to this day.

“We have five graduates here that when they first started, they were apprehensive about not knowing what to expect — the same as when you go into a college class and the professor says ‘Here’s a syllabus, you have a test’ and not knowing what the test is like until you’ve taken the test,” Barron-Brown said. “I think that’s what drug court has been for our clients. It’s a test of seeing how confident they can become and seeing how much self-esteem and self-worth they can gain. Obviously, all of them have shown they can be successful and they can be drug-free.”

West Virginia Supreme Court of Appeals Justice Brent D. Benjamin congratulated the five men and women for turning their lives around. He pointed out that West Virginia’s adult drug court system is celebrating its 10th anniversary this year, and that 1,000 adults and juveniles have successfully completed drug court programs in West Virginia.

“What you’ve done is something a lot of people can’t do or haven’t done,” Benjamin told the graduates during the ceremony. “Thankfully we have a state in which you have an opportunity to do this.

“You’re in control of your lives now, and you weren’t before. And now you have the opportunity that not many people have; to turn around to the next drug court class and help them,” Benjamin said.

Reeder said offenders can get into the drug court by either entering a hybrid or conditional plea that allows for their charges to be lessened or dropped upon successful completion of the program, or by accepting drug court as a sentence in lieu of prison time. He said drug court is a good alternative to prison, but it takes a lot of work and responsibility for those who go through the program.

“I think it’s very important not just for the graduates involved, but it’s also important for Putnam County and our community because drugs have become such a problem in our society,” Reeder said. “It’s good that a program like this does give these folks a chance to rehabilitate and to get back on track.”

Casto said drug court “completely saved my life” because it gave her the ability to get help to fight her addiction ­— something she says prison time wouldn’t have done. Now that she’s sober, Casto said she would like to help juveniles who are battling addiction problems.

“I knew I had to have something in my life in order to change my life,” Casto said. “They offered counseling, they offered classes on drug prevention, they offered all these different things that I knew prison wouldn’t do for me. I’ve been a drug addict for 30 years, but during this time, I’ve started going to church, I’ve given my heart to the Lord and my whole entire life has changed.

Barron-Brown said the graduates will go through six more months of “supervised release” from the drug court program until they are completely finished with the program. She said there are 19 people in Putnam’s adult drug court program, including the graduates.

There are 24 adult drug court programs in West Virginia serving 40 counties, and 16 juvenile drug court programs serving 20 counties with 581 people actively participating in the programs, the Daily Mail reported earlier this month. As part of the Justice Reinvestment Act, which was passed last year, adult drug courts will be in all of West Virginia’s counties by July 1 of next year.

Contact writer Marcus Constantino at 304-348-1796 or Follow him at

Source: 26th Feb. 2015

Teens can’t control impulses and make rapid, smart decisions like adults can — but why?

Research into how the human brain develops helps explain. In a teenager, the frontal lobe of the brain, which controls decision-making, is built but not fully insulated — so signals move slowly.  “Teenagers are not as readily able to access their frontal lobe to say, ‘Oh, I better not do this,’ ” Dr. Frances Jensen tells Fresh Air’s Terry Gross.

Jensen, who’s a neuroscientist and was a single mother of two boys who are now in their 20s, wrote The Teenage Brain to explore the science of how the brain grows — and why teenagers can be especially impulsive, moody and not very good at responsible decision-making. “We have a natural insulation … called myelin,” she says. “It’s a fat, and it takes time. Cells have to build myelin, and they grow it around the outside of these tracks, and that takes years.”  This insulation process starts in the back of the brain and heads toward the front. Brains aren’t fully mature until people are in their early 20s, possibly late 20s and maybe even beyond, Jensen says.

“The last place to be connected — to be fully myelinated — is the front of your brain,” Jensen says. “And what’s in the front? Your prefrontal cortex and your frontal cortex. These are areas where we have insight, empathy, these executive functions such as impulse control, risk-taking behavior.”   This research also explains why teenagers can be especially susceptible to addictions — including drugs, alcohol, smoking and digital devices.

Interview Highlights

On why teenagers are more prone to addiction

Addiction is actually a form of learning. … What happens in addiction is there’s also repeated exposure, except it’s to a substance and it’s not in the part of the brain we use for learning — it’s in the reward-seeking area of your brain. … It’s happening in the same way that learning stimulates and enhances a synapse. Substances do the same thing. They build a reward circuit around that substance to a much stronger, harder, longer addiction.

Just like learning a fact is more efficient, sadly, addiction is more efficient in the adolescent brain. That is an important fact for an adolescent to know about themselves — that they can get addicted faster.

It also is a way to debunk the myth, by the way, that, “Oh, teens are resilient, they’ll be fine. He can just go off and drink or do this or that. They’ll bounce back.” Actually, it’s quite the contrary. The effects of substances are more permanent on the teen brain. They have more deleterious effects and can be more toxic to the teen than the adult.

On the effects of binge drinking and marijuana on the teenage brain

Binge drinking can actually kill brain cells in the adolescent brain where it does not to the same extent in the adult brain. So for the same amount of alcohol, you can actually have brain damage — permanent brain damage — in an adolescent for the same blood alcohol level that may cause bad sedation in the adult, but not actual brain damage. …

Because they have more plasticity, more substrate, a lot of these drugs of abuse are going to lock onto more targets in [adolescents’] brains than in an adult, for instance.

We have natural cannabinoids, they’re called, in the brain. We have kind of a natural substance that actually locks onto receptors on brain cells. It has, for the most part, a more dampening sedative effect. So when you actually ingest or smoke or get cannabis into your bloodstream, it does get into the brain and it goes to these same targets.

It turns out that these targets actually block the process of learning and memory so that you have an impairment of being able to lay down new memories. What’s interesting is not only does the teen brain have more space for the cannabis to actually land, if you will, it actually stays there longer. It locks on longer than in the adult brain. … For instance, if they were to get high over a weekend, the effects may be still there on Thursday and Friday later that week. An adult wouldn’t have that same long-term effect.

On marijuana’s effect on IQ

People who are chronic marijuana users between 13 and 17, people who [use daily or frequently] for a period of time, like a year plus, have shown to have decreased verbal IQ, and their functional MRIs look different when they’re imaged during a task. There’s been a permanent change in their brains as a result of this that they may not ever be able to recover.

It is a fascinating fact that I uncovered going through the literature around adolescence is our IQs are still malleable into the teen years. I know that I remember thinking and being brought up with, “Well, you have that IQ test that was done in grade school with some standardized process, and that’s your number, you’ve got it for life — whatever that number is, that’s who you are.”

It turns out that’s not true at all. During the teen years, approximately a third of the people stayed the same, a third actually increased their IQ, and a third decreased their IQ. We don’t know a lot about exactly what makes your IQ go up and down — the study is still ongoing — but we do know some things that make your IQ go down, and that is chronic pot-smoking.

On teenagers’ access to constant stimuli

We, as humans, are very novelty-seeking. We are built to seek novelty and want to acquire new stimuli. So, when you think about it, our social media is just a wealth of new stimuli that you can access at all times. The problem with the adolescent is that they may not have the insider judgment, because their frontal lobes aren’t completely online yet, to know when to stop. To know when to say, “This is not a safe piece of information for me to look at. If I go and look at this atrocious violent video, it may stick with me for the rest of my life — this image — and this may not be a good thing to be carrying with me.” They are unaware of when to gate themselves.

On not allowing teenagers to have their cellphones at night

It may or may not be enforceable. I think the point is that when they’re trying to go to sleep — to have this incredibly alluring opportunity to network socially or be stimulated by a computer or a cellphone really disrupts sleep patterns. Again, it’s also not great to have multiple channels of stimulation while you’re trying to memorize for a test the next day, for instance.

So I think I would restate that and say, especially when they’re trying to go to sleep, to really try to suggest that they don’t go under the sheets and have their cellphone on and be tweeting people.  First of all, the artificial light can affect your brain; it decreases some chemicals in your brain that help promote sleep, such as melatonin, so we know that artificial light is not good for the brain. That’s why I think there have been studies that show that reading books with a regular warm light doesn’t disrupt sleep to the extent that using a Kindle does.


In the 1980s and 90s two successive waves of heroin use swept Britain resulting in massively escalating levels of addiction, deaths, crime, and HIV. At the same time the use of other drugs, cannabis, cocaine, etc was also increasing. There was a widespread sense of crisis with the fear that control of our cities would be lost to drug gangs, drug related crime would continue to grow exponentially, and injecting drug use would become a major route for the transmission of HIV across the population. The drug treatment system was under resourced with lengthy waiting times and high levels of drop out. In 1992 the Major government launched the first national drug strategy “Tackling Drugs Together” to grip these problems.

Fast forward to 2014. Drug use is falling, down from 12% in 2004 to 9% now. The use of heroin peaked at the end of the 1990s at 450,000, it is now 260,000. Young people are shunning heroin with typical users now in their 40s rather than the vulnerable teenagers of popular imagination. Drug related crime has fallen dramatically with investment in treatment initiated during the Blair government enabling offenders and other users to access treatment in days rather than months. The quality of treatment has improved with lower drop out and improved outcomes. The Home Office estimate 30% of the reduction in crime since 2000 is attributable to ready access to treatment which currently prevents 4.9m crimes a year. Levels of HIV among drug injectors is among the lowest in the world, 2% compared to 20% in the USA and 70% in parts of Russia, a legacy of the harm reduction policies pioneered by Norman Fowler as health secretary in the Thatcher government.

None of this featured in last weeks critique in the Huffington Post of the failures of current policy from Caroline Lucas and Julian Huppert, or in their speeches in last Thursdays parliamentary debate. Instead we had a tired unevidenced assertion that policy is a failure, in Nick Clegg’s dramatic language, “on an industrial scale”. Why are outcomes that would have been a cause of celebration in 1992 consistently derided as failure?

The major difference between 1992 and today is that the crisis has abated. There is no longer a plausible argument that drug misuse is spiralling out of control with potentially disastrous consequences for social stability. The absence of crisis frees up ideologues of right and left to posture either about the “failed war on drugs” on the left or the “calamitous consequences of 1960s hedonism” on the right.

The value of the drug debate as a badge of moral and political affiliation is too potent to allow inconvenient truths to intrude. The reality of less use and less harm has to be airbrushed out of the debate if the power of the opposing polemics is to be sustained.

The commentariat’s  self indulgence is buttressed by a political/media culture in which no government policy is allowed to succeed. Ministers are wary of claiming success, fearing charges of complacency today, and ridicule tomorrow if events turn for the worse. Perhaps surprisingly, success is more likely to be buried in Whitehall than failure. Civil servants, policy advocates, and service providers have learned to sidestep inconvenient good news to sustain an ever evolving narrative of failure which is the best route to maintain the high media and political salience on which future funding, policy influence and employment depend.

To highlight the hidden successes of current drug policy is not to deny the continuing challenges and deficits. In England drug related deaths rose alarmingly last year after falling significantly since 2008. The immediate and long term health risks of “legal highs” present an unknown threat. The lack of integration between drug and mental health services is a continuing scandal. Locking people up to protect them from themselves is difficult to justify. But the reality of our drug problem today is that fewer people are using drugs, fewer are becoming addicted, and the social and economic costs of drug use are shrinking.

Any evidence based change to policy needs to acknowledge its successes as well as its deficits. It isn’t enough to dust off arguments from the sixth form debating society as MPs did in the commons this week. The calls for a radical change in policy do not sit well with a significantly shrinking problem. Proponents of change need to explain, not only how reform will prevent imprisonment of users, a laudable aim, but also how they would prevent increases in use and harm arising as a consequence. To steer a sensible pragmatic evidence based route through these policy challenges requires all the evidence to be on the table, including the surprisingly good news that some people would prefer to see ignored.

Source:  4th Nov 2014

Many people who struggle with alcohol or drugs have a difficult time getting better. There are many reasons why these people do not get the help they need to get better. Many family members who see their loved ones struggle have a very difficult time in getting their loved ones assistance. Here are six suggestions on how to convince a person struggling with alcohol or drugs to get the help they need to get better. 

1. Family Intervention

The most popular way to get someone the help they need is to do a family intervention. This is when family members and an interventionist get together with the addict to tell them how they love them and wish that they get help to get better. Each family member takes a turn and tells the person how special they are and that they need to get help. The person who is struggling listens and hopefully they become convinced to get the help they need.

2. Talk To The Person On What Will Happen If They Do Not Get Help

Another way to convince the person who is struggling with alcohol or drugs is to get someone who is an expert on addiction and have them do a one on one talk with this person. This expert on addiction should explain to the addict what will happen if they do not get the help they need to get better. Basically, the expert should warn the person of the dire consequences of what will happen if they do not change their ways. The expert should be vivid as possible and hold nothing back. The goal is to convince the person to get help or they will suffer and eventually their life will slowly come to an end.

3. Use The Services of A Professional Or A Former Addict

Try to find a professional or even a former addict who has “Been There” to talk to the person. This is similar to Step Two, however instead of warning the person, these professionals can use their skills to talk and try to reason with the person. These experts are usually trained and can use a proactive approach into trying to convince the addict to get help. The goal is to try to reason and talk with the person so they can get professional help.

4. Find Out The Reasons Why The Person Won’t Get Help

Many people overlook this suggestion. Ask the person who is struggling with alcohol or drugs to list 3 reasons why they will not get help. At first, they will say all kinds of things, but continue to engage the person and get the 3 main reasons why they refuse to get help. It might take a couple of tries but listen to what they say. Once you get the answers, WRITE them down on a piece of paper. Note: Fear and Frustration are huge factors for the person not getting help.

5. Determine The Solutions To Those Barriers

Once you get those 3 reasons, get a professional or an expert to find the solutions to those issues. For example, the person says that they will not get help because they tried a few times and they failed and that they will fail again. Ask a few addiction professionals to find a solution to this issue that will help the addict overcome this barrier. One good answer to this example is the following: “Yes, you tried to get better and failed however this time we will do things differently. We will keep a daily diary of everything you do and you or someone else will document what you do each day. If you stumble or fail you will write down your feelings at the time and why you failed. When you recover from a bad episode you can READ your diary and find out what went wrong. Once you know what went wrong you will know why you failed and will find a way to prevent this from happening again.”

Use your list from step three and list every positive thing that will counter those barriers. When you are finished, present this to the person who is struggling and explain what you came up with. This will help reduce the person’s fears and anxieties and may convince them to get help. Developing a plan to counter their reasons of not getting help will go a long way.

6. Talk to the Person Instead of Talking At Them

Nobody wants to be lectured. Be honest with them and tell them that it will require some hard work on their part but that they can get better. If they don’t get help, they will suffer. The person who is struggling is scared and they need help in overcoming their fears and resistance to getting help. Remember to find out those fears, address possible solutions to those fears, and you will have a better chance of getting through to that person. Hopefully, sooner or later, you will be able to get through to the person. The key is to be persistent. Be very persistent.

Source:  25th September 2014

D.A.R.E. America joins every major public health association, including the American Medical Association, the American Psychiatric Association, the American Society of Addiction Medicine, and other groups in opposing the legalization of marijuana. Simply put, legalization would drastically increase marijuana use and use disorder rates, as well as hamper public safety and health at a cost of billions to society in lost productivity, impaired driving, health care, and other costs. 

Of particular concern to D.A.R.E. is the relaxed attitude regarding the use of marijuana, which will lead to increased accessibility and reduced perception of harm. This will undoubtedly contribute to greater youth use and abuse of the drug.

Legalized marijuana means ushering in the next “Big Tobacco.” Already, private holding groups and financiers have raised millions of start-up dollars to promote businesses that will sell marijuana and marijuana-related merchandise.  The former head of Strategy for Microsoft has even said he wants to “mint more millionaires than Microsoft” with marijuana and that he wants to create the “Starbucks of marijuana.” A massive industry has exploded in the legal marijuana states of Washington and Colorado.

Colorado’s experience is already going poorly. Colorado is the first jurisdiction to fully legalize marijuana and sell marijuana in state-licensed stores. And already in its first year, the experience is a disaster. Calls to poison centers have skyrocketed, incidents involving kids coming to school with marijuana candy and vaporizers have soared, and explosions involving butane hash oil extraction have increased. Employers are reporting more workplace incidents involving marijuana use, and deaths have been attributed to ingesting marijuana “edibles.” Open Colorado newspapers and magazines on your web browser (or look at the real thing) on any given day and you will find pages of marijuana advertisements, coupons, and cartoons. Remember Joe Camel and candy cigarettes? The marijuana industry offers a myriad of marijuana-related products such as candies, sodas, ice cream, and cartoon-themed paraphernalia and vaporizers, which are undoubtedly attractive to children and teens.i  As Al Bronstein, medical director of the Rocky Mountain Poison and Drug Center recently told the Denver Post, “We’re seeing hallucinations, they become sick to their stomachs, they throw up, they become dizzy and very anxious.” Bronstein reported that in 2013 there were 126 calls concerning adverse reactions to marijuana. From January to April 2014 alone the center receive 65 calls.ii Dr. Lavonas, also from the Rocky Mountain Poison and Drug Center, said in 2014 that emergency rooms have seen a spike in psychotic reactions from people not accustomed to high potency marijuana sold legally, severe vomiting that some users experience, and children and adults having problems with edibles. iii 

No advocate for marijuana legalization will openly promote making marijuana available to minors. However, it would be unwise to believe that relaxed attitudes about the drug, reduced perceptions of harm and increased availability will not result in increased youth use and abuse of marijuana. Children are the marijuana marketer’s future customers. Just as alcohol and tobacco companies have been charged with promoting their goods to children, so has the Colorado marijuana industry. In March 2014, the Colorado legislature was forced to enact legislation to prohibit edible marijuana products from being package to appeal to children. “Keeping marijuana out of the hands of kids should be a priority for all of us,” said Governor Hickenlooper, before signing the bill.iv But that was not enough.  

As discussed above, Dr. George Sam Wan of the Rocky Mountain Poison and Drug Center and his colleagues compared the proportion of marijuana ingestions by young children who were brought to an emergency room before and after October 2009, when Colorado drug enforcement laws regarding medical marijuana use were relaxed. The researchers found no record of children brought into the ER in a large Colorado children’s hospital for marijuana-related poisonings between January 2005 and September 30, 2009 — a span of 57 months. It is a different story following legalization.v Dr. Bronstein reported twenty-six people have reported poisonings from marijuana edibles this year, when the center started tracking such exposures. Six were children who swallowed innocent-looking edibles, most of which were in plain sight. Five of those kids were sent to emergency rooms, and two to hospitals for intensive

The scientific verdict is in: marijuana can be addictive and dangerous. Despite denials by legalization advocates, marijuana’s addictiveness is not debatable: 1 in 6 kids who ever try marijuana, according to the National Institutes of Health, will become addicted to the drug. Today’s marijuana is not your “Woodstock weed” – it can be 5-10 times stronger than marijuana of the past.vii More than 400,000 incidents of emergency room admissions related to marijuana occur every year, and heavy marijuana use in adolescence is connected to an 8-point reduction of IQ later in life, irrespective of alcohol use.

Marijuana legalization would cost society in real dollars, and further inequality in America. Alcohol and tobacco today give us $1 for every $10 that we as society have to pay in lost social costs, from accidents to health damage.viii The Lottery and other forms of gambling have not solved our budget problems, either. We also know these industries target the poor and disenchantedix – and we can expect the marijuana industry to do the same in order to increase profits. 



Marijuana is not addictive.

Science has proven – and all major scientific and medical organizations agree – that marijuana is both addictive and harmful to the human brain, especially when used as an adolescent. One in every six 16 year-olds (and one in every eleven adults) who try marijuana will become addicted to it.x

Marijuana MIGHT be psychologically addictive, but its addiction doesn’t produce physical symptoms.

Just as with alcohol and tobacco, most chronic marijuana users who attempt to stop “cold turkey” will experience an array of withdrawal symptoms such as irritability, restlessness, anxiety, depression, insomnia, and/or cravings.xi

Lots of smart, successful people have smoked marijuana. It doesn’t make you dumb.

Just because some smart people have done some dumb things, it doesn’t mean that everyone gets away with it. In fact, research shows that adolescents who smoke marijuana once a week over a two-year period are almost six times more likely than nonsmokers to drop out of school and over three times less likely to enter college.xii In a study of over 1,000 people in 2012, scientists found that using marijuana regularly before the age of 18 resulted in an average IQ of six to eight fewer points at age 38 versus to those who did not use the drug before 18.xiii These results still held for those who used regularly as teens, but stopped after 18. Researchers controlled for alcohol and other drug use as well in this study. So yes, some people may get away with using it, but not everyone.

No one goes to treatment for marijuana addiction.

More young people are in treatment for marijuana abuse or dependence than for the use of alcohol and all other drugs.xiv

Marijuana can’t hurt you.

Emergency room mentions for marijuana use now exceed those for heroin and are continuing to rise.xv




I smoked marijuana and I am fine, why should I worry about today’s kids using it?

Today’s marijuana is not your Woodstock Weed. The psychoactive ingredient in marijuana—THC—has increased almost six-fold in average potency during the past thirty years.xvi

Marijuana doesn’t cause lung cancer.

The evidence on lung cancer and marijuana is mixed – just like it was 100 years ago for smoking – but marijuana contains 50% more carcinogens than tobacco smokexvii and marijuana smokers report serious symptoms of chronic bronchitis and other respiratory illnesses.xviii

Marijuana is not a “gateway” drug.

We know that most people who use pot WON’T go onto other drugs; but 99% of people who are addicted to other drugs STARTED with alcohol and marijuana. So, indeed, marijuana use makes addiction to other drugs more likely.xix

Marijuana does not cause mental illness.

Actually, beginning in the 1980s, scientists have uncovered a direct link between marijuana use and mental illness. According to a study published in the British Medical Journal, daily use among adolescent girls is associated with a fivefold increase in the risk of depression and anxiety.xx  Youth who begin smoking marijuana at an earlier age are more likely to have an impaired ability to experience normal emotional responses.xxi


The link between marijuana use and mental health extends beyond anxiety and depression. Marijuana users have a six times higher risk of schizophreniaxxii, are significantly more likely to development other psychotic illnesses.

Marijuana makes you a better driver, especially when compared to alcohol.

Just because you may go 35 MPH in a 65 MPH zone versus 85 MPH if you are drunk, it does not mean you are driving safely! In fact, marijuana intoxication doubles your risk of a car crash according to the most exhaustive research reviews ever conducted on the subject.xxiii




Marijuana does not affect the workplace.

Marijuana use impairs the ability to function effectively and safely on the job and increases work-related absences, tardiness, accidents, compensation claims, and job turnover.xxiv

Marijuana simply makes you happier over the long term.

Regular marijuana use is associated with lower satisfaction with intimate romantic relationships, work, family, friends, leisure pursuits, and life in general.xxv

Marijuana users are clogging our prisons.

A survey by the Bureau of Justice Statistics showed that 0.7% of all state inmates were behind bars for marijuana possession only (with many of them pleading down from more serious crimes). In total, one tenth of one percent (0.1 percent) of all state prisoners was marijuana-possession offenders with no prior sentences. Other independent research has shown that the risk of arrest for each “joint,” or marijuana cigarette, smoked is about 1 arrest for every 12,000 joints.xxvi

Marijuana is medicine.



Marijuana may contain medical components, like opium does. But we don’t smoke opium to get the effects of Morphine. Similarly we don’t need to smoke marijuana to get its potential medical benefit.xxvii

The sick and dying need medical marijuana programs to stay alive.


Research shows that very few of those seeking a recommendation for medical marijuana have cancer, HIV/AIDS, glaucoma, or multiple sclerosis;xxviii and im most states that permits the use of medical marijuana, less than 2-3% of users report having cancer, HIV/AIDS, glaucoma, MS, or other life-threatening diseases.xxix

Marijuana should be rescheduled to facilitate its medical and legitimate use.


Rescheduling is a source of major confusion. Marijuana meets the technical definition of Schedule I because it is not an individual product with a defined dose. You can’t dose anything that is smoked or used in a crude form. However, components of marijuana can be scheduled for medical use, and that research is fully legitimate. That is very different than saying a joint is medicine and should be




Smoking or vaporizing is the only way to get the medical benefits of marijuana.


No modern medicine is smoked. And we already have a pill on the market available to people with the active ingredient of marijuana (THC) in it – Marinol. That is available at pharmacies today. Other drugs are also in development, including Sativex (for MS and cancer pain) and Epidiolex (for epilepsy). Both of these drugs are available today through research programs.xxxi

Medical marijuana has not increased marijuana use in the general population.

Studies are mixed on this, but it appears that if a state has medical “dispensaries” (stores) and home cultivation, then the potency of marijuana and the use and problems among youth are higher than in states without such programs. This confirms research in 2012 from five epidemiological researchers at Columbia University. Using results from several large national surveys, they concluded, “residents of states with medical marijuana laws had higher odds of marijuana use and marijuana abuse/dependence than residents of states without such laws.xxxii

Legalization is inevitable – the vast majority of the country wants it, and states keep legalizing in succession.

The increase in support for legalization reflects the tens of millions of dollars poured into the legalization movement over the past 30 years. Legalization is not inevitable and there is evidence to show that support has stalled since 2013.

Alcohol is legal, why shouldn’t marijuana also be legal?

Our currently legal drugs – alcohol and tobacco – provide a good example, since both youth and adults use them far more frequently than illegal drugs. According to recent surveys, alcohol use is used by 52% of Americans and tobacco is used by 27% of Americans, but marijuana is used by only 8% of Americans.xxxiii




Colorado has been a good experiment in legalization.




Colorado has already seen problems with this policy. For example, according to the Associated Press: “Two Denver Deaths Linked to Recreational Marijuana Use”. One includes the under-aged college student who jumped to his death after ingesting marijuana cookie.


The number of parents calling the poison-control hotline to report their kids had consumed marijuana has risen significantly in Colorado.

Marijuana edibles and marijuana vaporizers have been found in middle and high schools.xxxiv

We can get tax revenue if we legalize marijuana.

With increased use, public health costs will also rise, likely outweighing any tax revenues from legal marijuana. For every dollar gained in alcohol and tobacco taxes, ten dollars are lost in legal, health, social, and regulatory costs.xxxv And so far in Colorado, tax revenue has fallen short of expectations.

I just want to get high. The government shouldn’t be able to tell me that I can’t.


Legalization is not about just “getting high.” By legalizing marijuana, the United States would be ushering in a new, for-profit industry – not different from Big Tobacco. Already, private holding groups and financiers have raised millions of start-up dollars to promote businesses that will sell marijuana and marijuana-related merchandise. Cannabis food and candy is being marketed to children and are already responsible for a growing number of marijuana-related ER visits.xxxvi


Edibles with names such as “Ring Pots” and “Pot Tarts” are inspired by common children candy and dessert products such as “Ring Pops” and “Pop Tarts.” Moreover, a large vaporization industry is now emerging and targeting youth, allowing young people and minors to use marijuana more easily in public places without being detected.xxxvii




Legalization would remove the black market and stop enriching gangs.

Criminal enterprises do not receive the majority of their funding from marijuana. Furthermore, with legal marijuana taxed and only available to adults, a black market will continue to thrive. The black market and illegal drug dealers will continue to function – and even flourishxxxviii – under legalization, as people seek cheaper, untaxed marijuana.


Patients taking opioid painkillers for chronic pain not associated with cancer — conditions such as headaches, fibromyalgia and low-back pain — are more likely to risk overdose, addiction and a range of debilitating side effects than they are to improve their ability to function, a leading physicians group declared Wednesday.

A leading physicians group has laid out the conditions that should govern the long-term use of opioid painkillers such as OxyContin. (Toby Talbot / Associated Press)

The long-term use of opioids may not, in the end, be beneficial even in patients with more severe pain conditions, including sickle-cell disease, destructive rheumatoid arthritis and severe neuropathic pain, the American Academy of Neurologists opined in a new position statement released Wednesday.

But even for patients who do appear to benefit from opioid narcotics, the neurology group warned, physicians who prescribe these drugs should be diligent in tracking a patient’s dose increases, screening for a history of depression or substance abuse, looking for signs of misuse and insisting as a condition of continued use that opioids are improving a patient’s function.

In disseminating a new position paper on opioid painkillers for chronic non-cancer pain, the American Academy of Neurology is hardly the first physicians group to sound the alarm on these medications and call for greater restraint in prescribing them. But it appears to be the first to lay out a comprehensive set of research-based guidelines that outline which patients are most (and least) likely to benefit from the ongoing use of opioids — and what practices a physician should follow in prescribing the medications for pain conditions.

The statement would govern the prescribing of morphine, codeine, oxycodone, methadone, fentanyl, hydrocodone or a combination of those drugs with acetaminophen. It was published Wednesday in the journal Neurology.

The American Academy of Neurology’s position statement also urges physicians to work with officials to reverse state laws and policies enacted in the late 1990s that made the prescribing of opioid pain medication vastly more commonplace.

The position paper notes that despite a national epidemic of painkiller addiction that has claimed more than 100,000 lives in just over a decade, many of the laws and practices adopted in the late 1990s remain unchanged. It adds that prescription drug monitoring programs — online databases that would allow physicians to quickly check on all controlled substances dispensed to a patient — “are currently underfunded, underutilized and not interoperable across state lines or healthcare systems.” The result is that patients’ tendency to develop a tolerance for opioid drugs — and to require ever-higher doses to achieve pain relief — often go unnoticed. The result is not only addiction and misuse, but an escalating risk of accidental overdose, since opioid narcotics depress breathing and, especially when mixed with alcohol or other sedative drugs, can prove deadly.

In the age group at highest risk for overdose — those between 35 and 54 — opioid use has vaulted ahead of firearms and motor vehicle crashes as a cause of death.

The American Academy of Neurology statement cites studies showing that roughly half of patients taking opioids for at least three months are still on opioids five years later. Research shows that in many cases, those patients’ doses have increased and their level of function has not improved.

In addition to screening patients for depression or past or present drug abuse, physicians prescribing a long-term course of opioids to patients with pain should draw up an “opioid treatment agreement” which sets out the responsibilities of patients and physicians. Physicians should track dose increases and assess changes in a patient’s level of function, and if a specific daily dose is reached (a “morphine equivalent dose” of 80-120 mg) and a patient’s pain is not under control, doctors should seek the help of a pain specialist.

The statement also recommends against prescribing any benzodiazepines or other sedating drugs to patients who take opioid painkillers. And it recommends the “prudent use” by physicians of random urine testing for patients taking opioids to detect misuse of the drugs or abuse of other, non-prescribed drugs. When a physician takes on the care of a patient who has taken opioid painkillers for more than three months and has aberrant behaviour or a history of overdose, he or she should consider a trial aimed at weaning the patient off such medication.

Source:  1st October 2014

Prescription Drugs ‘Orphan’ Children In Eastern Kentucky

Orphaned by prescription drug overdoses .   Story highlights

  • Many children and teens in eastern Kentucky have lost a parent to drug overdose
  • “Without a normal mom and dad, you feel different,” one teen says
  • Kentucky is the fourth most medicated state in the nation and sixth for overdoses
  • A drug task force aims to help children left behind by parents’ addictions

This area of eastern Kentucky is known for lush, green hillsides and white picket fences. It is a place where bluegrass music may be heard trailing off when a car passes by, where “downtown” is a two-block stretch of quaint shops. Life here may seem simple, but a darkness has been quietly nestling itself into the community.

“Rockcastle County is averaging one drug-related death per week,” said Nancy Hale, an anti-drug activist and educator. “When your county is a little over 16,000 people and you’re losing a person a week … you’re losing a whole generation.”

The generation being lost, Hale said, is parents. An inordinate number of children in Rockcastle County — and in neighboring areas in eastern Kentucky — are living without them.

According to 2010 census data, more than 86,000 children in Kentucky are being raised by someone who is not their biological parent — mostly grandparents — and many here blame those fractured families on prescription drugs.

Prescription drugs can be dangerous 

“I know a little girl who found her father dead of a drug overdose, found her uncle dead of a drug overdose, and now she’s living with her aunt,” said Karen Kelly, executive director of Operation UNITE, a community coalition devoted to preventing overdose deaths in Kentucky.

“The kids really are the ones paying the biggest price.”

‘You’re always worried’

“It’s a terrible thing,” said Sean Watkins, 17, a junior at Rockcastle County High. “Especially in our community, it’s really bad.”

When he was 10, Watkins and his family were expecting his mother for dinner, but she never showed up. He and a family friend went looking for her at her home.

They walked into her bedroom and saw her face down, motionless. The friend quickly whisked Watkins out of the room. “I don’t know what was going on, but I knew something was wrong,” said Watkins.

His mother was dead after overdosing on Oxycontin.

At the time, Watkins says that he and his mother had been estranged for years because of her prescription-drug addiction. His father had not been in his life since shortly after his birth.

“Growing up without parents, without a normal mom and dad, you feel different,” said Watkins. “You go to your friend’s house and they have a happy family … you’re jealous. You want that.”

Shortly after his mother’s death, Watkins says his grandmother also became addicted to prescription drugs, and eventually vanished. Now he lives with his grandfather.  “I’m grateful that I have my grandfather who stepped in and takes care of me now,” said Watkins. Still, he calls growing up without parents “horrible.”

Gupta: Let’s end the prescription drug death epidemic

It sometimes feels is as if every student at his school has been touched by the epidemic, he said. “The hardest part of growing up without a dad would be not having that model family that you always see,” said Avery Bradshaw, 16, also a student at Rockcastle County High School.

Bradshaw’s father overdosed on Oxycontin when he was 7. His mother, he said, is in and out of his life, so he is being raised by his great-grandparents.

Avery knows many children at school who are not so lucky. After their parents overdose or abscond because of prescription drugs, the kids go from couch to couch and from home to home — living in a constant state of transience.

For those children whose parents have not overdosed but are deep in their addiction, there is a sense of perpetual wariness about what they might find when they get home from school.

“You’re always worried … if your parents are even going to be there, you know, what’s going on in your house?” said Bradshaw. “A lot of kids have to go through that every day and it definitely wears them down, you know.”

Guardians’ Day

The prescription drug overdose epidemic just recently began appearing on the national radar, so figures concerning the number of children orphaned after a parent overdoses are difficult to assess.

What is known is the high number of overdoses, broadly: In the United States, someone dies of a prescription drug-related overdose about every 19 minutes. The epidemic affects every state in the nation, and has hit hardest in places like Washington, Utah, Florida, Louisiana, Nevada and New Mexico.

Kentucky — and the Appalachian ridge, generally — is one of the regions hit hardest. Kentucky is the fourth most medicated state in the nation and it has the sixth highest rate of overdose deaths, according to the state’s Attorney General.

In Knott County, adjacent to Rockcastle, Kelly said more than half of the children have lost their parents due to death, abandonment or legal removal. Anecdotally, she says, the numbers in other areas could be even higher.

And in nearby Johnson County, so many children have lost parents that school administrators there changed “Parents’ Day” to “Guardians’ Day.”

Addiction and death are common concerns for families here, according to Kelly — too common.

Her voice wavering, Kelly recalled the story of a young girl who realized her mother was overdosing on prescription drugs right in front of her.

“She wanted to call the police and the other adults in the home were so high they wouldn’t allow her to call,” said Kelly. “So she crawled up into her mother’s arms while her mother died. Now she’s just living with a lady she met at the local Boys and Girls Club.

“Those are the situations we’re dealing with in eastern Kentucky.”

Prescription drug deaths: Two stories

“Someone has to take care of these kids, and we simply do not have the facilities to do that,” said U.S. Rep. Hal Rogers, whose district in Kentucky is mired in prescription drug abuse. “So it’s neighbors, it’s churches, other civic groups that are trying to be parents to these kids who are orphaned by drug-abusing parents.

“That’s a huge undertaking, because there’s literally tens of thousands of these young children,” he added.

Rogers started the Operation UNITE drug task force in 2003 as a response to the broader prescription drug abuse epidemic in his state. Initially, he thought, “If we could get the pushers off the streets, that the problem would be solved.”

But years after he launched the task force, groups of children were showing up at community meetings to speak of their struggles after one parent — or both — overdosed.

“That hit me like a ton of bricks in the head,” said Rogers. “These are young people who are now thrown into the streets. So there are some real side effects to these parents using drugs.”

Now, the UNITE program is channeling energy toward the children floundering socially, emotionally and academically after losing parents. They have programs set up at schools across Kentucky.

‘It’s time for it to stop’

Hale, who worked in the local school system for 34 years, started a UNITE chapter at Rockcastle County High.

“It really got to the point where we were sick and tired of going to funerals,” Hale said. “We were tired of having kids come in and not being able to sit through physics class because they were worried about Mom who had overdosed. So we were like, ‘What can we do? How can we help these families?'”

One way UNITE helps is by educating and counseling children who are having problems at home related to addiction. The group also empowers children like Bradshaw to speak out about their own loss.

“I know that a lot of kids deal with drug abuse from their parents,” said Bradshaw. “I don’t know how many have lost parents, but I know a lot of kids definitely deal with that going home every day. I think right now we’re definitely at a point where everybody needs to know about it and how it affects everybody.”

“It’s time for it to stop,” said Kelly. “It’s leaving our communities in shreds and we’re left behind to pick up the pieces from that.”

Advocates such as Hale and Kelly are desperate for an intervention to reach the thousands of children who are not being helped by programs like UNITE.  Watkins said that the pain of having no parents is something that he will deal with for the rest of his life.

“People have to understand that this is a problem,” he said. “It doesn’t affect just the person that uses, it affects the entire family.”


The NDPA have been concerned for some time about the easy availability of drugs online.   There are sites actively promoting the legalization of drugs, misinformation about drugs, and even sites showing young children smoking cigarettes and encouraging others to do so.   Shocking research showed recently that 8 out of 10 of  UK youngsters watch porn online.   The world wide web has been a tremendous force for good in many ways – but there is a very dark side to the internet.  The following items show the extent of  big business involved in making money out of selling illegal drugs online.   (is Google the Tesco of  the internet ?)


The article below from today’s Wall Street Journal shows the effectiveness of going after companies that aid and facilitate the illicit drug trade. Several years ago, I queried for a book on a particular drug that I was interested in learning more about and along with the responses from the search engine came a pop-up offering to sell me the very drug I was asking about — a Schedule II controlled substance – without a prescription! I wrote a letter to indicating that this could be interpreted as a “facilitation” violation of the Controlled Substances Act and needed to be stopped immediately.

Back came a nice letter (by FedEx) from’s chief counsel  advising me that the company was just as upset and concerned as I but was powerless to stop these “pop-ups.” The chief counsel said that the ad likely was inserted by one of the anonymous servers used to transmit my Internet request to It seems that data mining software used by the servers detect key words used in emails and unencrypted messages that pass through them and automatically generate unsolicited return messages to the sender offering, as in my case, something for sale. On the basis of what little I knew about all this, I concluded nothing further could be done.

I was wrong! Fortunately, in the interim, brighter minds at my alma mater (DOJ) and elsewhere figured this out and concluded that Google was one of several companies at fault.

A fine of $500  million is a drop in the proverbial bucket for Google. Of potentially greater interest here may be what happens after Google settles the current criminal case. Unlike a civil case in which a defendant may settle without having to admit wrongdoing, a settlement in a criminal case usually requires admissions of guilt to specific law violations. If this is the case, will there be subsequent state actions filed against Google on behalf of harmed residents? Will we begin seeing TV ads asking “If you or a loved one ever ordered drugs via the Internet, call the law offices of so-and-so; you may be eligible for a cash settlement, etc.”?

Given the fact that unregistered Internet “rogue” pharmacies more often than not sell counterfeit drugs or outdated, toxic, and/or ineffective drugs and, in doing so, accept only credit cards or international money orders in payment, I’m sure there are retrievable records of such purchases and possibly aggrieved patients who may have been harmed by products illegally advertised and sold via the Internet and facilitated by the advertising services provided by Google. When all is said and done, the total payout for these potential claims, if indeed they are viable, could be several times the amount of the proposed settlement in the current criminal case against Google. Better yet, it should be enough to end or severely curtail this aspect of modern-day drug dealing.

John J. Coleman, PhD  President, Drug Watch International  2011

Google Near Deal in Drug Ad Crackdown

Read more:

Google Inc. is close to settling a U.S. criminal investigation into allegations it made hundreds of millions of dollars by accepting ads from online pharmacies that break U.S. laws, according to people familiar with the matter.

The Internet company disclosed in a cryptic regulatory filing earlier this week that it was setting aside $500 million to potentially resolve a case with the Justice Department. A payment of that size would be among the highest penalties paid by companies in disputes with the U.S. government.   Google gave few details in its filing about the probe, saying only that it involved “the use of Google advertising by certain advertisers.”   The federal investigation has examined whether Google knowingly accepted ads from online pharmacies, based in Canada and elsewhere, that violated U.S. laws, according to the people familiar with the matter.

A Google spokesman declined to comment, as did a Justice Department spokeswoman.     WSJ’s Thomas Catan reports that Google is close to settling with the government over allegations that the company made millions from illegal ad companies.

Search engines can be liable if they are found to be profiting from illegal activity. In December 2007, the three largest Internet companies, Google, Microsoft Corp. and Yahoo Inc. agreed to pay a combined $31.5 million fine to settle civil allegations brought by the Justice Department that they had accepted ads from illegal gambling sites.

Prosecutors can charge such acts under a number of different statutes. From a legal standpoint, a key distinction for Google would be that the illegal activity allegedly took place through its paid advertising service, not just the results that its search engine produces.

There are scores of websites that offer to sell prescription drugs. Some violate U.S. laws by selling counterfeit or expired medicines or dispensing without a valid doctor’s prescription.  One question under investigation is the extent to which Google knowingly turned a blind eye to the alleged illicit activities of some of its advertisers—and how much executives knew, the people familiar with the matter said.   The probe has been conducted by the U.S. Attorney’s Office in Rhode Island and the Food and Drug Administration, among other agencies, according to these people. A spokesman for Rhode Island U.S. Attorney Peter Neronha declined to comment. A spokeswoman for the FDA said the investigation was ongoing and declined to comment further.

Google generated nearly $30 billion in total ad revenue in 2010, largely from its AdWords system. AdWords helped revolutionize online advertising, offering marketers the chance to bid to display their ads when people searched for certain keywords on the Google search engine. An advertiser only pays when a user clicks on the ad.

Google, like other Internet companies, has struggled for years to deal with what it calls “rogue online pharmacies.” In 2003, for instance, Google said it banned ads from U.S. companies that offer drugs like Vicodin and Viagra without a prescription.   Google acted after rivals, including Yahoo and Microsoft, made similar moves as the FDA began publicly pressuring sites to accept only drug ads from licensed Internet pharmacies.

But Google said in 2004 it would continue carrying ads for Canadian pharmacies that send medicines to U.S. customers. The decision riled some U.S. druggists and drew criticism from regulators.  After the FDA began its latest investigation, Google made changes last year to its policies for drug ads, according to a person familiar with the matter.

Google said in February 2010 it would begin allowing ads only from U.S. pharmacies accredited by the National Association of Boards of Pharmacy and from online pharmacies in Canada that are accredited by the Canadian International Pharmacy Association.   In September Google filed a federal lawsuit in San Jose, Calif., seeking to block individuals running illegitimate pharmacies from advertising on its search engine and to recover damages.

“Rogue pharmacies are bad for our users, for legitimate online pharmacies and for the entire e-commerce industry—so we are going to keep investing time and money to stop these kinds of harmful practices,” Google lawyer Michael Zwibelman wrote on the company blog at the time.

Sergey Brin, Google’s co-founder and a current high-ranking executive and board member, sidestepped questions about the investigation at a conference Wednesday and alluded to the fact that Larry Page is now running the company.

“Luckily, since we changed roles a few months ago, I don’t have to deal with filings, and the DOJ, the SEC or other acronyms,” Mr. Brin said, using the initials for the Justice Department and Securities and Exchange Commission.

The current investigation is Google’s latest brush with law enforcement and regulatory agencies in both the U.S. and abroad. The company is facing multiple investigations into possible antitrust and privacy violations in several nations. Google maintains that its breakneck growth will inevitably attract greater regulatory scrutiny, and that it’s done nothing wrong in connection with other probes.    There are other signs the government is serious about cracking down on illegal online pharmacies. On Thursday, entering the words “no prescription required” into Google’s search engine produced an ad that led to a Justice Department alert reading: “Prescription Drugs. Buying online could mean doing time.”

Source:  Wall Street Journal     MAY 13, 2011




Why are we doing this? It would be a lot easier not to have the headaches and hate-mail that come with fighting legalisation. But we want to safeguard the next generation, to protect our children. We want to stop the creation of the next Big Tobacco.

We don’t have the $100million megaphone of the pro-legalisation lobby figure-headed by Nathan Edelman and George Soros. So not enough people know the truth. Just as the tobacco industry put out false science when it started, so does the marijuana industry. We must bridge the gap between the public misunderstanding of the drug and the scientific understanding. We must give information to decision-makers so that they have the courage to go forward.

We don’t want to replace one public-health tragedy with another one.

Having said that, people are beginning to recognise that Big Marijuana, like Big Tobacco, is an industry that relies on addiction for profits. It is sending people to hospital emergency rooms as you read this. They will profit over people who have no voice, or the budget for a voice.

Our two choices are not “lock ‘em up or legalise”. That is a false dichotomy. We need a real conversation about pot instead. Families deserve that. “Incarceration or legalisation?” “Lock ‘em up, or let ‘em loose?” … These phrases have dominated the discussion about marijuana over the past decade. As a result, marijuana-legalisation advocates — not scientists, doctors, people in recovery, disadvantaged communities or young people affected by marijuana use and its policies — have been at the forefront of changing marijuana laws.

So we founded Project SAM to consist of experts and knowledgeable professionals advocating for a fresh approach that neither legalises, nor demonises, marijuana. We are a nonpartisan alliance of lawmakers, scientists and other concerned citizens who want to move beyond simplistic discussions of “incarceration versus legalisation” when discussing marijuana use, and instead focus on practical changes in marijuana policy. We support a treatment, health-first marijuana policy. CONFRONTING PRESIDENT OBAMA…

In January, the US president commented that marijuana was less dangerous than alcohol, which led to an international media frenzy in support of global legalisation of the drug. On 22 January, we took the decision to release a statement about this, as follows.

“We at Smart Approaches to Marijuana, joined by leaders of major medical associations, recognise that marijuana legalisation goes against the President’s own goals of effective education and health care reform. We have identified many of the same problems with marijuana legalisation that he acknowledged when quizzed about his views of the drug by a reporter for The New Yorker. Chief among them: the legalisation of marijuana leads quickly to a slippery slope that could open the gates to legalisation – and commercialisation – of other addictive substances for recreational use. Clearly, the President knows that, for decades, several of today’s largest pro-marijuana-legalisation groups have been advocating for the full-scale legalisation of all recreational drugs, including psychedelics and cocaine.  As the President noted, the case for marijuana legalisation is overstated. As parts of the US plunge headlong into ill-informed drug policies rooted in opinions, political agendas and corporate greed, the President astutely notes that it is a matter of time before we’re also asked to consider the legalisation of a “negotiated dose of cocaine” or “a finely calibrated dose of meth”. That is the nature of addiction and substance abuse. It leads to the next problem, and the next problem and the next – and many times, the damage is irreversible and irreparable.

“However, we take issue with the President’s comparisons between marijuana and alcohol, and we strongly encourage him – a president who has, on many occasions, championed rigorous science – to work closely with his senior drug policy advisors and scientists, who fully acknowledge the growing world body of science showing the harms of marijuana use to individuals and communities. Today’s marijuana is far more potent than the marijuana the President acknowledged using during his teens and early adulthood. The President must also stop to consider the highly concentrated – and increasingly popular – form of marijuana called “hash oil.” Doses of that oil often exceed 80% THC – which is essentially a different drug than the weed of Woodstock, which ranged around 1-3% THC. “We should know better than to follow the same path by legalising a third, addictive substance that will inevitably be commercialised and marketed to children. Two wrongs don’t make a right: just because our already legal drugs may have very dangerous impacts on society it does not mean that other drugs should follow the same path.”

On 31 January, Obama stated on CNN that “If we start having a situation where big corporations with lots of resources and distribution and marketing arms are suddenly going out there, peddling marijuana, then the levels of abuse that may take place are going to rise further”.

Despite the hate mail we receive, we are doing something right. Perhaps the hate mail is because we are doing something right.


Coming back to the alcohol argument: what is the No 1 most dangerous drug? Alcohol. Why would we want to create another alcohol? This big, legal, ‘regulated’ business knows that 80% of its revenue comes from the 20% of people who abuse substances, the people who are most vulnerable, from people who shouldn’t be drinking any more. That is how they have marketed for decades. The people who will suffer most will be the most vulnerable, those who cause trouble to their communities – and cannot afford rehab when problems worsen. They are the target market for Big Pot.

People raise the issue of alcohol harms ‘versus’ marijuana harms. Yes, alcohol is worse when it comes to violence or liver damage. But marijuana is worse when it comes to IQ and loss of competitiveness and motivation, lung issues, mental health. Both cause traffic fatalities when drivers drug/drink drive. Two wrongs don’t make a right.

Once we have an industry whose business it is to increase addiction, then we will have a public-health problem on our hands.

Legalisers constantly refer to people in prison for marijuana. But there are three times as many alcohol arrests as there are for marijuana; do we want marijuana arrests to soar to that level by legalising it? In the UK, only 0.2% of people in prison are there for marijuana offences alone; in the US it is also less than 1%.  What do we have to say about our legal drugs: alcohol, tobacco and prescription drugs?  “600,000 deaths a year. A trillion dollars in the cost to society. And some of the most effective lobbies accessing governments.”


People have not woken up to what legalisation is all about. It would be the fourth wave of legal pharmaceuticals, following alcohol, tobacco, prescription drugs. After the debate about marijuana legalisation, there will be debates about heroin legalisation, cocaine legalisation: in a TV interview, Edelman has publicly expressed his ambition to legalise all drugs.

People are beginning to wake up to the fact that legalising marijuana is not about ‘responsible’ adults using pot in the privacy of their own homes. It is about the pot shop in your neighbourhood, about the advertising being viewed by children – and this is an industry which cannot be tamed once it is unleashed. There is smuggling of drugs across state lines in Washington and Colorado; the black market is alive and well, undiminished by legalisation.

On 17 February, we announced that Conspire, a company that provides drug testing to businesses and schools via Alere Toxicology and others, found that the number of their clientele testing positive for THC, the active ingredient in marijuana, rose 44% since December 2013. The announcement was made as we launched to track legalisation’s effect in Colorado and Washington. With new data coming in every week to confirm that negative impact and the fuelling of drug use, it is important to have a central repository for tracking and collecting information.

We hope that other states and countries will pause and take note before they consider change so that we don’t have to relearn damaging lessons over and over again. While it is good to learn from experience, it is better to learn from other people’s experience!

Sadly, the marijuana conversation is mired with myths. Recent surveys show that many people do not think that marijuana can be addictive, despite scientific evidence to the contrary. Many would be surprised to learn that the American Medical Association has come out strongly against the legal sales of marijuana, citing public health concerns. Its opinion is consistent with most major medical associations, including the American Academy of Paediatrics and American Society of Addiction Medicine.

Because today’s marijuana is at least 5-6 times stronger than the marijuana smoked by most of today’s parents, we are often shocked to hear that, according to the National Institutes of Health, one in six 16-year-olds who try marijuana will become addicted to it; marijuana intoxication doubles the risk of a car crash; heavy marijuana use has been significantly linked to an 8-point reduction in IQ; and marijuana use is strongly connected to mental illness.

Constantly downplaying the risks of marijuana, its advocates have promised reductions in crime, flowing tax revenue and little in the way of negative effects on youth. We shouldn’t hold our breath, though.  We can expect criminal organisations to adapt to legal prices, sell to people outside the legal market – children – and continue to profit from larger revenue sources, such as human trafficking and other drugs. If drugs become legal, criminals will not become saintly citizens overnight but merely change commodities, such as profiteering from human trafficking instead of drugs.

We can expect the social costs ensuing from increased marijuana use to greatly outweigh any tax revenue — witness the fact that tobacco and alcohol cost society $£10 for every $£1 gained in taxes. Probably worst of all, we can expect our teens to be bombarded with promotional messages from a new marijuana industry seeking lifelong customers.

In light of the currently skewed discourse on marijuana, these are difficult facts to digest. People have been promised great things with the legalisation experiment. They can expect to be let down.

What makes a person great is the power and ingenuity and imagination of their brain. Their brain is the single most important organ in the body. It is everything to who we are as human beings. Our countries should be doing better to protect our most vital natural resource: our brains. We should not consign the next generation to substandard opportunities, simply because we have not been grown-up enough to know that there are consequences to public policies which we did not consider. Every life is so important that it must be given the best chance.

Legalisation is not inevitable. We must remind people who struggle with addiction that they are not alone: we are with them. The APA, ASAM are with us. On the other side is an alliance of people who want to line their pockets with money from those are addicted. We cannot give up. We are in this for the long haul.

Source:  March 07 2014

Peter Hitchens

The hunt for the Mr Big behind the drug trade is over at last. We have found him. It is you. The urban, educated middle classes of the rich nations, who take drugs or don’t object to others taking them, fuel the enormous demand for marijuana, cocaine and heroin.

Without their dollars, euros and pounds, there would be no billions to fight over, no gangs, no narco-states or narco-terror.

Yet for some reason, whenever we discuss the alleged ”war on drugs”, we never mention demand. There are evil dealers, whom we all deplore. There are still more evil traffickers and gangs, whom we deplore still more.

But why are they evil? It is not the acts of transporting or selling that make them wicked. If it were soap or scented candles, nobody would mind. It is the thing they deal in. But why are drugs evil? Because of what they do to people.

And that can only happen if individuals buy those drugs and use them. It is at that moment that they cease to be inert matter, and do the damage they undoubtedly inflict.

There is no sense to this. While warships churn the seas, and special forces of many nations patrol the jungles of the Third World, interdicting supply, we have, for the past 40 years, refused to interdict demand. Demand has, unsurprisingly, grown.

To be sure, there are vestigial laws in most advanced countries, which formally prohibit possession of drugs. But they are sporadically and feebly enforced by police, prosecutors and courts.

In the US, 20 states and the District of Columbia have adopted ”medical marijuana” statutes which, in practice, decriminalise possession – so fulfilling the 1979 prediction of the American legalisation campaigner Keith Stroup that ”we are trying to get marijuana reclassified medically. If we do that … [we] will be using the issue as a red herring to give marijuana a good name”.

In Britain, the courts were instructed in 1973 to stop sending anyone to prison for cannabis possession. The police forces recently adopted an empty gesture called the ”cannabis warning” as their preferred response to finding someone in possession of this still technically illegal substance. That is, assuming that they act at all. Those who attend the major British rock festivals expect that the police will ignore cannabis smoking unless forced to take notice.

This relaxed attitude does not apply only to cannabis. In January 2010, British rock singer Peter Doherty was caught in a criminal court building with heroin valued at $300. Mr Doherty already had a long record for drug offences and had just been fined (again) for heroin possession. Yet he walked free from the building. If this is a ”war on drugs”, what would a surrender look like? The cultural background to this is hugely important. Many respectable newspapers, prominent political, academic, artistic, and medical figures – even police officers – have for years called for weaker laws against drugs.

Most of them, unsurprisingly, are members (as am I) of the 1960s radical generation, the cultural revolutionaries whose long march through the institutions is now pretty much complete.

They see nothing wrong in a little self-stupefaction; far from it. The same elite have readily embraced the mass prescription of legal ”antidepressants” and in Britain have removed almost all restraints on the sale of legal alcohol. They often indulge their own children’s drug-taking. And they have encouraged the approach of ”harm reduction” in schools and health education, assuming that the young will (as they always put it) ”experiment with drugs”.

Unsurprisingly, such attitudes, which also deliberately confuse the legal and the illegal drugs, do not exactly discourage such experiments. And rather a lot of those experiments end in the tragedy of irreversible mental illness, increasingly correlated with cannabis use among the young.

Our self-excused ”experimentation” also fuels the tragedies of Mexico and Colombia. Yet tender-hearted bourgeois-bohemians, who proudly buy Fairtrade goods and huffily refuse to buy the products of sweatshops, militantly campaign for the freedom to take and buy the mental poisons which feed the gangs and bring misery to millions far away.

It is of course a moral question, of pleasure versus restraint, of chemical stupor versus hard-edged discontent with reality, of selfishness versus self-control. By choosing the hard path, our civilisation became free, peaceful and prosperous. Do we really think we can now choose the easy road, and not pay for it?

Peter Hitchens is the author of The War We Never Fought – The British Establishment’s Surrender to Drugs and is a columnist for the London Mail on Sunday. He will be speaking at the Festival of Dangerous Ideas on Sunday.

Source:    Oct 31st 2013

In a hidden corner of the web, the Silk Road site quietly earns millions as an illegal-drug marketplace – a kind of ‘amoral eBay’. But start-up Atlantis wants a share, and it’s pulling in business fast with ads on YouTube. Paul Peachey reports on a cybercrime turf war.  It has all the hallmarks of a drugs turf war. The don is under threat, wounded by a series of attacks, with key players swapping sides and prices undercut by a hungry young rival. He lashes back: the newcomer “gets no respect from me” and the dealers watch carefully for shifts in power.

This, however, is not a battle fought with weapons on street corners. The fight is for ownership of one of the darkest corners of the internet, where high-grade drugs at street-level prices are available at the click of the button.

After more than two years of undisputed leadership, Silk Road – the one-stop shop for drugs, porn and dodgy documents described as an “amoral eBay” – is facing a challenge from a rival hungry for a slice of its multimillion-pound revenues. Established in 2011 by a shadowy founder known as Dread Pirate Roberts, Silk Road has been a business success story. It has provided anonymity to its users and sellers on a sub-layer of the internet unreachable by normal search engines such as Google.

Now a new start-up, Atlantis, has copied many of its features but changed the rules with an unexpectedly public promotional campaign and financial incentives to dealers to switch to its marketplace.   Founded by libertarian activists with backgrounds in business, technology and drug dealing, Atlantis stepped up its offering last month with a YouTube advertising campaign and a question and answer session with its anonymous chief executive officer. The advert – featuring an animated figure called Charlie the stoner – led to rapid growth with 500 sign-ups a day and 50,000 registered users, according to a senior figure at Atlantis, “Heisenberg2.0”, in response to a series of questions from The Independent on Sunday. Among its selling points: next-day delivery, no hidden fees and an “eBay-style feedback system”.

“If we continue growing at the pace we are now we will be bigger than Silk Road this time next year, but we are playing the long game and know a lot will change in the world around us between now and then,” said Heisenberg2.0. “Maybe when the world’s leaders are ready to give up the prohibition game we will be ready to come out of the shadows and help clean up the mess they made. In the meantime we are quite happy to operate outside of the current legal frameworks that exist.”

The site is set up like a typical online marketplace offering forgeries, porn, memorabilia, sports shirts and a deal to “buy” Twitter followers for the online narcissist. Items banned from sale include “anything related to paedophilia, poisons, loans, investment opportunities, assassination services or anything which can inflict harm on another person”.

But its staple is drugs. Though the sums represent a tiny fraction of the multibillion-pound global market, the sites represent an emerging threat to law enforcement and an end to the reliance on street-corner deals. High-grade cocaine with purity claimed at more than 80 per cent is sold at £65 a gramme, and shipped from Belgium. Average street price in the UK is £46 a gramme, according to the charity DrugScope, but for inferior purity.

“If people can become aware of being able to source cocaine of that purity … then we will see a change,” said Allen Morgan, an expert witness and former police officer. “There’s definitely a market for high-grade cocaine among professionals, and people are

fed up of getting ripped off with low-quality cocaine. I think we will see a seismic shift in the UK drugs market and it will take the police a long time to get a grip on this.”

Atlantis is just the latest example of anonymous online markets – offering illegal merchandise or services – which are beginning to prosper and proliferate. Only The Armory – which sold weapons – was scrapped, because of low sales. Operators use the cloaking anonymity of the Tor network – known as the hidden web – created by the US military and designed to hide the identity of users and sellers.

Nicolas Christin, of Carnegie Mellon University, who has studied Silk Road, says the proof of its success is the emergence of competition. “You don’t have to interact with shady characters, you just click on a few buttons and you get what you want in the mail,” he said. “Silk Road was always under the radar. Atlantis is very aggressively marketing itself. It’s a very different approach.”

Deals on Atlantis are done via encrypted software and paid for with cybercurrency, an internet cash equivalent. Sellers are encouraged to “creatively disguise” shipments as business mail, and vacuum-pack them to avoid sniffer-dog detection.  The identity of those behind Atlantis is a mystery, and Heisenberg2.0 declined to reveal even the nationality of its founders. The Serious Organised Crime Agency said it was “aware of the so-called ‘hidden’ areas of the internet, and has the capability to investigate organised criminal groups seeking to exploit them”.

Police have successfully targeted sellers on such sites. In April 2012, US authorities busted a secret drugs marketplace known as the Farmer’s Market, resulting in eight arrests in the US, the Netherlands and Colombia. Officials said the ring handled over $1m (£655,000) in drugs sales from 2007 to 2009. It had customers in every US state, and in 34 countries, according to court documents.

Peter Wood, the founder of the ethical hacking firm First Base Technologies, said breaking open the networks depended on identifying individuals, then seizing their computer equipment. “It’s a case of tricking the person into engaging with them to get access to a computer,” he said. “It’s the same sort of techniques as traditional police work, and conning the conmen.”

Global crime goes online

Organised gangs are increasingly switching from traditional crimes to cyber scams to tap lucrative new opportunities through the relative anonymity of the web, statistics showed this week – with a sharp rise in online crimes recorded in England and Wales.

The cracking of criminal rings involved in child sex abuse, fake credit cards and online drug sales have led to gangs going deeper into the so-called Darknet to avoid the law. The Child Exploitation and Online Protection Centre this month revealed its concern over the growing use of anonymous online encrypted networks, with use in Britain increasing by two-thirds, one of the largest increases globally.

Europol warns that new technologies adopted by criminals mean that previous investigative methods “will prove ineffective”.   Deputy Chief Constable Jeff Farrar, of the Association of Chief Police Officers, said: “Crime is moving to the online world.”

The advantages for criminals are clear: the web allows greater penetration of global markets without the risk of border security, and profit potential is huge through the activities of small numbers of criminals. The 27 per cent rise in frauds last year was accompanied by falls in most other crimes.

The benefits were highlighted by the tiny operation that ran a “Facebook for fraudsters” from an internet café but acted as a supermarket for a global network of cyber criminals that led to losses of tens of millions of pounds. A Sri Lankan-born Briton, Renukanth Subramaniam, was jailed for nearly five years for orchestrating the Darkmarket site, where  2,000 fraudsters traded credit cards and viruses. Prosecutors said that the scam utilised modern technology with “no more than a dishonest will, a laptop, a mouse and internet access” to commit theft on an unprecedented scale.

But Darkmarket is dwarfed by what US authorities claim is a £4bn money-laundering project by a firm that hid proceeds of crimes such as theft, drug trafficking and child porn. Liberty Reserve was the front for 55 million illegal transactions, according to an indictment lodged in the US courts after its founder was arrested in Spain in May.

The Serious Organised Crime Agency said it had sent “cyber liaison officers” to key locations abroad to work with other agencies.

Source:  24th July 2013

Filed under: Social Affairs (Papers) :


Ageing festivalgoers still treat smoking weed as harmless fun. But its mind-destroying effects can no longer be denied  The festival season looms, mud and music for the wristbanded, tent-toting Glastobunnies, Latitudinarians and Bestivators. Sellers of falafels and fairy wings stock up, headliners and hopefuls load amps, and an MSN survey reveals that without children the average age of festivalgoers is now 35. The average! Even the BBC’s mass invasion of Glastonbury doesn’t explain that.

Of course many festivals are family outings, spawning happy tribal jokes about when Dad couldn’t find the tent after a 3am pee or Mum grumbled that the heavy-metal arena was drowning the verbose miserabilist in the Poetry Tent. Since the free, heady Sixties when my generation defied parental interdicts, festivals have become big business with £200 tickets, media villages and corporate VIP areas. And that’s fine. A British friend exiled in the upper echelons of Italian society mourned at Latitude that her new compatriots are just not “ludic” like us: too elegant to camp and romp and play.

But there’s a side to this romping that I hate. As one friend said, “It’s a moment to revive old habits”, the habit in question being cannabis. He knows that weed will be plentiful, and legal reprisals unlikely. Festival organisers piously warn against drugs but surging muddy crowds are hard to police. Last year the value of illegal substances seized at festivals saw a 75 per cent decline in confiscated cannabis while others, including Class A, rose. This suggests to me not so much a decline in festival spliffery (just stand downwind of one in the dusk) but an understandable reluctance by police to spend time snatching roll-ups from woozy middle-aged ravers who know that nothing worse than a warning or spot fine will result anyway.

So what’s the big deal, why mention it? It’s part of summer, innit, getting down with the kids and mellowing to the music. Why so sour, sister?

I wish I wasn’t, but it is only a few days since we heard that hospital admissions for mental disorders linked to cannabis use have risen by 50 per cent in three years. Psychiatrists warned for years that this could happen, estimating that people who smoked the newer strong stuff (now 80 per cent of the UK market) are many times more likely to suffer psychotic episodes. Youth runs the sharpest risk: a study of young Germans over a ten-year period found that those who started in their teens were nearly twice as likely to develop psychotic symptoms. Other factors (trauma, class, etc) were accounted for. In this country Professor Robin Murray of King’s College London says that even “use of traditional cannabis is a contributory cause of psychoses like schizophrenia”. An American study found that after cannabis became widely available in the US army in Europe, schizophrenia among troops increased 38-fold.

It needn’t even be the strong new stuff: it is fully forty years since Sir William Paton, professor of pharmacology at Oxford, found that even quite limited use could precipitate enduring hallucinations and fragmented paranoid thinking in people with no previous problems.   Let us be cautious and fair. There are more than 2 million users in Britain and most do not become psychotic. Either they don’t smoke enough, or they aren’t vulnerable. It is possible that people with a predisposition to mental torment are more likely to turn to cannabis for comfort anyway. And yes, alcohol is a vast problem too; so are harder drugs.   But slice it how you like, the evidence is ever stronger that young cannabis users not only risk what one study called “significant and irreversible” reduced IQ, but are playing Russian roulette with their mental health.

The criminal courts see cases of violence, including infanticide, linked by defence lawyers to a cannabis habit and resulting delusions. But the likelihood of self-harm is far greater. Which is why I get ever more sorrowful about the nonchalant normalisation of the drug,

and despise those who scoff at the evidence and shrug off their children’s and friends’ use in order to seem free-spirited: joking about being stoned, choonged, zoned, high.

I hate it because those who do suffer, suffer horribly. Patrick Cockburn, the eminent foreign correspondent, wrote movingly about (and with) his son Henry, who smoked joints heavily from the age of 14 and ended up with years of severe mental illness and near-death exploits of irrationality: swimming across a freezing river, climbing a railway viaduct. He would be found wandering naked, and spent years in institutions diagnosed as schizophrenic. Read Henry’s Demons. Then try to get the nearest pothead or stupid-cool parent to read it too.

Because, get this, my friends: psychosis is not fun. Really not. It is not some fabulous doors-of-perception experience from which creative minds return inspired. Some have been lucky with drugs and returned to fame and equilibrium. Lucky them. Others never come back but wander lost in a horrible world of threats and terrors, savage demons and shivering humiliations, cut off from love and health and fun and success and proper adventure. They are driven to the streets, the cells, to suicide. Yes, we all need risk: but the risk of madness is not an exhilarating one.

My sorrow over cannabis-cool has a personal dimension because my own son was a young suicide suffering (probably, from the evidence) from slowly advancing prodromal schizophrenia. It can happen spontaneously, or after physical illness, and so it did. Nicholas was never a drug user, recognising his fragility, and yet the tiger got him. So now I loathe seeing healthy kids deliberately strolling around in the tiger’s cage, assuming that it won’t ever wake up. And I despise adults who turn a blind eye or skin-up alongside their young at festivals, and fashionable role models who giggle irresponsibly about it in self-regarding articles and interviews. They are demons too.

As to the law, it could be that limited decriminalisation, Netherlands-style only more circumscribed, would serve better than our hypocritical semi-tolerance. I don’t know. But above all, just despise it. Bring on a culture of healthy social contempt, award cannabis its “tobacco moment” of declining status. My son, sailing with young Dutch shipmates, reported that they spoke of frequenters of cannabis cafés as pathetic: losers, unattractive wimps. Right on! If youth can’t laugh and relax without chemical assistance, it really is pathetic.


Source:   Libby Purves June 17 2013 

Filed under: Social Affairs (Papers) :

It seems like everyone — informed by the science or not — has an opinion on marijuana research these days. And while I may disagree with their conclusions, many editors’ pro-legalization opinion columns are smartly formulated and backed by some credible research. But this past week’s opinion article by a member of the Chicago Tribune’s editorial board, Steven Chapman, was neither. Mr. Chapman makes eight particularly incorrect and misleading assertions that deserve a correction:

1.”Existing laws aren’t keeping kids away from pot.”

Fact: It’s true that many kids smoke marijuana. About half of high school seniors have done so at least once. But many more kids drink alcohol — a legal, addictive, commercialized drug. And while tobacco has been decreasing among kids and is now used slightly less than pot among high schoolers, we can thank a societal shift on attitudes and also 80 years of learning the hard way for that. Overall, still, alcohol and cigarettes are used far greater than marijuana.

We also have had a relatively recent societal shift in attitudes about marijuana. As our country increasingly shuns tobacco, it also has made marijuana more accessible and socially acceptable — and youth are reporting easier access to weed at the same time.

But are they really getting marijuana more easily than beer? The 2009 survey Mr. Chapman referenced has been debunked. A recent by the University of Maryland showed that kids alcohol and cigarettes were the most readily accessible substances, with 50% and 44% respectively, of youth reporting that they could obtain them within a day. Youth were least likely to report that they could get marijuana within a day (31%); 45% report that they would be unable to get marijuana at all.

2. “The sale and use of a substance does not necessarily mean more people will use it.”

Fact: Of course it does. Tobacco and alcohol are legal and readily accessible — and our nation’s use of those substances reflect this. According to the National Survey on Drug Use and Health, past-month use of tobacco stands at about 27%t, and past-month use of alcohol is about 52%. Meanwhile, past-month use of marijuana stands at about 8%of Americans. When RAND researchers analyzed California’s 2010 effort to legalize marijuana, they concluded that the price of the drug could plummet and therefore marijuana consumption could increase. When something is legal, it is very likely that more people use it.

3. “No one, after all, is talking about putting pot in vending machines.” Fact: Yes, as a matter of fact, they are. And it’s not just vending machines. It’s the “Starbucks of marijuana,” too. American society loves commercialization and Big Business has proven time and time again that they just can’t control themselves. A volunteer ban on liquor ads is completely ignored, as are bans on gambling advertising.

And remember what we have learned about Big Tobacco? Here’s evidence presented during the 1990s tobacco settlements to jog your memory:

The Liggett Group: “If you are really and truly not going to sell [cigarettes] to children, you are going to be out of business in 30 years.”

R. J. Reynolds: “Realistically, if our company is to survive and prosper over the long-term, we must get our share of the youth market.”

Lorillard: “The base of our business is the high school student.”

Phillip Morris: “Today’s teenager is tomorrow’s potential regular customer… Because of our high share of the market among the youngest smokers, Philip Morris will suffer more than the other companies from the decline in the number of teenage smokers.” Philip Morris (now Altria) just bought the domain names “” and “”

We are incredibly naive to think a commercial marijuana industry wouldn’t employ all of the same strategies to convince people — especially young people — to use marijuana.

4. “The tolerance-fuels-use theory is thunderously lacking in real-world support. In the Netherlands, where ‘coffee shops’ are allowed to sell pot, teenagers are far less likely to use it than their American peers.”

Fact: The Netherlands experience is far more complicated than Mr. Chapman would care to discuss. Yes, the Netherlands has always had drug use rates below or at around the same rate as the U.S. Frankly, American drug use rates have far exceeded most of the world’s for a few hundred years now. But when the Netherlands started advertising pot – something we in America would be extremely susceptible to — they witnessed a tripling in youth use marijuana use rates, according to independent researchers. Their citizens now have a higher likelihood of needing treatment for marijuana than most of Europe. And they are closing many of their “coffee shops” after years of tolerance because of very potent pot that is saturating the market.

5. “‘In the states that have passed medical-marijuana laws, youth marijuana use has decreased,’

Amanda Reiman, policy manager for the Drug Policy Alliance, told me. In California, “the number of seventh, ninth and 11th graders reporting marijuana use in the last six months and in their lifetimes all declined” after 1996, when the state passed its medical marijuana law.”

Fact: Rule number one in journalism: Check your facts. Informal rule #2: Make sure the facts you do use come from scientists, not advocates. There are two major problems with this statement:

(a) First, it does not come from a respected source, peer-reviewed journal, or anything of the like. The truth is that we are only beginning to learn about what happens to youth marijuana use when marijuana is “medicalized.” The only two peer-reviewed studies that I’ve seen on this shows that marijuana use is higher in medical marijuana states than non-medical marijuana states. And we have seen rapid increases in marijuana use since medical marijuana has been more widely accepted, since about 2007 or so. But we’re still learning. At the very least, the jury is out. But ask kids what they think about marijuana and you’ll probably get the answer that “if it’s medicine, it must be okay.” We know, for example, that the diversion of medical marijuana is common among adolescents in substance treatment. (b) Second, even if we were to look at the overall use statistics and make a wide generalization about the link between medical marijuana and youth use, we would not look at 1996 as a starting point. Medical marijuana outlets were not implemented en masse until about 2006 or so. So while the law passed in 1996, it’s fair to say it was not fully implemented until 10 years later. And what has happened since 2006 in California and nationwide? Use rates have rapidly increased. But as I said before, we still need more research on the topic.

6. “The alleged harms of cannabis on the teen mind and body are exaggerated.”

Fact: By whom? The producers of the 1936 film Reefer Madness? Maybe so. But today’s science has moved beyond scare tactics and there are some general beliefs scientists hold about marijuana and its effect on teens: Addiction: 1 in 6 kids who ever smoke marijuana will become addicted, according to independent research. Mental Health: Marijuana use is significantly linked with mental illness, especially schizophrenia and psychosis, but also depression and anxiety. Learning: Heavy, persistent marijuana use in adolescence is linked to a strong decline in IQ. A new analysis of this study has raised doubts among some, but the original study authors redid their analysis and are sticking to their findings. Also researchers unconnected to both studies have concluded that the new analysis does not overturn the original study. The Director of the National Institute on Drug Abuse summed it up nicely:

…observational studies in humans cannot account for all potentially confounding variables. In contrast, animal studies — though limited in their application to the complex human brain — can more definitively assess the relationship between drug exposure and various outcomes. They have shown that exposure to cannabinoids during adolescent development can cause long-lasting changes in the brain’s reward system as well as the hippocampus, a brain area critical for learning and memory. The message inherent in these and in multiple supporting studies is clear. Regular marijuana use in adolescence is known to be part of a cluster of behaviors that can produce enduring detrimental effects and alter the trajectory of a young person’s life — thwarting his or her potential. Beyond potentially lowering IQ, teen marijuana use is linked to school dropout, other drug use, mental health problems, etc. Given the current number of regular marijuana users (about 1 in 15 high school seniors) and the possibility of this number increasing with marijuana legalization, we cannot afford to divert our focus from the central point: regular marijuana use stands to jeopardize a young person’s chances of success–in school and in life.

7. “A kid who gets his hands on beer doesn’t have to worry about getting toxic chemicals or nasty fillers. Buying pot in illicit markets may also expose users of all ages to violence, robbery or extortion. But you don’t see innocent bystanders getting killed in shootouts among liquor store owners.”

Fact: Marijuana legalization would do little to curb the black market, especially because that market could easily undercut the new, taxed price of legal marijuana . And let’s be clear: Most kids get their pot from a friend or family member indoors, not from some shady character on a street corner. Don’t believe everything you see in the movies.

8. “The alternative to legalization is sticking with a policy that has produced millions of arrests, squandered hundreds of billions of dollars and turned many harmless people into criminals in the eyes of the law — all while failing to stem the popularity of pot. For kids or adults, there is nothing healthy in that.”

Fact: This is probably my biggest beef with this piece. And it is not because the facts about marijuana use trends over the past 30 years are dead wrong (in fact, marijuana use is much lower than it was in the late 1970s).

To say that the only alternative to current policy is legalization is like saying the only alternative to current gun policy is the repeal of the Second Amendment. Actually, there are myriad of things short of legalization we can do to lessen the harms of current policy while improving upon it. That is why I launched Project: SAM (Smart Approaches to Marijuana) with Patrick Kennedy last week. And many public health professionals have joined us already, including Harvard’s Sharon Levy; University of Kansas’ famed tobacco treatment pioneer, Kim Richter; Denver’s Paula Riggs, a leader in drug treatment in the US, and many others.

So if neither legalization nor prohibition, then what?

Science-based drug education for parents and kids needs to become a top national priority. Community coalitions that engage in multiple community sectors, and drug courts that leverage the criminal justice system with treatment must be brought to scale. Strategies that implement job and stable housing programs should also be more widespread. We do not need to stigmatize people whose only crime is smoking marijuana, of course. But while “lock ’em up” or “legalize” may both fit neatly on a bumper sticker, they are not thoughtful ways to implement drug policy. There exists an approach that neither legalizes, nor demonizes, marijuana. We reject dichotomies — such as “incarceration versus legalization” — that offer only simplistic solutions to the highly complex problems stemming from marijuana use and the policies surrounding it. We champion smart policies that decrease marijuana use — and do not harm marijuana users and low-level dealers with arrest records that stigmatize them for life and in ways that make it even harder for them to break free from cycles of addiction.

People can disagree about whether or not legalization would result in a net benefit or net harm to society. But making up facts or revealing only half-truths gets us nowhere near the reasoned debate on this issue that we all crave.

Source: 24th January 2013

A NIDA-supported clinical trial, the Maternal Opioid Treatment: Human
Experimental Research (MOTHER) study, has found buprenorphine to be a safe and effective alternative to methadone for treating opioid dependence during pregnancy. Women who received either medication experienced similar rates of pregnancy complications and gave birth to infants who were comparable on key indicators of neonatal health and development. Moreover, the infants born to women who received buprenorphine had milder symptoms of neonatal opioid withdrawal than those born to women who received methadone.

Methadone and buprenorphine maintenance therapy are both widely used to help individuals with opioid dependence achieve and sustain abstinence. Methadone has been the standard of care for the past 40 years for opioid-dependent pregnant women.

However, interest is growing in the possible use of buprenorphine, a more recently approved medication, as another option for the treatment of opioid addiction during pregnancy.

“Our findings suggest that buprenorphine treatment during pregnancy has some advantages for infants compared with methadone and is equally safe,” says Dr. Hendrée JonesExternal link, please review our disclaimer., who led the multicenter study while at the Johns Hopkins University School of Medicine and is now at RTI International.

A Rigorous Trial Design
Methadone maintenance therapy (MMT) enhances an opioid-dependent woman’s chances for a trouble-free pregnancy and a healthy baby. Compared with continued opioid abuse, MMT lowers her risk of developing infectious diseases, including hepatitis and HIV; of experiencing pregnancy complications, including spontaneous abortion and miscarriages; and of having a child with challenges including low birth weight and neurobehavioral problems.

Along with these benefits, MMT may also produce a serious adverse effect. Like most drugs, methadone enters fetal circulation via the placenta. The fetus becomes dependent on the medication during gestation and typically experiences withdrawal when it separates from the placental circulation at birth. The symptoms of withdrawal, known as neonatal abstinence syndrome (NAS) include hypersensitivity and hyperirritability, tremors, vomiting, respiratory difficulties, poor sleep, and low-grade fevers. Newborns with NAS often require hospitalization and treatment, during which they receive medication (often morphine) in tapering doses to relieve their symptoms while their bodies adapt to becoming opioid-free.

The MOTHER researchers hypothesized that buprenorphine maintenance could yield methadone’s advantages for pregnant women with less neonatal distress. Buprenorphine, like methadone, reduces opioid craving and alleviates withdrawal symptoms without the safety and health risks related to acquiring and abusing drugs. Therapeutic dosing with buprenorphine, as with methadone, avoids the extreme fluctuations in opioid blood concentrations that occur in opioid abuse and place physiological stress on both the mother and the fetus. However, unlike methadone, buprenorphine is a partial rather than full opioid and so might cause less severe fetal opioid dependence than methadone therapy.

The MOTHER study recruited women as they sought treatment for opioid dependence at six treatment centers in the United States
and one in Austria. All the women were 6 to 30 weeks pregnant. The research team initiated treatment with morphine for each woman, stabilized her dose, and then followed with the daily administration of buprenorphine therapy or MMT for the remainder
of her pregnancy. Throughout the trial, the team increased each woman’s medication dosage as needed to ease withdrawal symptoms.

The study incorporated design features to ensure that its findings would be valid. Among the most notable were measures taken to prevent biases that might arise if staff and participants knew which medication a woman was getting.

To treat the participants without knowing which medication each woman was receiving, the study physicians wrote all prescriptions in pairs, one for each medication, in equivalent strengths. Study pharmacists matched the patient’s name and ID number to her medication group and filled only the prescription for the medication she was taking.

Each day, participants dissolved seven tablets under their tongues and then swallowed a syrup. If a woman was in the buprenorphine group, one or more of her tablets contained that medication, depending on her prescribed dosage, while the rest of the tablets and the syrup were placebos. If a woman was in the methadone group, the syrup contained that medication in her prescribed strength and the tablets all were placebos. In this way, each woman’s complement of medications appeared identical to that of every other participant. The placebo tablets and syrup were crafted to look, taste, and smell like the active medications.

As Good For Mothers, Better for Infants
Of 175 women who started a study medication, 131 continued until they gave birth. Those who received MMT and those given buprenorphine experienced similar pregnancy courses and outcomes. The two groups of women did not differ significantly in maternal weight gain, positive drug screens at birth, percentage of abnormal fetal presentations or need for Cesarean section, need for analgesia during delivery, or serious medical complications at delivery.

As the MOTHER researchers had hypothesized, the infants whose mothers were treated with buprenorphine experienced milder NAS than those infants exposed to methadone (see graph). Whereas most infants in both groups required morphine to control NAS, the buprenorphine group, on average, needed only 11 percent as much, finished its taper in less than half the time, and remained in the hospital roughly half as long as the infants exposed to methadone.

At Dr. Gabriele Fischer’s Medical University of Vienna site in Austria, three women became pregnant for a second time during the time MOTHER was enrolling participants. This development allowed researchers to compare the two medications’ relative safety and efficacy in individual women as well as across groups. During her second pregnancy, each of the three women took the alternative medication to the one she took in her first pregnancy. In each instance, the child born following buprenorphine treatment exhibited milder NAS symptoms than the one born following methadone treatment. This result suggests that differences in the effects of the two medications, rather than women’s individual differences in physiology, underlie the group findings.

“Buprenorphine may be a good option for pregnant women, particularly those who are new to treatment or who become pregnant
while on this medication,” says Dr. Jones. “If a patient is on methadone maintenance and stable, however, she should remain on methadone.”

MOTHER researchers observed that although the women in their buprenorphine and methadone groups benefited equally from treatment, the drop-out rate was higher in the buprenorphine group (33 vs. 18 percent). This difference was not statistically
significant. The researchers speculate that if it is meaningful, it may be owing to factors other than different responses to the two medications. They surmise that the experimental treatment protocols may have moved patients from morphine to buprenorphine too rapidly, causing discomfort, or that buprenorphine may have been easier than methadone to discontinue when women decided to become abstinent.

The MOTHER study did not include women with some substance use disorders that are commonly comorbid with opioid abuse.

“Future studies should compare neonatal abstinence syndrome, birth outcomes, and maternal outcomes of these two medications for pregnant women who also abuse alcohol and benzodiazepines,” Dr. Jones says.

“The field also needs data on neonatal outcomes when pregnant women are treated with buprenorphine combined with naloxone, the current first-line form of buprenorphine therapy for opioid dependence,” Dr. Jones notes. The MOTHER study administered buprenorphine without naloxone to avoid exposing the fetus to a second medication with potential adverse effects.

“Research challenges remaining after this brilliant study are to determine the factors that resulted in the differential drop-out rates between the two medications,” says Dr. Loretta P. Finnegan, who did pioneering work in the assessment and treatment of NAS. “Additionally, researchers need to conduct followup research on these children to determine the longer term significance of the differences in newborn withdrawal symptoms.” Dr. Finnegan, now president of Finnegan Consulting, was formerly the medical advisor to the director of the Office of Research on Women’s Health at the National Institutes of Health.

“Neonatal abstinence syndrome is a terrible experience for infants, and there is a great need to improve care for this condition,” says Dr. Jamie Biswas of NIDA’s Division of Pharmacotherapies and Medical Consequences of Drug Abuse. “Dr. Jones’ study is a superb contribution to this area of clinical research, and the robust results should provide more treatment options for a syndrome that affects thousands of infants each year.”

Unger, A., et al. Randomized controlled trials in pregnancy: Scientific and ethical aspects. Exposure to different opioid
medications during pregnancy in an intra-individual comparison. Addiction 106(7):1355–1362, 2011. Abstract Available

Even smart people make mistakes, sometimes surprisingly large ones.  A current example is drug legalization, which way too many smart people consider a good idea.  They offer three bad arguments.

First, they contend, “the drug war has failed”, despite years of effort we have been unable to reduce the drug problem.  Actually, as imperfect as surveys may be, they present overwhelming evidence that the drug problem is growing smaller and has fallen in response to known, effective measures.  Americans use illegal drugs at substantially lower rates than when systematic measurement began in 1979, down almost 40 percent.  Marijuana use is down by almost half since its peak in the late 1970s, and cocaine use is down by 80 percent since its peak in the mid-1980s.  Serious challenges with crack, meth, and prescription drug abuse have not changed the broad overall trend: Drug use has declined for the last 40 years, as has drug crime.

The decades of decline coincide with tougher laws, popular disapproval of drug use, and powerful demand reduction measures such as drug treatment in the criminal justice system and drug testing.  The drop also tracks successful attacks on supply, as in the reduction of cocaine production in Colombia and the successful attack on meth production in the United States.  Compared with most areas of public policy, drug control measures are quite effective when properly designed and sustained.

Drug enforcement keeps the price of illegal drugs at hundreds of times the simple cost of producing them.  To destroy the criminal market, legalization would have to include a massive price cut, dramatically stimulating use and addiction.  Legalization advocates typically ignore the science.  Risk varies a bit, but all of us and a variety of other living things, monkeys, rats, and mice, can become addicted if exposed to addictive substances in sufficient concentrations, frequently enough, and over a sufficient amount of time.  It is beyond question that more people using drugs, more frequently, will result in more addiction.

About a third of illegal drug users are thought to be addicted (or close enough to it to need treatment), and the actual number is probably higher.  There are now at least 21 million drug users, and at least 7 million need treatment.  How much could that rise?  Well, there are now almost 60 million cigarette smokers and over 130 million who use alcohol each month.  It is irrational to believe that legalization would not increase addiction by millions.  

We can learn from experience.  Legalization has been tried in various forms, and every nation that has tried it has reversed course sooner or later.  America’s first cocaine epidemic occurred in the late 19th century, when there were no laws restricting the sale or use of the drug.  That epidemic led to some of the first drug laws, and the epidemic subsided.  Over a decade ago the Netherlands was the model for legalization.  However, the Dutch have reversed course, as have Sweden and Britain (twice).  The newest example for legalization advocates is Portugal, but as time passes the evidence there grows of rising crime, blood-borne disease, and drug usage.

The lessons of history are the lessons of the street. Sections of our cities have tolerated or accepted the sale and use of drugs.  We can see for ourselves that life is not the same or better in these places, it is much worse.  If they can, people move away and stay away.  Every instance of legalization confirms that once you increase the number of drug users and the addicted, it is difficult to undo your mistake.

The most recent form of legalization, pretending smoked marijuana is medicine, is following precisely the pattern of past failure.  The majority of the states and localities that have tried it are moving to correct their mistake, from California to Michigan.  Unfortunately, Washington, D.C., is about to start down this paths.  It will end badly.

The second false argument for legalization is that drug laws have filled our prisons with low-level, non-violent offenders.  The prison population has increased substantially over the past 30 years, but the population on probation is much larger and has grown almost as fast.  The portion of the prison population associated with drug offences has been declining, not growing. The number of diversion programs for substance abusers who commit crimes has grown to such an extent that the criminal justice system is now the single largest reason Americans enter drug treatment.

Despite constant misrepresentation of who is in prison and why, the criminal justice system has steadily and effectively focused on violent and repeat offenders. The unfortunate fact is that there are too many people in prison because there are too many criminals. With the rare exceptions that can be expected from human institutions, the criminal justice system is not convicting the innocent.

Most recently, crime and violence in Central America and Mexico have become the third bad reason to legalize drugs.  Even some foreign leaders have joined in claiming that violent groups in Latin America would be substantially weakened or eliminated if drugs were legal.

Many factors have driven this misguided argument.  First, while President Álvaro Uribe in Colombia and President Felipe Calderón in Mexico demonstrated brave and consequential leadership against crime and terror, such leadership is rare.  For both the less competent and the corrupt, the classic response in politics is to blame someone else for your failure.

The real challenge is to establish the rule of law in places that have weak, corrupt, or utterly inadequate institutions of justice.  Yes, the cartels and violent gangs gain money from the drug trade, but they engage in the full range of criminal activities, murder for hire, human trafficking, bank robbery, protection rackets, car theft, and kidnapping, among others.  They seek to control areas and rule with organized criminal force.  This is not a new phenomenon, and legalizing drugs will not stop it.  In fact, U.S. drug laws are a powerful means of working with foreign partners to attack violent groups and bring their leaders to justice.

Legalization advocates usually claim that alcohol prohibition caused organized crime in the United States and its repeal ended the threat.  This is widely believed and utterly false.  Criminal organizations existed before and after prohibition.  Violent criminal organizations exist until they are destroyed by institutions of justice, by each other, or by authoritarian measures fueled by popular fear.  No honest criminal justice official or family in this hemisphere will be safer tomorrow if drugs are legalized, and the serious among them know it.

Are the calls for legalization merely superficial, silly background noise in the context of more fundamental problems?  Does this talk make any difference? Well, suppose someone you know said, “Crack and heroin and meth are great, and I am going to give them to my brothers and sisters, my children and my grandchildren.”  If you find that statement absurd, irresponsible, or obscene, then at some level you appreciate that drugs cannot be accepted in civilized society.  Those who talk of legalization do not speak about giving drugs to their families, of course; they seem to expect drugs to victimize someone else’s family.

Irresponsible talk of legalization weakens public resolve against use and addiction.  It attacks the moral clarity that supports responsible behavior and the strength of key institutions.  Talk of legalization today has a real cost to our families and families in other places.  The best remedy would be some thoughtful reflection on the drug problem and what we say about it.

Source: 7th May 2012

Written by Bonnie Benard, NIDA, USA.(Originally in training manuals for Project Snowball, Illinois Teen Institutes, 1987)

Published in Britain in ‘Drug Prevention – Just say Now’ by Peter Stoker, pub. David Fulton Publishers,London, 1992.

Programme comprehensiveness/intensity

A.        Multiplicity: the causes of drug/alcohol abuse are multiple: personality, environmental, behavioural (Kandel, Logan, 1984; Hawkins et al, 1951).  Programmes tackling only one area usually fail.  You should target multiple systems (youth, families, schools, community, workplace, media, etc).  Also use multiple strategies (information, lifestyles, positive alternatives, community policies) (Botvin, 1982).

B.         Target whole community.  School-based programmes achieve less than community-based approaches.

C.         Target all youth for prevention – not just “high risk”.  Adolescence is seen to be a high-risk time for all youth in terms of health-compromising behaviour.  Labelling “high risk” youth can provoke stigmatisation and lead to self-fulfilling prophecies.  There is however an argument for defining “high risk” communities where an additional resource over and above the general prevention effort could be justified.

D.        Build drug prevention into general health promotion.  Drug abuse has been found by several (Lofquist, 1993) to be part of a complex pattern of interrelated factors – e.g. delinquency, truancy, school failure, precocious sexuality, which share common antecedents.

E.         Start at an early age and keep going!  Even in infancy there are influences in later behaviour.  Developmental difficulties by age 3 are difficult to overcome (Burton, White).  Here, it is of course relevant to mention Trevor Williams, Noreen Wetton and Alysoun Moon of the Southampton University team who have demonstrated so graphically in their “Jugs and Herrings” research papers that primary age children are not blissfully ignorant of drugs and alcohol.  Prevention programmes starting from what children actually know are essential.  Many secondary schools still seem to regard years 11 and 12 as the age at which discussion of drugs (or indeed sexuality) should be facilitated.  Don’t wait until the horse has run away before you lock the stable doors!

F.         Adequate quantity.  ‘One-shot prevention efforts do not work” (Kumpfer, 1988) there must be a substantial number of interventions, each of a substantial duration.  Project D.A.R.E. (Drug Abuse Resistance Education) initiated by Los Angeles Police and now in several countries, delivers no less than seventeen one-hour lessons to any given year and this is only part of the school programme.

G.        Integrate family/classroom/school/community life.  This is easier to say than do, but where it has happened results have been enhanced.

H.        Supportive environment, empowerment.  Where young people are encouraged to participate and take responsibility their behavioural outcomes are improved.  In Britain now peer-education methods which have been proven elsewhere have been applied to good effect.

Programme strategies

J.          ‘KAB’ – Knowledge/Attitudes/Behaviour.  Address these as a set, i.e. each must be directly tackled rather than assuming one will flow from another.  The behavioural component is in part addressed by social skills development, but also supported by positive reinforcement activities – drug free social/sporting events, commendations (preferably with something for everyone), media coverage, etc.  Research suggests that social learning theory (Bandura, 1977) produces some of the most profound improvements.

K.         Drug specific curriculum.  Affective education programmes that had not specifically covered drugs (including alcohol) were found unsuccessful, even though they addressed knowledge, attitudes and lifeskills.

L.         Gateway drugs.  So-called because people now using heavy-end drugs almost always started on these.  Gateway drugs can be tobacco, alcohol and cannabis or, these days inBritain, even heroin!  Concentration on prevention of these is therefore likely to prevent all substances.  British research by PaT (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco.  It should be particularly noted that cannabis is far from harmless; physical, mental and social damage is now being increasingly accepted as a reality.

M.        Salient material.  Whatever is used needs to identify with the audience, including:

•          ethnic/cultural sensitivity

•          appeal to youth’s interests

•          short term outcomes to be emphasised as important to youth as well as long term

•          appropriate language, readability

•          appealing graphics

•          appropriate to real age/reading age – a key factor

In a survey of 3, 700, 000 young American children, 25% of 9 year olds felt “some” to “a lot” of peer pressure to try drugs or alcohol (Weekly Reader, 1987).

N.        Alternatives.  Activities have to be plausible, be more highly valued than the health-compromising behaviour.  Too often these alternatives are poorly thought through. ( ‘Ping-pong = prevention’? No!)

P.         Lifeskills.      Development of these will be of wider benefit than drug prevention.  Included will be

communication, problem solving, decision-making, critical thinking, assertiveness, peer pressure reversal, peer selection, low-risk choice making, self-improvement, stress reduction and consumer awareness (Botvin, 1985).

Choosing your friends has been found in some research to be more effective than resisting the peer pressure of said friends.  Consumer awareness is a “companion” to resisting peer pressure, i.e. resisting media pressure.

Q.        Training prevention workers.  For the school setting the greater emphasis on experiential and interactive work requires teacher training to extend into youth work skills.  Community development skills are valuable in taking school initiatives into the community.  Imported “prestige” role models are all very well, but good results have been achieved with parents, peers, teachers, or outside agency workers.

R.         Community norms.  Consistency of policies throughout schools, families and communities can greatly enhance impact.

S.         Alcohol norms.  Because of its dual status as a beverage and as a culturally accepted drug, alcohol is problematic for prevention.  However, heart disease and tobacco prevention programmes have shown that societal norms can be changed.

T.         Improve schooling!  Listed here as a target because of its important correlation with healthy lifestyle.  Within the current British economic and academic climate one realistic hope may lie with co-operative learning, see the ‘Tribes’ programme, for example.

U.        Change society.  Don’t just stop with improving schools; add your voices to pressure for improvement in employment, housing, recreation and self-development; it is naïve to suppose that prevention can take place in a political vacuum.  Jessor recognises that failing to acknowledge the need for macro-environmental improvement while at the same time placing the responsibility for health solely with the individual is tantamount to “blaming the victim”.

The planning process

V.         Design, implementation, evaluation.  Evaluations have generally concentrated on outcomes rather than the quality of design.  However, implementation is as much dependent on engaging all sectors of the community (be it a school, a workplace, or a town) as it is on quality of design.  Evaluation should therefore measure process as well as outcome.

W.        Goal-setting.  Unrealistic or immeasurable goals help no-one.  It is important to set not only long-term outcome goals (for prevention is long-term) but also “process goals” such as increased involvement of parents and community, academic success, increased student-teacher interaction, and so on.

X.         Evaluation and amendment.  Prevention workers have been criticized for giving too little attention to this area, the crushing shortage of funds has much to do with it (inAmerica the ratio of funding between interdiction-policy and prevention is about 200:1).  This lack of emphasis on evaluation has been the Achilles heel that pro-drug campaigners have gleefully attacked.  Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost-benefit analysis (CBA).  CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

Source: Quoted in book Drug Prevention Just Say Now (1992) by Peter Stoker.  Contact NDPA


BANGOR, Me. — The mother got the call in the middle of the night: her 3-day-old baby was going through opiate withdrawal in a hospital here and had to start taking methadone, a drug best known for treating heroin addiction, to ease his suffering.
The mother had abused prescription painkillers like OxyContin for the first 12 weeks of her pregnancy, buying them on the street in rural northern Maine, and then tried to quit cold turkey — a dangerous course, doctors say, that could have ended in miscarriage. The baby had seizures in utero as a result, and his mother, Tonya, turned to methadone treatment, with daily doses to keep her cravings and withdrawal symptoms at bay.
As prescription drug abuse ravages communities across the country, doctors are confronting an emerging challenge: newborns dependent on painkillers. While methadone may have saved Tonya’s pregnancy, her son, Matthew, needed to be painstakingly weaned from it. Infants like him may cry excessively and have stiff limbs, tremors, diarrhea and other problems that make their first days of life excruciating. Many have to stay in the hospital for weeks while they are weaned off the drugs, taxing neonatal units and driving the cost of their medical care into the tens of thousands of dollars.
Like the cocaine-exposed babies of the 1980s, those born dependent on prescription opiates — narcotics that contain opium or its derivatives — are entering a world in which little is known about the long-term effects on their development. Few doctors are even willing to treat pregnant opiate addicts, and there is no universally accepted standard of care for their babies, partly because of the difficulty of conducting research on pregnant women and newborns.
Those who do treat pregnant addicts face a jarring ethical quandary: they must weigh whether the harm inflicted by exposing a fetus to powerful drugs, albeit under medical supervision, is justifiable. “I’ve had pharmacies that have just called back and said: ‘This lady’s pregnant. Why do you want me to fill this scrip? I can’t do that,’ ” said Dr. Craig Smith, a family practitioner in Bridgton, Me. “But when you stop and think about what actually happens during withdrawal and how violent it can be, that would certainly be not in the baby’s best interest.”
Still, even doctors who advocate treating pregnant addicts have had moments of doubt. “At first I was going, ‘Gosh, what am I doing?’ ” said Dr. Thomas Meek, a primary care physician in Auburn, Me. “ ‘Am I really helping these people?’ ”
There are no national figures that document the extent of the problem, but interviews with doctors, researchers, social workers and women who abused painkillers while pregnant suggest that it has grown rapidly, especially in rural regions, where officials say such abuse is most common.
In Maine, which has been especially plagued by prescription drug abuse, the number of newborns treated or watched for opiate withdrawal, known as neonatal abstinence syndrome, at the state’s two largest hospitals climbed to 276 in 2010 from about 70 in 2005. Hospitals in states including Florida and Ohio reported similar increases, and experts said the numbers were probably higher since pregnant women are rarely tested for drug use and many mothers do not admit to abusing opiates.
Tonya, 24, said she was introduced to painkillers like OxyContin, Percocet and Vicodin while working the overnight shift at an industrial bakery an hour from her home. Everyone — including co-workers, the boyfriend she met on the job and their manager — was taking pills, she said. “It was a lot easier to get through life and have energy,” Tonya said at Eastern Maine Medical Center here in January, holding Matthew a month after his birth. He was still being weaned off methadone.
Before she was pregnant, Tonya said, she quickly became addicted, spending all of her money on pills bought on the street. She and her boyfriend, Josh, needed to stave off withdrawal and get through the day, she said. Now that she is in treatment, Tonya, who like most mothers interviewed for this article did not want her last name used, said her focus was on Matthew. “We put him in this situation,” she said, “and we have to help him out of it.”
‘How Little We Know’

Rigorous studies on treating infant withdrawal are scarce, and the American Academy of Pediatrics has not published guidelines since 1998. “It’s really remarkable how little we know about the effect of prescription drugs and even nonprescription drugs on the fetus,” said Dr. Nora D. Volkow, director of the National Institute for Drug Abuse. “There are real roadblocks in terms of helping us advance the field.”
Dr. Mark L. Hudak, a neonatologist in Jacksonville, Fla., is helping to revise the pediatrics academy’s guidelines. “There are commonalities, but it’s not like you can go to a Web site that says, ‘This is what should be used by everyone,’ ” Dr. Hudak said. “No one knows what the best approach is.”
Within states, every hospital that delivers babies exposed to painkillers may have its own approach. Eastern Maine treats affected newborns with tiny doses of methadone, while Maine Medical Center in Portland uses morphine combined with phenobarbital, a barbiturate that prevents seizures. Some hospitals are also experimenting with clonidine, a mild sedative that can relieve withdrawal symptoms.
There is growing debate over treatment for pregnant women addicted to prescription drugs, in light of concerns over the effects on their babies. Many are slowly weaned from their dependence with methadone, the standard of care for decades. Methadone, when taken in prescribed doses, keeps a steady amount of opiate in the body, preventing withdrawal and drug cravings that occur when levels dip. But it, too, can be addictive and cause nagging side effects like drowsiness. And for addiction treatment, it can be obtained only at federally licensed clinics where most users have to report for a daily dose.
A growing number of addicts are instead taking buprenorphine, another drug used to treat addiction that some studies suggest staves off drug cravings as effectively as methadone but is less likely to cause withdrawal in newborns. In rural areas of the nation, where methadone clinics are few, buprenorphine is considered a promising alternative because it can be prescribed by primary care doctors and taken at home. But buprenorphine also appears not to work for some addicts.
Still, a study published in December in The New England Journal of Medicine showed that babies whose mothers had taken buprenorphine required significantly less medication after birth and less time in the hospital than did babies whose mothers were treated with methadone. But researchers cautioned that exposure to buprenorphine in utero can still cause withdrawal symptoms and that further study was needed. “We don’t want it misconstrued that buprenorphine is a miracle drug,” said Hendrée E. Jones, a Johns Hopkins University researcher and the study’s lead author.
Even less is known about longer-term effects on babies exposed to painkillers, though in a second leg of their study, Dr. Jones and her fellow researchers plan to follow the 131 babies in the cohort until they turn 3. A recent study by the Centers for Disease Control and Prevention found that babies exposed to opiates in utero, in this case legally prescribed painkillers, had slightly higher rates of birth defects, including congenital heart defects, glaucoma and spina bifida.
Experts say that since many drug users also smoke and abuse alcohol, not to mention that they face extenuating circumstances like poverty, it is difficult to tease out the effects of each substance on their offspring. “Most of the literature suggests consistently that the drug exposure itself is not the primary concern,” said Karol Kaltenbach, a professor at Jefferson Medical College in Philadelphia who studies addiction in pregnant women. “It’s the cumulative effect of the drug-using lifestyle — poverty, chaos in the home, domestic violence. All those things affect development.”
Not all newborns exposed to opiates have severe enough withdrawal to need medicine; at Maine Medical Center since 2003, about 55 percent of babies exposed to buprenorphine and 80 percent of those exposed to methadone have needed treatment. But it is hard to predict which ones will need it: a newborn whose mother was on a high dose of either drug might need none, while a baby whose mother took a low dose might experience acute withdrawal. Babies known to have been exposed to drugs are often kept in the hospital for at least five days because withdrawal symptoms usually do not set in immediately. Nurses examine them for a checklist of symptoms every few hours, assigning each baby a score that, if high enough, calls for treatment.
“They don’t stop crying, they can’t settle down, they don’t relax,” said Geraldine Tamborelli, nursing director of the birthing unit at Maine Medical Center, which in 2010 diagnosed opiate withdrawal in 121 newborns. “They’re struggling in your arms instead of snuggling into you like a baby that is totally fine.”
In the neonatal intensive care unit at Eastern Maine, Kendra, 3 days old, was sleeping in a dark, silent room one morning, away from the bustle and bright lights that can be especially irritating to babies going through withdrawal. Nurses frequently crept in to observe her, though, and by the afternoon her limbs had stiffened and she was crying excessively and having tremors; it was enough to begin treatment. “This seems to be ramping up fairly quickly for her,” said Dr. Mark Brown, the hospital’s chief of pediatrics, “so the decision was to start treatment more quickly.”
On the pediatric ward, Matthew started fussing while his mother, Tonya, talked to reporters that afternoon in January; his cry had a strange, reedy pitch that nurses say is common to babies with his condition. The small dose of methadone he had received gave him gas and heartburn, for which he was given two stomach medications. He also was on clonazepam, a muscle relaxant and anti-anxiety drug that helped him metabolize the methadone more slowly.
Tonya said that at first she “didn’t believe in” methadone treatment during pregnancy and that doctors had to persuade her that it would not hurt her fetus. She had experienced wrenching withdrawal when she stopped using painkillers after learning she was pregnant, she said, and the doctors had warned her that “when I was feeling that bad, he was feeling 1,000 times worse.” Tonya said that in a previous pregnancy, she quit using drugs altogether and miscarried a month later. “That was the last thing I wanted to happen this time,” she said.
Avoiding Addicts, and Liability
Treating drug-dependent mothers and babies is often lonely work, with little communication among the doctors who take it on. As Dr. Brown said, “My network for people who do this is really very small.”
Dr. Mark R. Publicker, an addiction medicine specialist at Mercy Recovery Center in Westbrook, Me., is on a mission to get more of the state’s doctors to treat pregnant prescription drug abusers and more hospitals to deliver their babies. Only a handful of doctors here treat pregnant women with buprenorphine, Dr. Publicker said, partly because they fear liability and do not want to deal with addicts. The fact that most hospitals will not deliver the babies makes doctors even less likely to treat the women. “It’s mostly ignorance,” Dr. Publicker said. “It’s a concern that it’s a risky proposition and that they’re going to wind up with an ill baby.”
In February, Dr. Smith persuaded Bridgton Hospital, which has only 25 beds, to deliver the babies of women on buprenorphine — a major victory, he said, because until then women in rural southwestern Maine had to drive an hour or more to Maine Medical to deliver. Courtney, a patient of Dr. Smith’s who discovered she was pregnant while in jail for stealing OxyContin from her landlord, said buprenorphine treatment seemed the best of her bleak options. “I just don’t want to mess up,” she said.
Tonya, too, said she was determined to make things right for Matthew, who was five weeks old when she took him home to a trailer outside Bangor. He is off the methadone now and appears healthy, but Tonya still has to go to a methadone clinic in Bangor every day for her dose and resist the pressures to return to illicit drug use. Her boyfriend began using opiates as a young teenager, she said, and his father and grandmother abused OxyContin along with him. “I’m proud that I changed my life,” Tonya said. “But at the same time, when you see your child in pain and you know your child is in pain because of a life decision you made, it’s the hardest thing in the world.”

Source: New York Times April 9th 2011

For health care workers in psychiatric hospitals, it is no secret: one of the major issues confronting psychiatric facilities seeking to institute blanket no-smoking policies concerns chronic inpatients with schizophrenia. Patients with schizophrenia are almost always heavy cigarette smokers, given a choice. As Edward Lyon wrote in an analysis of studies and surveys performed throughout the 1990s: “Many patients in psychiatric hospitals would smoke two, three, or even four packs of cigarettes a day if an unlimited supply of cigarettes were available.”
Generally, the rate of inpatient smoking among schizophrenics is three to four times higher than the general smoking population. In one British study of 100 institutionalized schizophrenics cited by Lyon, 92% of the men and 82% of the women were smokers. Moreover, schizophrenics smoke more cigarettes per day than other smokers do, and they commonly smoke high-tar, unfiltered cigarettes — niche brands for heavy smokers used by only 1% of the total smoking population.
Australian research performed in 2001 found that because of high rates of smoking, “people with mental illness have 30% more heart disease and 30% more respiratory disorders,” according to Ann Crocker, now a professor of Clinical Psychiatry at McGill University.
Not only do an estimated 80% of schizophrenics smoke, compared to roughly 25% of the total adult population, psychiatric facilities report that depressives and those with anxiety disorders also smoke in great numbers.
The review of studies through 1999, undertaken by Lyon and published in Psychiatric Services, shows unequivocally that schizophrenic smokers are self-medicating to improve processing of auditory stimuli and to reduce many of the cognitive symptoms of the disease. “Neurobiological factors provide the strongest explanation for the link between smoking and schizophrenia,” Lyons writes, “because a direct neurochemical interaction can be demonstrated.”
Of particular interest is the interaction between nicotine and dopamine in the nucleus accumbens and prefrontal cortex. Several of the symptoms of schizophrenia appear to be associated with dopamine release in these brain areas. A 2005 German study concluded that nicotine improved cognitive functions related to attention and memory. “There is substantial evidence that nicotine could be used by patients with schizophrenia as a ‘self-medication’ to improve deficits in attention, cognition, and information processing and to reduce side effects of antipsychotic medication,” the German researchers concluded.
In addition, the process known as “sensory gating,” which lowers response levels to repeated auditory stimuli, so that a schizophrenic’s response to a second stimulus is greater than a normal person’s, is also impacted by cigarettes. Sensory gating may be involved in the auditory hallucinations common to schizophrenics. Receptors for nicotine are involved in sensory gating, and several studies have shown that sensory gating among schizophrenics is markedly improved after smoking.
There is an additional reason why smoking is an issue of importance for health professionals. According to Lyon, “Several studies have reported that smokers require higher levels of antipsychotics than nonsmokers. Smoking can lower the blood levels of some antipsychotics by as much as 50%…. For example, Ziedonis and associates found that the average antipsychotic dosage for smokers in their sample was 590 mg in chlorpromazine equivalents compared with 375 mg for nonsmokers.”
Smoking among inpatient psychiatric patients is not trivial. Neither is the decision to institute smoking bans in psychiatric hospitals, a move that is understandably unpopular with patients.
Lyon, E. (1999). A Review of the Effects of Nicotine on Schizophrenia and Antipsychotic Medications. Psychiatric Services, 50, 1346-1350.
Cattapan-Ludewig, K. (2005). Why do schizophrenic patients smoke? Nervenarzt, 76 (3), 287-294.
Mueser, K., Crocker, A., Frisman, L., Drake, R., Covell, N., & Essock, S. (2005). Conduct Disorder and Antisocial Personality Disorder in Persons With Severe Psychiatric and Substance Use Disorders Schizophrenia Bulletin, 32 (4), 626-636 DOI: 10.1093/schbul/sbj068
Adler, L., Hoffer, L. Wiser, A. (1993). Normalization of auditory physiology by cigarette smoking in schizophrenic patients. American Journal of Psychiatry, 150, 1856-1861.

3rd July 2009

Filed under: Social Affairs (Papers) :

HIGH POINT, N.C. — For over three months, police investigated more than 20 dealers operating in this city’s West End neighborhood, where crack cocaine was openly sold on the street and in houses. Police made dozens of undercover buys and videotaped many other drug purchases.
They also did something unusual: they determined the “influentials” in the dealers’ lives — mothers, grandmothers, mentors — and cultivated relationships with them. When police felt they had amassed ironclad legal cases, they did something even more striking: they refrained from arresting most of the suspected dealers.
In a counterintuitive approach, police here are trying to shut down entire drug markets, in part by giving nonviolent suspected drug dealers a second chance. Their strategy combines the “soft” pressure from families and community with the “hard” threat of aggressive, ready-to-go criminal cases. While critics say the strategy is too lenient, it has met with early success and is being tried by other communities afflicted with overt drug markets and the violence they breed.
Overt drug markets — street-corner dealing, drug houses, and the like — constitute one of the worst scourges of poor communities. Such markets foment violent clashes between dealers, as well as robbery by addicts desperate for drug money. Property values suffer. Businesses and families move out — or avoid moving in. Many residents who remain feel under siege. Police often rely on sweeps — mass arrests of street-level dealers — to eradicate drug-related crime. But those rarely provide more than short-term relief. In High Point, police believe that the combination of extensive investigation of the entire market and community involvement has helped solve the problem.
In May 2004, after accumulating evidence in the West End, police chief James Fealy invited 12 suspected dealers to a meeting at the police station, with a promise that they wouldn’t be arrested that night. Encouraged by their “influentials,” nine showed up.
In one room, they met with about 30 clergy, social workers and other community members who confronted them with the harm they were doing, implored them to stop dealing, and offered them help. The suspects, however, “were slouching in their seats and one guy even seemed to be dozing off,” recalls Don Stevenson, pastor of a local congregation, the First Reformed United Church of Christ. “Their attitude was, ‘This is just another program and it will blow over.'”
Then the alleged dealers moved to a second room where they encountered a phalanx of law-enforcement officials: police, a district attorney, an assistant U.S. attorney, and representatives of the federal Drug Enforcement Administration and the Bureau of Alcohol, Tobacco and Firearms, and others. Around the room hung poster-size photos of crack houses that had been the dealers’ headquarters. In front of each alleged dealer was a binder, laying out the evidence against him or her. There were even arrest warrants, lacking only the signature of a judge.
The law-enforcement officials made an ultimatum: stop dealing or go to jail. Several suspected dealers with violent records had already been arrested and were facing maximum charges. The same fate, officials emphasized, awaited anyone in the room who returned to dealing drugs. The district attorney promised to seek the maximum possible sentences, and the assistant U.S. attorney threatened to bring federal charges, which, he stressed, don’t allow for parole. Police from surrounding areas warned them against trying to relocate operations, noting that their names were flagged on statewide law-enforcement computers.
Rev. Stevenson recalls that the alleged dealers “seemed to be paying a lot more attention.”
The West End street drug market closed “overnight” and hasn’t reopened in more than two years, says Chief Fealy, who was “shocked” at the success. High Point police say they have since shut down the city’s two other major street drug markets, using the same strategy.
Police in neighboring Winston-Salem, N.C., as well as Newburgh, N.Y., have deployed the strategy with success, and word is spreading. Encouraged by the National Urban League, which wants to see the approach replicated nationwide, police departments in Tucson, Ariz., Providence, R.I., Kansas City, Mo., and elsewhere are gearing up to try it.
“It’s the hottest thing in drug enforcement,” says Mark A. R. Kleiman, a University of California, Los Angeles professor who specializes in illicit drug issues and isn’t involved in the project.
Some police and prosecutors object to the approach.
“Why not slam ’em from the beginning and forget this foolishness?” says Karen Richards, county prosecutor in the Fort Wayne, Ind., area. The Urban League tried to convince her and the Fort Wayne police to try the strategy, but Ms. Richards didn’t support it. She draws a distinction between addicts, who she believes should get social support, and dealers, who she believes deserve incarceration. “Drug dealers are drug dealers,” she says. “They won’t have an epiphany and end up as model citizens.”
In Winston-Salem, many officers at first dubbed the initiative “hug-a-thug,” though few do so now that they’ve seen it in practice.
In High Point, the West End neighborhood had been a major drug market for almost 15 years, with 16 known crack houses operating at the start of the initiative. A traffic jam began almost every afternoon, as buyers, many destined for homes in the suburbs, converged on the area seeking crack, according to residents and police.
Charlie Simpson, who owns and operates a radiator-repair shop in the West End, says he frequently saw drug dealers “on all four corners, selling drugs out of their pockets.” The dealing drove away business “because women were afraid to come, men didn’t want to bring their wives, plus they didn’t want to leave their car overnight.”
The neighborhood of modest clapboard bungalows became the city’s crime capital. Lucille Dennis, 89, who has lived in the West End for half a century, says that before the initiative, she suffered three break-ins within a year and a half, and she stopped sitting on her porch for fear of getting robbed.
After the West End initiative, violent crime — defined as murder, rape, robbery, aggravated assault, prostitution, sex offenses, and weapons violations — dropped. More than two years later, violent crime remains more than 25% lower in the area, according to police statistics. Since the initiative, there hasn’t been a single murder or rape reported in the West End. “I don’t know exactly how to phrase it,” Mrs. Dennis says, “but you just don’t see as many people riding around doing nothing.”
It isn’t clear how well such an approach would work in big cities, which have much higher absolute numbers of crimes. High Point has about 90,000 residents and Winston-Salem has 190,000. In Kansas City, a city of about 500,000, Police Chief James Corwin says, “Will it work in Kansas City? I don’t really know.” His police department has almost finished the undercover investigation of a drug market it has targeted.
The initiative hasn’t eradicated illegal drug use — and it doesn’t aim to. “This is not a war on drugs,” says Chief Fealy. Rather, he says, the goal is to shut down overt drug markets because “street-level dope-dealing is what drives a significant amount of crime.”
The police had been trying to drive dealers out of the West End for years. “We were actually doing a sting every month in [West End] making dozens of arrests,” says High Point Assistant Police Chief Marty Sumner. “But the market persisted.”
It’s a pattern seen nationwide. In a report published last year by the American Enterprise Institute, authors David Boyum and Peter Reuter point to government statistics that show arrests per dollar of cocaine and heroin sold in the U.S. soared tenfold from 1981 to 2001. Moreover, the percentage of arrests that led to incarceration also shot up; in 2001 more than half the inmates in federal prisons were convicted of drug crimes, up from just 5% in 1981. Yet, during that same two-decade period, the street price of cocaine and heroin, measured in constant dollars, dropped by two-thirds, suggesting it isn’t more difficult to deal. Indeed, the authors estimated that the risk of arrest per individual cocaine sale is less than one in 15,000.
When police do sweep in, Chief Fealy says, they often capture “targets of opportunity” — dealers who are easy to nab. Hardened dealers expect dragnets, so they rarely conduct sales themselves or have significant amounts of drugs in their possession.
Drug dragnets can actually worsen the problem, because some residents resent the heavy-handed tactics, which can inflame racial tensions. Many community members “wonder whose side are the police on,” says Janet Zobel of the National Urban League. Either out of a sense of futility or suspicion, many residents stop cooperating with the police.
The High Point strategy was the brainchild of David Kennedy, a 48-year-old professor at New York’s John Jay College of Criminal Justice. In the 1990s, when he was at Harvard University, Mr. Kennedy helped develop Boston’s anti-gang strategy, a community-involvement approach credited with drastically reducing violent crime.
But the drug initiative was a much harder sell. Mr. Kennedy says he had been trying for more than five years to convince police departments across the country to try it. When Mr. Kennedy first approached Winston-Salem, “We all told him he was crazy,” says Police Chief Patricia Norris. Mr. Kennedy says he would ask, “When do you think what you’re doing now is going to start working?”
Chief Fealy took to the idea the first time he heard it in 2003. He came to High Point from Austin, Texas, where he had been assistant chief and commanded the security detail for then-Gov. George W. Bush.
Before his job interview in High Point, Mr. Fealy drove around the city and was struck by the open drug dealing. “It was just so blatant and in-your-face,” he says. Poring through crime statistics, he saw “well over 60% of our homicides were directly drug-related, and almost 100% of our person-on-person robberies.” He decided to give Mr. Kennedy’s idea a try.
First, police crunch data to find the “hot spots” most plagued by violent and drug-related crime. Then they engage in months of undercover research to understand the local drug market and identify the players — big and small. Police are accustomed to spending months undercover only to nab a major criminal, such as an organized-crime boss. “So putting three months’ work into investigating 20 corner rock dealers” normally would be considered a waste of time, Assistant Chief Sumner says.
But there is a payoff. “A market is something that requires a large number of actors,” says Mr. Reuter, who is an economist as well as an illicit-drugs expert. “If can you can get all the actors out, you can disrupt the system.”
Randy Dejournette, one of the alleged dealers invited to come to the second-chance meeting at the police station in 2004, says “everybody’s gone” from the streets in the West End — and that’s one reason he says he doesn’t deal now. “I’m not going to go out there by myself and sit on the corner and look dumb.”
The High Point police knew who were the lookouts, the runners, the petty dealers and the big wheels. Analyzing the overall market led them to suppliers they might not have found otherwise. Assistant Chief Sumner points to Kevin Cotton, a six-foot-two man with a tattoo that read “thug life,” who was a major source of drugs in a neighborhood targeted by police. An informant told them that he not only supplied dealers, but robbed and intimidated them. He “controlled the market,” Mr. Sumner says. But because he didn’t live in the area, “we probably never would have focused on him.” Police made enough undercover buys to warrant federal charges, then arrested Mr. Cotton because they felt his record was too violent for him to be offered a second chance. He’s now serving 20 years in federal prison.
Arresting violent offenders is one key to making the initiative work. It removes the dominant actors in the market and sets a powerful example. But the other key is that police refrain from arresting suspects who haven’t become hardened, violent criminals. These are often young people — Mr. Dejournette, for example, was 19 when he was invited to the second-chance meeting. For them, police try to implement a communitywide intervention, choreographed to send three clear messages: If they return to dealing, they’ll go to jail; their community will help them turn their lives around but won’t tolerate drug crime any longer; and the police and community are working together to combat dealing.
At the second-chance meeting, police lay out their evidence in a deliberately theatrical way. The Winston-Salem police edited hours of undercover surveillance footage into a short video that showed each suspect making at least one sale. “Raise your hand when you see yourself committing a felony,” the prosecutor told the suspects, according to two people who were there. They started raising their hands, and “that was a thing of beauty,” police captain David Clayton recalls. “They knew we had ’em.”
Alleged dealers are told that they have been put on a special list. “Every one of my assistants has your name,” the district attorney told the suspects at the West End meeting. “And if they don’t prosecute you as aggressively as they can, I’ll fire ’em.” Even the public defender — who would likely represent them in court — warned that the cases were so tight there would be virtually nothing he could do to help them.
Immediate enforcement bolsters that message. The three suspected dealers who didn’t attend the West End community meeting were arrested the next day. One person who attended the meeting but tried to sell drugs days later was also arrested. Police and community groups advertised the arrests by posting fliers throughout the neighborhood with pictures of the suspects.
The threat of going to jail is coupled with a message of support from locals. Jim Summey, pastor of the West End’s English Road Baptist Church and a leader in the community’s anticrime crusade, sums up the message: “We are against what you’re doing, but we’re for you.”
Mr. Dejournette recalls, “We wasn’t expecting that….It did make an impression on me.”
So did something deeply personal: the fact that his mother, Annette Dejournette, was, in her words, “disappointed,” “ashamed” and “hurt” by her son’s actions. She convinced him to attend the meeting even though he had been afraid it was a ploy to arrest him.
Ms. Dejournette works as a clerk in a thrift shop. Money is tight, and often the electricity or phone will get cut off, her son says. “Momma be sitting back crying and stressing, and that make me want to go back outside [on the streets] and really do something to stop my momma from crying, but she the one who talks me out of it.”
The fact that the police are giving nonviolent dealers a second chance has encouraged community cooperation. West End residents have been increasingly calling police to report minor offenses, such as truancy or drunkenness. Ms. Dejournette says she went up to several police officers and city officials and “thanked them for trying to help my son.”
The Winston-Salem neighborhood where the approach was launched last year has proved tougher. The area, centered on the Cleveland Avenue Homes housing project, has fewer community institutions, such as churches, than West End does. Turnover in its public housing is extremely high. Mattie Young, 78, president of the Cleveland Avenue Homes residents’ council for almost 18 years, says the initiative eradicated open drug dealing during the first four months. But since then, she says, it has begun to creep back, especially at night.
Police captain David Clayton says that much of the new dealing may be due to one “very dangerous individual” recently identified by residents, whom police are seeking. Still, comparing the year before the initiative to the year after, major property crimes, such as robbery and burglary, dropped by 35%, according to police figures.
In the three neighborhoods where High Point has implemented the initiative, a total of 40 alleged dealers attended the second-chance meetings. Since then, six have been arrested for dealing. Another 10 have been arrested for various other crimes, from robbery to possession of marijuana. The rest — 24 out of 40 — have stayed clear of the law, police say.
After a dispute with his boss, Mr. Dejournette lost a job with the city parks department. Now, he says, “I fill out applications, but I never get that call back.” He works odd jobs, many through a brother who does construction, but he doesn’t make the $200 a day he says he made running errands for dealers. In April, Mr. Dejournette was arrested but not charged for a nondrug offense, so he is “teetering on the edge,” as Assistant Chief Sumner puts it.
Latisha Fisher, 32, of Winston-Salem, says she had been dealing drugs on and off since she was 15. After going to a community meeting and seeing herself on a police undercover videotape, she took her second chance. Her first job was at a fast-food restaurant. The pay: $6.50 an hour. “I toughed it out” for eight months, she says. “My church and family helped me.” This summer, she landed a job on an assembly line manufacturing earth excavators, making $8.50 per hour.
Yon Weaver, a High Point city employee who helps ex-offenders or suspects find jobs, says only 10 to 15 companies in the area are willing to hire people convicted of a crime. Of the 40 suspected dealers called in to the community meetings, about 10 contacted his office for assistance. He knows three have found jobs. Some suspected dealers have simply dropped out of sight. Police say they don’t think dealers merely relocated, because no new drug hot spots have emerged since High Point’s three markets closed.
Rev. Stevenson says the alleged dealers “are still God’s people, and I want them to do well and have productive, law-abiding lives.” But noting that two murders took place within a block of his church before the initiative, he doesn’t gauge the effort’s success by whether dealers turn their lives around.
“It sounds a little ugly,” he says, “but my first priority is the community.”


Source: WallStreetJournal online. Sept. 27th 2006

Published: Nov. 12, 2006

The young wrestler was sitting on the kitchen floor, his bloody face illuminated by the early-morning light that streamed through a nearby window. In other parts of the world, the shadow of the moon was edging across the rising sun, marking the beginning of a dramatic and well-publicized total eclipse. Will Hollingsworth had talked of little else for the past four days: the last eclipse of the millennium and the apocalypse some believed would follow. He had not slept in more than 100 hours, holed up in his room, paging restlessly through a Bible, his television tuned to news of the eclipse. It was a peculiar obsession for a 20-year-old college student who spent most of his time training to be a world-class athlete.
Will didn’t appear intoxicated. To the contrary, he was alert, engaging and philosophical, though strangely fixated on current events.

Now this.

On any other day, he would have been out the door — running for miles along eastern Hillsborough County’s busiest roads, pumping iron at the gym, working out with his old high school wrestling team.

But on this August morning in 1999, there was only the inexplicable blood and the vacant stare that greeted me when I came to make breakfast. “What happened?” I asked my only son. “I’ve been fighting demons,” he replied.


“It’s true,” he insisted, gesturing to his bloody face and filthy shirt. “I’ve been fighting demons all night. And I won.”

I followed his gaze through the window into the back yard. There, the torn sod and blood-stained patio marked the spot where he had pounded his face into the ground as his father and I slept, oblivious to the war we were about to wage with an invisible enemy. Will would battle his demons for the next three years. But he would never exorcise them. GHB already had laid claim to his sanity, and there was no one who could tell us how to retrieve it.

Dying To Win

Trinka Porrata is all too familiar with the phenomenon of young men who speak of mortal conflict with demons — men who pound their heads on concrete as they experience the unique and little-known psychosis that accompanies GHB withdrawal. “I can’t tell you how many times I’ve heard about that,” said the retired Los Angeles narcotics detective. “Some of them try to put their heads through plate-glass windows.” Some succeed.

Porrata, founder of Project GHB, has spent seven years throwing a lifeline into cyberspace for addicts desperate to escape the grip of a nutritional supplement promoted as a safe, non-habit-forming sleep aid that claimed to build lean muscle mass. Most have been athletes or bodybuilders, but GHB use cuts across all demographics. “It’s the most unique drug,” she said. “We have a lot of senior citizens hooked on it thinking it’s antiaging. It’s big in the gay community, big in the gym scene, big in the club scene. Yet it’s invisible.”

Porrata said she has had more than 1,800 inquiries from GHB users and their family members since Project GHB went online in December 1999. “We were getting: ‘I thought I was the only person in the world with this problem,’” she said.

Before the debut of Project GHB, anyone looking for information on the chemical discovered a nest of Internet sites featuring glowing testimonials, mail-order supplies and recipes for cooking it at home. Central Florida, with its fitness culture, was a watershed for the craze during the 1990s, before GHB-related products were outlawed.

Tampa had its own cottage industry in the form of Body Life Sciences, a now-defunct company that produced and marketed the supplement under the brand names Revivarant and Revivarant G. GHB seemed to offer something for everyone, depending on the dosage: sedation, exhilaration, sexual stimulation, weight loss and the unsubstantiated promise of massive muscles. It was readily available at health food stores and gyms, where it entered the marketplace as an ostensibly safe, legal alternative to steroids.

In recent years, its ability to induce mild euphoria and amnesia attracted a new kind of customer who employed it as a party drug associated with overdoses and sexual assaults. GHB’s link to “date rapes” and all-night raves quickly overshadowed its widespread use in the athletic community. Yet it is the athletes and bodybuilders, who incorporate it into a daily regimen, who are most at risk of becoming addicted.

“It’s really the frequency of the dose as opposed to the amount of the dose that leads to this very striking psychosis,” said David Kershaw, a psychologist for Hillsborough County’s Mobile Crisis Unit. Kershaw has seen his share of GHB addicts in withdrawal — beginning in late 1999, when the county’s mental health center saw a rash of cases involving muscular young men suffering from hallucinations and paranoia.

One believed he had an invisible tape recorder fastened to his leg. Another saw a swarm of flies covering his body. All were regular users of GHB. “The irony is that despite the fact that they wouldn’t deliberately pollute their bodies like that, they get sucked into using it,” Kershaw said. “The people I see are all athletes, all concerned with being as healthy as they can be.”

One of them was Will.

The Runner Stumbles

Will’s descent into madness was swift and seemingly irreversible.

The first sign that something was amiss came one night in the spring of 1999, when he called to ask his father to come help him change a flat tire. It turned out the tire was flat because Will had drifted off an exit ramp on Interstate 75 and into a tree. Weeks later, another late-night call — this one from an ex-girlfriend, who said she had received an urgent message from Will asking her to pick him up at a gas station near the University of South Florida.

When she arrived, she found the car, with the engine still running, the driver’s door ajar, but no sign of Will. He turned up at another nearby gas station — incoherent, with no memory of how he got there. His father and I were mystified. Will seemed as bewildered as we were. “I keep making mistakes, and I don’t know why,” he said.

He never made the connection between the potion he bought at the local health food store and the bizarre things that happened when he stopped using it. We didn’t know he was using GHB. There were a lot of things we didn’t know.

The Will we knew was exceptionally bright, responsible, hardworking and honest. A good student, a loyal friend and — most striking — a gifted athlete with a passionate dream to be the best of the best — at something.

He was, at one time, the fastest boy in Hillsborough County — sprinting and jumping his way through a medley of track-and-field titles during his middle school years. There was a charisma about the sturdy blond boy whose blistering speed brought stadium crowds to their feet as he entered the homestretch.

When he earned a place on the Brandon High School wrestling team — one of the premiere prep athletic programs in the nation — he told a sports reporter what it meant to soar with the Eagles. “I feel there is no limit to where I can go,” he said in a 1997 newspaper interview. “It is a great team and I don’t think my life will ever be the same.”

Death And Detox

About the time the young wrestler was beginning to unravel in Florida, bodybuilder Mike Scarcella, a former Mr. America, was arrested in Texas, charged with felony possession with intent to distribute GHB.

The U.S. Food and Drug Administration had banned the supplement in 1990 but left loopholes that allowed its analogues — chemical cousins that turn into GHB after ingestion — to be sold for another decade. By all accounts, including his own, Scarcella had been using the supplement for years — first as a muscle-building nightcap, then as a morning pick-me-up. Eventually he was sipping capfuls throughout the day, a classic pattern among athletic users that can lead to physical dependence in a matter of weeks or months. Scarcella was hooked. His May 1999 arrest, which resulted in 10 years’ probation, was not enough to pry him from the grip of GHB.

The 1992 Mr. America continued to use and sell the drug, even as he tried to kick the habit — first on his own, then in hospitals, where doctors had no experience with the bizarre hallucinations and raging psychosis of GHB withdrawal.

Even with a doctor’s help, withdrawal can be deadly. Stroke, heart attack and suicide are among the consequences for addicts in withdrawal, which can start within one to three hours of a missed dose.

Anxiety, restlessness and insomnia can quickly progress to delirium, muscle tremors and delusions.

“They think they’re on fire. They’re moving, thrashing, screaming,” said Karen Miotto, a University of California-Los Angeles addiction psychiatrist who helped develop a GHB detox protocol. “I think GHB is probably harder to get addicted to than some other drugs,” she added. “But once people get addicted, it is far harder to get off than any drug I’ve seen.”

Scarcella’s battle ended in August 2003, when the 39-year-old bodybuilder was admitted to a Texas hospital feeling the first effects of GHB withdrawal. By the 10th day, he had become delusional and suffered what the medical examiner termed “sudden cardiac death.”

Doctors and psychiatrists have been slow to recognize GHB withdrawal. Most know little beyond its reputation as a date-rape or club drug with the potential to deliver a swift, deadly knockout punch. Emergency room physicians have become familiar with the unconscious overdose patients — generally youthful partiers — who are often treated and released.

But they rarely consider GHB use in the muscular, hallucinating patients who are delivered in four-point restraints. “ER doctors don’t really know what to look for,” Kershaw said. Most physicians and mental health professionals also fail to recognize the early stages of withdrawal, when careful detoxification using the right medications might head off a spiral into psychosis. “It really means that the only time they’re going to get help is when they’ve reached the state of hallucinating,” said San Francisco addiction specialist Alex Stalcup. By then, their condition may be far less treatable.
“It’s just heartbreaking.”

Jesus’ Son

The angels appeared in September 1999, shortly after the eclipse that marked the end of life as we knew it.
These were not benevolent guardians, but mute, shadowy creatures only Will could see. What was their purpose? I asked him. “They’re here to watch us,” he said. Not as protectors but observers. They were neither dangerous nor benign. They just WERE, he said. Six weeks had passed since the morning of Will’s bloody battle with the backyard demons.

His father and I had spent the first week taking turns staying home from work with him as he slept round-the-clock, sedated by a physician.

The sleep deprivation that preceded the incident was enough to cause hallucinations, according to a psychologist friend. Perhaps sleep would bring him out of it, she suggested. We knew by this time that GHB had played some role. Will had acknowledged taking the supplement in the week before the eclipse. But he had stopped about three days before, he insisted. When Will finally woke up by week’s end, the crisis seemed to have passed.

He returned to his part-time job as a waiter at a Brandon restaurant and began his junior year at USF. With his sights set on the Olympics since high school, he resumed his regular workouts — and, according to his off-campus roommates, resumed his GHB use. “It takes you to a place you never want to come back from,” Will said.

On Labor Day, he was back home, reading the Bible around the clock. He stopped attending classes, didn’t report for work and did not return to the apartment he shared with three other students. He had stopped taking GHB.
He also had ceased his workouts and stopped eating. He claimed he was going to fast for two weeks — “like Jesus.”

Once again, his father and I took turns working from home, watching, waiting. He was, by law, an adult and could not be forced into an evaluation unless he proved to be a danger to himself or others. He didn’t meet that criterion — not yet. His father took his car keys, just in case. Sept. 17, 1999. It was my turn to watch over Will.

I worked on a news story from my laptop on the dining room table, just outside his bedroom. Each time I checked on him, he was sitting on his couch, reading his Bible. He had not eaten since Sept. 6. Shortly before 6 p.m., Will wandered out of his room and pulled up a chair across from me. My fingers froze on the keyboard as I met his gaze. “What are you working on?” he asked. I knew he couldn’t possibly be interested, but it was the first time in weeks he had made any effort to engage in conversation. I began to explain the story I was writing. Then I saw it, so plainly that for a moment I thought I was the one losing touch with reality.

Will’s gray-green eyes, the windows to his troubled soul, suddenly transformed into black pools of blazing madness. And for the first time, I understood the concept of possession. I was still answering his question when he cut me off in midsentence. “You don’t know who you’re dealing with, do you?” hissed the suddenly dark, dangerous creature.

“No,” I replied, cautiously. “Who AM I dealing with?” He rose from his chair and took a step toward me, his fist clenched, his face contorted with rage. “I am the Lord Jesus Christ, and I want my car keys.” I glanced at the clock. His father was due home any time now.

Will’s lips smiled, but his eyes still glittered with that dark madness. “He’s not going to save you,” he said, as though he had read my mind. The phone rang. Will answered. “Yeah, Dad. She’s right here,” he said, handing me the phone, still smiling that frightening smile. Whatever I had seen in Will’s eyes, his father heard in his voice. “Can you talk?” he asked me. “No.”

“Something is wrong?”


“Get out of the house,” Will’s father told me. “Get out NOW.” Clearly the time for watching and waiting was over. His father dialed 9-1-1.

That night, the angels made their first appearance as Kershaw and his mobile crisis unit came to commit Will for 72 hours of psychiatric observation under Florida’s Baker Act — the first of nearly a dozen hospitalizations over the next 30 months. It wasn’t a tough call. Will was in “florid psychosis” and claimed alternately to be God, Jesus and Jesus’ son.

Then there were the angels, who would, in time, become Will’s constant companions. Kershaw was among the few professionals we encountered over three years who took serious note when we told him of the GHB link.

“Will’s case prompted me to educate myself on this,” he said. “If I have someone who’s got psychotic symptoms, and they’ve got a history of being a fairly well-functioning athlete with no history of mental illness, one of the first things I think of now is GHB.”

Spontaneous Combustion

GHB was the last thing David Johnson thought of as he searched the Internet for information about “Enliven,” a supplement his 28-year-old son, Tyler, purchased at a health food store near his home in Beebe, Ark.

Tyler, who had graduated weeks before from the University of Arkansas, became restless and “fidgety” on the night of July 15, 2000. His pulse raced, and he began to say things that didn’t make sense, Johnson said. Unknown to Johnson, the young bodybuilder had been taking Enliven for about a year. Now, engaged to be married and about to begin law school, Tyler had decided to stop taking it. That night, he showed his father a bottle of the supplement, labeled as a “100% Pure Cellular Recovery System” that “Renews the Body Naturally.”

What it didn’t say was the active ingredient — 1,4 butanediol, better known as BD — is a solvent that converts into GHB once ingested.

Withdrawal from GHB is among the most prolonged and severe of any drug and should not be undertaken without medical supervision.

Cardiovascular distress is significant, posing the risk of stroke or heart attack. Spikes in blood pressure from repeated bouts of withdrawal can result in arterial damage and an enlarged heart. Withdrawal grows more severe with each subsequent attempt, “kindling” the nervous system to the point of inducing delirium or seizures.

Patients treated before they reach this stage stand a better chance of successful recovery. Detox begun in early stages of withdrawal, with onset of restlessness and anxiety, works best. Detox generally takes at least two weeks, often requiring heavy doses of sedatives, accompanied by monitoring of blood oxygen levels. David Johnson didn’t know it, but Tyler was in GHB withdrawal.

“I wanted to take him to the hospital, but he told me he was all right and he went to bed,” Johnson said.

The next morning, shortly after dawn, a neighbor discovered Tyler’s body on the Johnsons’ front lawn. He had shot himself in the head. Suicide is an all-too-common outcome in cases of GHB addiction, though the true numbers will never be known. Porrata has seen it over and over.

“It’s like spontaneous combustion, not like they pondered it. They just shoot themselves in the head,” she said.
Detox from GHB can take at least two weeks.

“I think one of the most dangerous periods is after detox, where they are suffering depression, anxiety, and it becomes this protracted withdrawal state,” Miotto said. GHB anxiety is malignant — the frightening dreams at night, the terror during the day as the central nervous system tries to deal with the legacy of a little-understood chemical assault on the brain, Stalcup said. “If I had to go through what I see people going through, I don’t know if I could do it,” he said.

Perhaps the harshest irony, Porrata said, is the people who become addicted to GHB in the pursuit of health and fitness and end up turning to street drugs to counter the effects of withdrawal. Black-market Xanax, Valium and similar drugs tend to be the ones of choice. Alcohol, cocaine, Ecstasy and even crystal methamphetamine aren’t far behind.

Of Dreams And Nightmares

In the weeks and months that followed Will’s first Baker Act, life took on a rhythm of sorts — but not the sort we envisioned.

By day, Will continued to run, lift weights, wrestle and pursue his athletic dreams. By night, he battled the demons that invaded his sleep. The boy who once was a designated driver for friends retreated to his room, alone, to drown the delusions in rum and vodka.His circle of friends shifted from students and athletes to dropouts and drug dealers who could ensure a steady supply of sedatives and anything else that might quiet the voices and visions.

I purchased a dreamcatcher and hung it beside his bed, hoping the mystical Indian legend would offer some comfort.

But nothing could banish the nightmarish images that appeared when he closed his eyes. “You can’t imagine what is happening in the world,” he told me. “Yes, I can.” I had to look no further than the gaping hole in his soul.

Laced with antipsychotics prescribed by his doctors, supplemented by a pharmacopia of his own invention, Will struggled to hold down a job and tried, unsuccessfully, to complete his junior year.

He teetered for months on the brink of madness, alternately stabilizing, then disintegrating into a series of forced hospital stays. We didn’t know whether he continued to use GHB or whether the drug had permanently rewired his brain.

“With Will, when I saw him again and again, I wasn’t sure if the GHB had triggered more of a chronic process with him,” Kershaw said. Each time Will was committed, we asked the nurses and doctors to flag his chart to reflect his GHB use — a request that often was received with blank stares and dismissive waves. Will continued to slip from our grasp, trapped in a world inhabited by demons and angels, a world defined by the absence of light or joy.

We wondered how long he could survive in such a dark and hopeless place. It didn’t help that he had come to believe he possessed the gift of prophesy and claimed to have seen his own death many times. He wouldn’t tell us when this was to occur. All he would say was that it involved fire.

Drowning In Cases

In the beginning, the addicts who flocked to Project GHB for help tended to be young men in their late teens and early 20s. Today, Porrata is seeing older men who have been using for five to 10 years. Most are 30 to 55 years old.
“It’s not the party kids,” she said. “It’s the man in midlife crisis who starts going to the gym and wants to lose a few pounds, look a little better, rekindle things — and someone introduces him to ‘G.’”

But still it is the athletes who concern her the most. “Any place you see steroids, GHB is right in the shadows,” she said. “The sports world won’t admit this drug. It’s like their secret drug, and they won’t give it up.”

Unlike steroids, there is no evidence GHB enhances physique or performance. Still, users subscribe to the myth.

“What makes GHB so attractive to athletes is it’s very difficult to detect. They pass all the routine urine drug screens that you do,” said Tampa addiction specialist David Myers.

One of Myers’ patients — a Major League Baseball player — sipped GHB from a small mouthwash bottle during his games. He told Myers and his team managers that GHB use was widespread in pro sports, including among his teammates.

“He relapsed,” Myers said. “There was no support from team management, and it was clear they were not interested in tackling GHB issues.”

There is some speculation that stepped-up enforcement has limited the drug’s availability. But despite a major Drug Enforcement Administration sting that netted 115 Internet distributors in 84 North American cities in 2002, followed by a $7 million bust this year in Scotland, there is plenty of GHB to go around. With Project GHB and other Internet sources supplying information that wasn’t available to addicts six years ago, many users are taking matters into their own hands, Porrata said. “They’ll die from other drugs,” she said. “And we’ve had so many suicides — so many.”

The Three Demons

Will’s final Baker Act took place Jan. 18, 2002. His slide into psychosis began as it always did: He stopped eating.

This time he said he planned to fast until Easter. When he entered Memorial Hospital’s psychiatric unit that day, he had been fasting for two weeks and had lost nearly 30 pounds. A public defender assigned to Will’s case blocked every effort to give him intravenous fluids and nutrients. If he wanted to starve himself, it wasn’t our business, or his doctor’s, she said. By February, Will was still fasting and began walking into walls. He fell and hit his head.

Then something remarkable happened: After three years of inexplicable madness, someone finally decided to take a look at Will’s brain. A nurse requested a CT scan. It was then that we finally met his demons. There were three of them: inoperable brain lesions whose nature and origin doctor’s couldn’t even guess at. Will was transferred to the medical floor, and for the first time in nearly two months, he received IV fluids and nutrients. Too late.

The neurological collapse began with involuntary flickering of his eyelids, which grew more pronounced each day. His hearing began to fail. He started to lose the use of the right side of his body. Still he would not eat. “Don’t worry,” he said. “I’ll be fine.” “All you have to do is start eating, and they’ll let you out of here,” I pleaded. “Isn’t there someplace you’d rather be?” “Heaven,” he said. On Easter, Will broke his fast with a Cadbury egg. He was transferred to a physical therapy unit, then sent home.

The brain scan was sent to Johns Hopkins University in an attempt to identify the lesions. The young wrestler, once the fastest boy in Hillsborough County, could not get from the bedroom to the bathroom without a walker. His balance was gone, his hearing severely impaired. And his flickering eyes couldn’t focus on a television screen, much less a Bible.
But he could kneel, and he could pray. And that is what Will did each day. “Everything will be fine,” he kept saying. “I’ve seen the future, and I’ll be wrestling.”

One of the saddest things about GHB, Miotto said, is the way the drug affects the mind. “They don’t grasp the level of their impairment,” she said. But the saddest thing about Will’s experience was his ability to grasp just that.

Despite his irretrievably broken mind, he knew what he had lost. He knew it all along. Will had always felt a particular affinity for the homeless. In the years he struggled with GHB psychosis, he actively sought them out to give them money as they picked through garbage bins. “That could be me someday,” he said. Despite his intermittent delusions of grandeur, his goals were humble. “What do you want from life?” I asked him shortly before that last Baker Act.

“I just want to be able to take care of myself,” he said. “To drive a car. To have a place of my own.”
Weeks after Will’s release from the hospital, his doctor evaluated him. He checked his eyes, his ears, his balance. This, he told him, was as good as it was going to get. As for the three still-unidentified brain lesions — things could get worse, he added.

Four days later, on June 3, 2002, my son took a gas can from the garage to the back yard. He doused himself and lit a match. A young man approached me after the memorial service. He said his name was Brandon and that Will had persuaded him to seek treatment for cocaine addiction.

“I’m two years clean and sober now,” he said. “Will saved my life, and I just wanted you to know.”

Source: Researcher Mike Messano contributed to this project. Reporter Jan Hollingsworth can be reached at (813) 865-4436 or


Blue Nitro
Revitalize Plus
Thunder Nectar
Flower Power
Dream On
Weight Belt Cleaner

Source: Project GHB

Filed under: Social Affairs (Papers) :

A rare finding of substantially reduced youth substance use following a media campaign demonstrates the value of well tailored content and an effective, manageable delivery mechanism.
The campaign included print materials such as posters and promotional items such as book covers, tray liners, T-shirts, water bottles, rulers and lanyards, intended to associate drug-free lives with early teen aspirations for autonomy (“Be Under Your Own Influence” was the campaign’s identifier). Over two years school staff distributed the materials to secondary school pupils while community leaders involved in drug prevention worked with project staff to devise broader campaigns intended to reinforce the school-based measures. 16 communities across the United States were randomly allocated to mount these campaigns or to act as controls. Parental permission was received for 4216 first year pupils (average age 12) to participate in the study. They were surveyed before the interventions and then three more times, the last time after they had ended.

The key question was whether growth in substance use was retarded in the media campaign communities. The answer was yes, most clearly for drinking and cannabis use and less clearly (but still substantially) for smoking.
In the two sets of communities, at the start roughly the same proportions of pupils had tried these substances. Over the next two years, half as many pupils in the campaign communities started to use each of the three.
An earlier analysis suggested that the school campaign had worked by fostering the perception that substance use was incompatible with the pupils’ aspirations.

In context

Its inexpensive strategy meant the project could afford repeated exposure in a way that would not have been possible with mass media ads. It also gave teachers and school counsellors (who often distributed the materials) a chance to amplify the effects through interaction with the pupils and for pupils to discuss the campaign among themselves. Possibly relevant too were the marketing and PR backgrounds of the leading researcher and campaign strategist, who co-opted strategies used by companies seeking to sell to young people. Effects were much larger than the norm, probably because the study incorporated principles of effective media campaigns including tailoring to the community, preparatory research with the intended audience, a theoretical foundation, targeting to relevant sub-groups (in this case, youngsters largely yet to try drugs), novel and appealing messages, and effective delivery channels.
However, a third of the pupils did not participate in the study (among whom are likely to have been those most prone to substance use) and larger conurbations were excluded. Nor we do not know whether frequent use was also retarded, though this seems likely.

Practice implications An expertly planned and adequately resourced media campaign systematically focused on preventing substance use in young people can make a difference. Localities which want to achieve this will need to maintain focus on this objective rather than the many others campaigns can explicitly or implicitly serve. Upbeat messages about the advantages of not using seem to have more effect and less potential to backfire than negative warnings. Despite the emergence of important principles ( Incontext), there is no formula which guarantees success. Especially since there are also no demonstrably successful UK examples, any campaign should be evaluated against its objectives or a close proxy. If they will cooperate, schools are an effective and inexpensive delivery mechanism, but such activities are not an alternative to drug education lessons or pastoral interventions for high-risk pupils.
Featured studies Slater M.D. et al. “Combining in-school and community-based media efforts: reducing marijuana and alcohol uptake among younger adolescents.”
Health Education Research: 2006, 21(1), p. 157–167 DS
Contacts Michael Slater, School of Communication, Ohio State University, 3022
Derby Hall, 154 North Oval Mall, Columbus, OH 43210, USA,
Thanks to Neil McKeganey of the Centre for Drug Misuse Research at the University
of Glasgow for his comments.


1. Executive Summary
Policymakers and other stakeholders can use cost-benefit analysis as an informative tool for decision making for substance abuse prevention. This report reveals the importance of supporting effective prevention programs as part of a comprehensive substance abuse prevention strategy. The following patterns of use, their attendant costs, and the potential cost savings are analyzed:
• Extent of substance abuse among youth;
• Costs of substance abuse to the Nation and to States;
• Cost savings that could be gained if effective prevention policies, programs, and services were implemented nationwide;
• Programs and policies that are most cost beneficial.

1.1. Costs of Substance Abuse
Studies have shown the annual cost of substance abuse to the Nation to be $510.8 billion in 1999 (Harwood, 2000). More specifically,
• Alcohol abuse cost the Nation $191.6 billion;
• Tobacco use cost the Nation $167.8 billion;
• Drug abuse cost the Nation $151.4 billion.

Substance abuse clearly is among the most costly health problems in the United States. Among national estimates of the costs of illness for 33 diseases and conditions, alcohol ranked second, tobacco ranked sixth, and drug disorders ranked seventh (National Institutes of Health [NIH], 2000). This report shows that programs designed to prevent substance abuse can reduce these costs.

1.2. Savings From Effective School-Based Substance Abuse Prevention
If effective prevention programs were implemented nationwide, substance abuse initiation would decline for 1.5 million youth and be delayed for 2 years on average. It has been well established that a delay in onset reduces subsequent problems later in life (Grant & Dawson, 1997; Lynskey et al., 2003). In 2003, an estimated:

• 5.6 percent fewer youth ages 13–15 would have engaged in drinking;
• 10.2 percent fewer youth would have used marijuana;
• 30.2 percent fewer youth would have used cocaine;
• 8.0 percent fewer youth would have smoked regularly.

The average effective school-based program in 2002 costs $220 per pupil including materials and teacher training, and these programs could save an estimated $18 per $1 invested if implemented nationwide. Nationwide, full implementation of school-based effective programming in 2002 would have had the following fiscal impact

• Saved State and local governments $1.3 billion, including $1.05 billion in educational costs within 2 years;

• Reduced social costs of substance-abuse-related medical care, other resources, and lost productivity over a lifetime by an estimated $33.7 billion;
• Preserved the quality of life over a lifetime valued at $65 billion.

Although 80 percent of American youth reported participation in school-based prevention in 2005 (SAMHSA, 2004), only 20 percent were exposed to effective prevention programs (Flewelling et al., 2005). Given this level of participation, it is possible that some expected benefits already exist for these students, and the estimates in this paper are adjusted for these probable benefits.
These cost-benefit estimates show that effective school-based programs could save $18 for every $1 spent on these programs.

In a program targeting families with low income, intensive home visitation coupled with preschool enrichment reduced infant/toddler abuse (Aos et al., 1999; Karoly et al., 1998). As these toddlers reach adolescence and adulthood, visitation programs also can reduce a range of problems including substance abuse and violence.

Among indicated programs (targeted to individuals who have detectable symptoms), cost estimates that primarily focused on substance abuse were not available. However, estimates indicating good returns on the investment were available for several violence prevention interventions that address the roots of multi-risk behavior. Moral reconation therapy for adult and youth offenders, and multi-systemic therapy and functional family therapy for youth offenders returned more than $30 per dollar invested.

1.3. Conclusion
The cost of substance abuse could be offset by a nationwide implementation of effective prevention policies and programs. SAMHSA’s Strategic Prevention Framework should include a planning step that considers cost-benefit ratios. Communities should consider a comprehensive prevention strategy based on their unique needs and characteristics and use cost-benefit ratios to help guide their decisions. Model programs should include data on costs and estimated cost-benefit ratios to help guide prevention planning.

Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis
Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Prevention (CSAP)

UN-commissioned guidance from international experts on how to mount prevention programmes based on family skills training involving parents and children in a joint effort to improve family dynamics and child development. Engaging parents seems the major barrier.

This review and guidance initiated by the UN Office on Drugs and Crime concerned the role of family skills training programmes in the prevention of substance use problems among children in families across the board (‘universal’), or families whose children are particularly at risk (‘selective’). Unless integrated with these types of interventions, the document did not include programmes aimed at individuals identified as at high risk or as already experiencing substance use problems (‘indicated’). A literature and website review identified 130 universal and selective programmes. Research articles and programme descriptions were solicited from the developers. Practitioners, managers, researchers and developers from these programmes throughout the world were invited to a technical consultation meeting. The guide was drafted on the basis of the discussions and the literature review. This account largely relies on its final chapter, which summarised the major points.
Families can act as powerful protective forces in healthy child development, in particular with regard to substance use. To bolster this process, universal and selective family skills training programmes generally aim at strengthening the protective factors in families, equipping parents with the skills to provide supportive parenting, supervision, monitoring and effective discipline, and giving entire families opportunities and skills to strengthen attachment between parents and children. These approaches are more intensive and differ from parent education, which typically limits itself to providing parents with information about substances and their effects and does not involve the children.
Such programmes have been extensively evaluated and found effective in preventing substance abuse and other risky behaviours – about three times more effective than life skills education programmes aimed only at children and young people, and with more long-lasting benefits. Conservative estimates indicate that for each pound spent, over the long term these programmes return a saving of nine pounds. They also form part of effective multi-component programmes which offer other interventions in other settings (such as schools, media and the community), and of tiered programmes which operate across several levels of prevention simultaneously according to the needs of the families (universal, selective and indicated).
Although the evidence is limited to few programmes in high-income countries, recommended principles for family skills training programmes can be identified. These include a solid theory of how the training will affect risk and protective factors based on research on factors related to substance abuse which can be addressed at the family level. Programmes should be matched to the target population, especially the age and developmental stage of the children and the level of risk or problems in the families. This makes accurate needs assessment vital. Programmes must be of sufficient intensity and duration to address the targeted outcomes. In general, universal programmes extend over four to eight sessions, selective programmes for higher risk families, 10 to 15. Sessions last about two to three hours and should be based on interactive techniques implemented in small groups of eight to 12 families. A typical and effective programme will provide parents with the skills and opportunities to strengthen positive family relationships, family supervision and monitoring, and improve the communication of family values and expectations.
Recruitment and retention of parents are significant barriers to the dissemination of such programmes. However, retention rates of over 80% can be achieved by addressing the practical (transportation, childcare) and psychological (fear of stigmatisation, feelings of hopelessness) barriers. Interventions are most effective if participants are ready for change, such as at major transition points like children starting school or a new school phase.
Often it most feasible and/or cost-effective to base a project on an evidence-based programme developed elsewhere for a similar target group, preferably one with the best prevention record. In this case, it is important to carefully and systematically adapt the programme to the cultural and socioeconomic needs of the target population. Such adaptations enhance recruitment and retention of families. However, during its initial use the programme should be implemented with only minimal local adaptations or changes. Feedback from participants and group facilitators on what worked or did not work so well can be used as the basis for further refinements. Experience with these and outcome evaluations should be used to assess whether a deeper adaptation is required.
As with other types of programmes, adequate training and ongoing support must be provided to carefully selected staff. Most evidence-based programmes require two to three days of training for 10 to 30 future group leaders. Training should give them the opportunity to practise their skills, but also discuss the theoretical foundations, evidence of effectiveness, and the values of the programme. Ongoing support by programme managers and supervisors (and, if possible and appropriate, from programme developers) is important, especially in the form of e-mail contacts and web-based networking of group facilitators across agencies. Site visits and debriefing sessions also enhance quality and fidelity of implementation, as well as the collection of monitoring data.
Programmes should include strong and systematic monitoring and evaluation components. This work contributes to the understanding of prevention strategies, indicating which programmes are effective, under which circumstances, and for which populations, and provides evidence of effectiveness which can be used to lobby policymakers and donors, potentially helping to sustain the programme.
There is no question that the family is a powerful influence on child development and on substance use and problems in particular, nor that interventions with families and parents can (see for example this demonstration from Sweden) help prevent substance use in various forms. What is questionable is whether the research, though sometimes promising, is sufficiently extensive and sound to warrant widespread implementation of these programmes. Searching for practical guidance, British reviewers found that research deficiencies mean that no clear choice could be made about what works best either for marginalised and vulnerable groups, or for families in general. The background notes focus on two of the best researched family skills interventions (the Strengthening Families Programme and the Family Check-Up) as a way of testing the adequacy of the evidence overall, and address the issue of engaging families of early adolescent children. For other relevant evidence run this search for pre-school and parenting interventions on the Findings site.
When in 2008 the US government analysed the costs and benefits of substance use prevention programmes, family skills training programmes were among those with the highest benefit to cost ratio, though they lagged behind some other school/community/family programmes, and also well behind some entirely different kinds of initiatives like enforcing laws on serving drunk customers in licensed premises. Estimates for the two relatively well researched family skills interventions focused on in the background notes rested on one or two studies, which in both cases provided a narrow and at best tentative basis for the calculations, casting doubt over the degree to which they can be relied on to guide prevention programme planning. Nevertheless, the same may be said of some of the other programmes included in the analysis. For the analysts, the major drawback of family training as a universal prevention modality was its higher cost relative to other types of initiatives, leading them to suggest that this approach be reserved for high risk schools, areas or families
A particular issue is whether by the time family skills training comes in to its own – from age six to 11, and in major studies not until the early years of secondary schooling – enough families can be involved to make these strategies a viable way of curbing youth substance use problems across the population as a whole. British experience so far suggests this is not the case, though high-risk families under pressure to attend and/or energetically and sensitively targeted can be engaged in and benefit from family skills training. As the featured review comments, one way cost and accessibility barriers are being addressed is through computerisation of such programmes so families can go though them at times convenient to them and in their own homes, a tactic trialled for example with some success among mothers and daughters in New Jersey.
Based on UK experience and the adequacy of the international evidence, family skills training programmes of the kind reviewed can be recommended for consideration for families who have come to attention because their children (age six upwards) are at risk of behavioural problems which may include risky substance use. Sensitive personal approaches from programme staff, perhaps preferably from the same communities, can recruit many to participate, stay in and benefit from the programmes. Universal application to all families seems at the moment to lack sufficient evidence (especially in the UK) to warrant the considerable investment required, a situation which may change if low-cost, accessible computer-based alternatives prove feasible, effective and capable of widespread implementation.

Source: K. Kumfer 09 March 2010

Journalist Nick Davies has  written  about legalising Heroin before and more recently. This is a rebuttal by an Australian professor and researcher. 

Nick Davies is right about one thing; drug policy is typically surrounded by an absurd amount of disinformation and misinformation. The truth is not always easy to find.  Governments the world over are perennially advised by experts of the day and the scientific establishment. Science, like most human activities, has within it schools of different thought and is very subject to the winds of its own internal fashions.  Phrenology in the 1930’s was one glaring example and the recent man made global warming debate is another. Many of my friends in the UK and on the East coast of the US are desperate for a good dose of global warming to thaw out their cars, homes and driveways.  The dearth of quality information in this field, and in many cases its deliberate suppression implies that, to borrow another of Davies’ metaphors, the policy debate continues to impersonate a drunken man on a dark night.  The main thing I learnt from Davies’ polemic was that the political and social left dislike Margaret Thatcher – who would have guessed?

Davies dutifully recites the many alibis and mantras of the liberal drug left including principally that heroin itself is intrinsically benign, and it is the illegal status of the drug along with the high cost, the impurities with which it is mixed and injected, and the unknown purity of the drug which are responsible for its toxicity. 

Astonishingly Davies even manages to trivialize heroin overdose, and claims it is relatively rare.  Perhaps this extraordinary claim is due to the fact that his references are mainly to Wikipedia, advised by a few drug liberalization sites or other journalists.

It is well known that the rate of death amongst heroin addicts is about 16 times higher than that of non-addicts, with some estimates from Sweden placing it 55 times higher, and others 70 times higher.  Overdose is not rare amongst heroin addicts, and many studies show that it is a common feature of people who have been injecting it for several years, and more have overdosed than have not.  In some Australian studies about half overdose several times annually.  Rather than heroin being safe as suggested, the levels of opiates in the blood are often relatively low or in the therapeutic range at post-mortem.  Therefore the reason some addicts die is often not well understood, although in the overdose situation it may be mixed with other drugs.  This does not exonerate heroin as it is a depressant drug, and obviously depressant drugs can sum together, or even potentiate the effects of each other to have a super-additive effect to halt breathing.  Moreover opiate addiction, which includes methadone and heroin, likely changes the central appetite mechanism deep in the hypothalamus of the forebrain, so that the appetite for other drugs is increased.  Davies also fails to mention that many heroin programs are actually heroin and methadone programs.  Heroin works for such a short time, that the overnight doses have to be of methadone to keep patients comfortable during the night.  So heroin programs are more properly thought of as “heroin top up programs.”

Rather than heroin being benign for the brain, the scientific literature is replete with studies and claims that long term opiate use causes damage to the mood centres in the limbic system, and the extended limbic system which includes the hippocampus and hypothalamus, which it turns out are also responsible for memory formation, learning and hormone control.  There is no such thing as a drug addict with a good memory and this is not related to the legal status of the drug.  Similarly the majority of opiate addicted patients have psychological disorders with rates in various studies particularly of depression and anxiety at over 70-90%.  Similarly epilepsy is far more common in opiate dependent patients, and there are several reasons for this.  Opiates have been shown to impair the renewal of brain stem cells, particularly in the hippocampus.  As this area is in charge of memory formation and emotionality, and is frequently the site of origin of fits, disturbances in these functions are to be expected, and are in fact commonly observed.  Indeed opiates have been shown to impair the growth of all organs, likely by impairing stem cell growth and activity.  This likely accounts for the evidence of disease and dysfunction in virtually every organ system of the body in long term users.  Opiates have actually been shown to impair the ability of cells to divide by blocking the normal progression of stem cells through the cell cycle, right at the very beginning of these transitions.  This effect is exacerbated by the action of morphine and its derivates including heroin to trigger programmed cell death, which researchers refer to as “apoptosis”.  Clearly the increased cell death, and the relative inability to replace the lost cells can hardly be good either for the health of the body’s cells and organs individually, or the patient as a whole.

It has also been shown that – pure – opiates both suppress and stimulate the immune system.  Whilst some may find this dual action confusing, it is reminiscent of an old car struggling to keep up with the speed limit with a dying engine.  As the car goes up the highway it blows smoke everywhere, and gets pulled over by the police for failing to keep up to the speed limit!  It is also very noisy, as its engine rev’s hard to do its best.  It is clearly working both hard and weakly at the same time.  This seems to be the picture of the opiates saturated immune system.  It parallels other clinical disorders such as rheumatoid arthritis and lupus, where patients with an overactive immune system also display evidence of generalized immunosuppression.  This immune stimulation is particularly damaging for the body, and likely takes a big toll of all organ systems.  Such immunity has been found to be important in many diseases including dementia, atherosclerosis, diabetes, obesity, osteoporosis, chronic periodontitis, cancer development and the ageing process itself.  Opiates have been shown to directly stimulate many aspects of the innate immune system, an evolutionarily ancient and very powerful arm of the immune response which acts quickly and promptly to alert the body to danger signals, and to summon other yet more powerful components of the truly matching adaptive immune response.  Moreover components of the innate immune system have now been shown to be also involved in controlling brain formation, synapse formation between nerve cells, brain stem cell generation and differentiation, and controlling neuronal and dendrite growth in the brain.  The immunosuppressive action of opiates increases the infectivity of, and damage caused by HIV in the immune system and brain, and Hepatitis C damage in the liver.

In particular one of the most sensitive tissues are actually stem cells, as these fragile baby cells, which all carry opiate receptors, are unusually sensitive to the noxious effects both of opiate agents and immunity.  This means that opiates actually pack a triple punch on cells throughout the organism:  there is the devastating effect of opiates on cell growth, and particularly stem cell growth; there is the stimulating effects of opiates on the immune system which leads to damage to the body as a whole; and then there is the compounded interactive effect of the immune effects of opiates particularly on the stem cells, which is likely more severe than the effect of either action working alone. 

Evidence of damage to the vascular system has also been published, which has been linked with stroke and heart attack.  Evidence of widespread hormonal disruption has also been shown.  The dental disease is well known, and this in its turn has been shown to be linked with higher rates of systemic pathology including hardening of the arteries and the development of dementia, probably by further stimulating the immune system.  Opiates disrupt cellular barriers both in the gut, allowing increased access of highly toxic germs to the blood stream, and in the brain where the immune system gains increased access to the nerve cells of the critical centres of the brain through a leaky blood brain barrier.  Similarly bone healing and formation is disturbed by opiates, likely by both stem cell and immune stimulatory mechanisms.  90% of an American study of opiate dependent males, with a mean age of about 40 years, had evidence of measurable and clinically significant bone loss, called osteopaenia or osteoporosis.  This is very important as it integrates the effects of addiction over significant time.  The liberalists argue that opiates are without intrinsic harm themselves, whilst conservatives argue the obvious denigration of virtually all drug users with time.  In one sense both might be true.  If the net defect suffered is only minor – say 5% annually, then over 20 years, the total deficit suffered is 64%!  Over 40 years this is 87%!  This implies that studies which demonstrate short term efficacy, typically over 6-12 months, really have essentially nothing to say about the long term toxicity of the drugs, as none of them have the necessary sensitivity to assess damage at this high degree of precision.

In fact there are very few published studies which examine the effect on physiology over the very long term.  Those which are available all paint a very bleak picture, with one major American study recently calling for geriatricians to be appointed to those addicts who survive to the age of 50 years, as their health was essentially falling apart in many body systems with evidence of widespread physical and mental disease, disability, misery and – of course – death in those who had not survived to complete the survey.

As for giving heroin out, one must be very careful.  The recent report of the Canadian heroin trial showed that it had a primary failure rate over one year of 40%.  This makes it far from the panacea depicted in its marketing blurb.  Data from the Sydney injecting groom, a room where illegal heroin can be taken under the supervision of Government employed nurses, showed that the rate of overdose was over 30 times higher than that in the general community.  In other words, in the presence of support staff clients were more than happy to “go for the magic big hit”, with near fatal overdoses on many occasions only averted by prompt action from the attending professional staff.

Davies mentions the disrupted social networks characteristic of heroin users.  It is sad that people who are dearly loved by their families die alone.  The utter chaos surrounding the heroin addicts life is legendary.  So many patients have told me that while they are using they think they are only hurting themselves; however when they get clean they realize how destructive their drug abuse is on all their family, friends and social relationships.  Most of these patients tell me that the best thing they could do is to come upon a bag of free heroin, and when they are sick many admit praying for a free hit.  However they freely and universally admit that this is also the worst thing that could happen to their own children.  When I ask them which view is correct, their view for themselves or their view for their children, they start to see that they have been badly deceived, and wickedly seduced.  It also becomes very obvious to them that they will not be truly free from their addiction in their mind until the way they think about heroin for themselves is the same as the way they think about heroin for their children.  As much is likely also true of societies.

As to heroin use being normalized in Switzerland and Zurich, that is not what the many refugees from that city who have fled all the way to Australia have told me on many occasions, nor is it the story which is in the published medical press.  Many have fled the gross social degradation which have taken over the forced closure of the Swiss “Needlepark” [ “Platzspitz”], and the criminal explosion which accompanied it.  According to published reports the top 1 meter of soil had to be bulldozed out of the park to clean it up.  Its closure only saw it move over the road to the abandoned railway station. 

Davies’ claim that the introduction of methadone was a cunning move to push up the price of black market heroin betrays his obvious agenda.  The simple fact is that a wave of heroin abuse has taken the world since the 1960’s which the various programs were designed to allay.  I found his figures for the majority of property crime in the UK being related to heroin use interesting in that they are virtually identical to those from Australia. 

The arguments of the left are seductively simple, but they are best addressed by stating the obvious from everyday life, the social, physical and psychological nightmare of active addiction.  These are the hard lessons learnt in places such as Sweden in 1968 and in Zurich where liberal policies such as those presently advocated were tried on the basis of seductive supposedly compassionate advice such as that which Davies and his ideological colleagues presently so eloquently argue.  Whilst there is a superfluity of robust evidence available in the scientific literature to refute such claims, it is also clear that much more work in this area could be done.  Nor is it relevant only to addiction medicine.

The fact that opiate addicts notoriously suffer from exorbitant rates of atherosclerosis, dementia, psychological disorders, osteoporosis, dental disease, immune dysfunction, hormonal disturbances and disruption of their sleep-wake cycles and appetite drives, and a very high rate of some cancers, implies that if we understood more of this process we could treat these major disorders much better.  Moreover, collectively they demonstrate an acceleration of the ageing process, so we would likely begin to understand the ageing process much better, potentially developing treatments which might increase the human “healthspan”, or our number of disability free years, minimizing our risk of long term disablement and years spent in a nursing home.  And the deficit of detailed long term studies of these important issues is clearly a major gap in our understanding, which urgently needs to be addressed.  Whilst it is true that there exists enough data in the published science to effectively refute the raucous arguments for legalization of all presently proscribed drugs, it is equally true that much more could be done in the toxicological sciences to explore these issues in more detail.  That western societies allow mainstream science to continue to overlook such areas, whilst drugs pose so present and imminent a major social threat, is an international disgrace, and one which can only be overcome by the will of the people being felt by the policy makers, to properly protect the coming generations. 

For example cannabis has been shown to be linked with eight cancers, including congenital leukaemia and brain cancer, and has been shown to be mutagenic.  This may be related to its genotoxic effects mediated via AP-1 and MAP kinase pathway activation.  Opiates also stimulate these same pathways, and have also been shown to be linked with carcinogenesis.  Environment has been shown to impact gene regulation through epigenetic regulation including chromatin methylation confirming the Barker hypothesis that in utero and neonatal influences can permanently affect gene expression for decades to come.  There is no liberalization argument to address genotoxicity in this generation, and no liberalist defence of genetic mutagenicity in the next generation.  The demonstration in many studies that parental opiate use produces body and organ growth retardation, impairs brain growth, induces organ structural abnormalities, and intellectual and behavioural disabilities in affected offspring into their teenage years has no liberalist defence, and is in fact egregariously indefensible.  As developed nations we have much more to learn and much more to do

The author runs the largest heroin detox clinic in Queensland Australia, and has published many papers on heroin and drug addiction and its treatment.

Source: Stuart Reece Feb.2010

Filed under: Social Affairs (Papers) :

Two NIDA-funded studies identify health risks that  underscore the importance of curbing marijuana abuse.

BY PATRICK ZICKLER, NIDA Notes Contributing Writer                             

A large new epidemiological study suggests that marijuana smoke can cause the same types of respiratory damage as tobacco smoke. Significant associations between marijuana smoking and a variety of respiratory diseases also have been confirmed by an extensive review of clinical literature.


Dr. Brent Moore and colleagues at Yale University, the National Cancer Institute, and the University of Vermont evaluated data from a nationally representative sample of 6,728 adults. Their analysis indicated that a history of more than 100 lifetime episodes of smoking marijuana, with at least one episode in the past month, increased an individual’s risk of chronic bronchitis, coughing on most days, wheezing, chest sounds without a cold, and increased phlegm.

“The most significant difference between tobacco smoke and marijuana smoke is their principal active ingredients—nicotine in tobacco and delta-9-tetrahydrocannabinol (THC) in marijuana. Beyond that, marijuana contains at least as much tar and half again as many carcinogens as smoke from conventional tobacco,” says Dr. Moore. “Quitting marijuana smoking may benefit respiratory health as much as quitting cigarettes, in addition to the clear and considerable health, psychological, and social benefits of no longer abusing an illicit drug.”

The information Dr. Moore and his colleagues analyzed was gathered through the third National Health and Nutrition Examination Survey (NHANES III), conducted between 1988 and 1994. Participants included 4,789 nonsmokers of either tobacco or marijuana; 1,525 smokers of tobacco but not marijuana; 320 smokers of both marijuana and tobacco; and 94 who smoked marijuana only. On average, marijuana abusers had smoked the drug on 10 of the preceding 30 days, with 16 percent reporting daily or almost daily smoking. Tobacco smokers consumed roughly the same number of cigarettes—averaging 19.2 per day—whether or not they also smoked marijuana. Survey participants answered questions about their experiences of a range of respiratory symptoms and were examined for signs of respiratory abnormalities.



The researchers concluded that tobacco smokers who also smoked marijuana had a higher prevalence of most respiratory symptoms than tobacco-only smokers. Compared with tobacco-only smokers, however, those who also smoked marijuana were less likely to have had pneumonia during the previous year or to show spirometric evidence of obstructive pulmonary disorder. Commenting on this finding, Dr. Moore says that it is important to note that the marijuana smokers in the sample were significantly younger (average age 31.2 years) than the tobacco smokers (average age 41.5 years). “The marijuana-related respiratory effects correspond to a relatively young population, and NHANES III did not ask participants older than age 59 about drug use,” he adds. “It is likely that respiratory effects will be higher in older marijuana smokers, and, because of the high prevalence of tobacco use among marijuana smokers, there appears to be an increased risk for illness due to cumulative effects of smoking both drugs.”


Further evidence of marijuana’s respiratory toxicity emerged from a study conducted by Dr. Donald Tashkin at the University of California, Los Angeles. Dr. Tashkin conducted an extensive review of clinical and epidemiological research to determine the extent to which chronic marijuana smoking might lead to long-term pulmonary effects and diseases similar to those caused by tobacco. Unlike the NHANES III data examined by Dr. Moore, the studies evaluated by Dr. Tashkin made it possible to assess a possible association between marijuana smoking and respiratory cancers.

The results of animal and cell culture studies are mixed with respect to the carcinogenic effects of THC, some studies showing that THC promotes lung cancer growth and others showing an anti-tumoral effect on a variety of malignancies. Although the results of epidemiological studies are also mixed, a large, recently completed case-control study has failed to find a direct link between marijuana use (including heavy use) and lung, throat, or other head and neck cancers. “Nevertheless, there is evidence that suggests precarcinogenic effects in respiratory tissue,” Dr. Tashkin says. “Biopsies of bronchial tissue provide evidence that regular marijuana smoking injures airway epithelial cells, leading to dysregulation of bronchial epithelial cell growth and eventually to possible malignant changes.” Moreover, he adds, because marijuana smokers typically hold their breath four times as long as tobacco smokers after inhaling, marijuana smoking deposits significantly more tar and known carcinogens within the tar, such as polycyclic aromatic hydrocarbons, in the airways. In addition to precancerous changes, Dr. Tashkin found that marijuana smoking is associated with a range of damaging pulmonary effects, including inhibition of the tumor-killing and bactericidal activity of alveolar macrophages, the primary immune cells within the lung.

Taken together, Dr. Tashkin’s survey of clinical and epidemiological studies and Dr. Moore’s assessment of self-reported and clinically observed effects provide an extensive catalog of respiratory and pulmonary damage associated with marijuana smoking. Smokers are subject to:

·         Coughing and phlegm production on most days;

·         Wheezing and other chest sounds;

·         Acute and chronic bronchitis;

·         Injury to airway tissue, including edema (swelling), increased vascularity, and increased mucus secretion;    

·         Impaired function of immune system components (alveolar macrophages) in the lungs.

Moore, B.A., et al. Respiratory effects of marijuana and tobacco use in a U.S. sample. Journal of General Internal Medicine 20(1):33-37, 2005. [Full Text]

Tashkin, D.P. Smoked marijuana as a cause of lung injury. Monaldi Archives for Chest Disease 63(2):93-100, 2005. [Abstract]

Hashibe, M., et al. Marijuana use and aerodigestive tract cancers: a population-based case control study. Cancer Epidemiology, Biomarkers & Prevention (In Press).

Source:NIDA Notes > Vol. 21, No. 1  Oct.2006





Fred M. Jacobs, M.D., J.D., Commissioner,
New Jersey Department of Health and Senior Services
August 2007

Dear Dr. Jacobs,

Re: Establishment of Needle and Syringe Programs

I understand that the state of New Jersey is considering a needle and syringe “exchange” program. I am also advised that New Jersey is a liberal democratic society whose members for the most part believe in freedom of the individual to pursue “life, liberty and happiness”. This of course is wonderful! And also provides a useful opportunity to note that no drug addict enjoys real freedom while their will, their lives, their relationships and their resources are largely dedicated to the service and slavery of their chemical addiction. This would make your lovely part of the world an excellent place in which to pursue those liberties which should be the birthright of every human being.

To introduce myself I am a family physician in Australia, and have pursued a special interest in the treatment of addiction especially for heroin, but also other drugs of addiction for the last ten years. Health department figures indicated last year that in the years 2001-2006 I single handedly registered 11,000 of the 14,000 registrations for opiate detoxification in the state of Queensland. I have also attained one of the three largest numbers of naltrexone based rapid opiate detoxifications in the country of Australia with over 1,800 procedures performed including 600 naltrexone implants. This was done with only two overnight hospital admissions which is a world safety record. I have also submitted evidence to several Government committees and leaders on the subject of drug policy.

As the so-called “needle “exchange” programmes” make little effort to exchange syringes, and as actual exchange makes little difference to the operation or mission of the programs, it is probably more accurate to refer to them as needle and syringe distribution programs, or NSP’s. It is important that your community appreciate this because syringe disposal is a real problem with these facilities. It has been so in this country. Our lovely and world famous Bondi beach in Sydney is now said to be one of the best places in the country to get a needle stick injury, due to the many syringes hidden in the sand. Clean up patrols have operated in King’s Cross twice daily for years to clean up the extreme public nuisance of hundreds of used syringes left dangerously in the streets and side walks, to protect the public . This is a well recognized problem with NSP’s which is generally covered up while such programs are in the planning phase.

Epidemiological Evidence

Since the NSP experts readily resort to discussion of “evidence based treatments”, and since the community decision to fully implement this program has such far reaching implications both in terms of needle disposal bins in all public toilets and for the time and direction of public health policy in the management of addiction, it is very appropriate that careful consideration be given to the quality of evidence which is typically cited in support of NSP’s. In particular the evidence based literature waxes lyrical about “levels of [reliability of] evidence.”

Self-report data is widely used in the addiction literature but it has been shown many times to be highly flawed and unreliable, and to fails to correlate with more objective and hard signs of HIV rates. As was pointed out to you by Dr. Fred Payne’s letter, and as was noted in the Institute of Medicine Report on this subject, it is well recognized that most of the literature on the subject of needle exchange is based on self report. This would clearly make it the least reliable form of evidence by their own criteria. Actually one would have to wonder if the evidence based gurus would accept such data at all.

Secondly we are aware of the “ecological” studies where they repeatedly report many cities with and without NSP’s. The work of Dr. Kirsten Kall’s group from the University of Linkoping shows clearly that in such an epidemic the rate of rise of the epidemic is related to the population at risk. Epidemics it is argued have a natural life history with a rise, fall and usually stabilization levels. Depending where in the natural history of the epidemic one takes one’s samples one will get a different picture of the efficacy of the NSP’s. It is for this reason that showing either a rise or a fall in HIV incidence or prevalence after NSP introduction is irrelevant if one is not informed of the natural history of the epidemic, and unless one can adduce by other means the likely outcome in its absence. This is a severe criticism, and one which effectively invalidates the whole of this genre of studies. I am also assured by epidemiologists familiar with such matters, that such studies are given no weight in epidemiological circles for this reason. That they have been foisted upon the rest of the world and even mentioned in major UN reports shows the degree to which such sloppy unscientific methods have been adopted within such agencies.

Indeed Dr. Alex Wodak, understood to be one of the primary authors of the relevant section of the 2006 UNAIDS report which eulogized NSP’s and the harm minimization addiction management paradigm, unequivocally stated in 1995 that formal proof of the methods of harm minimization would be impossible as it would not be possible to control in real life the many confounding factors which would be acting, and thereby prove that any particular intervention alone had been salient in controlling the target disorder .

Furthermore there is a clear conflict of interest by some of the leading proponents of NSP’s . Dr. Alex Wodak was for many years the President of the International Drug Law Reform Foundation and is the current president of the Australian Drug Reform Foundation which lobbies unceasingly for drug decriminalization. Dr. Don Jaralais in the USA is also understood to be of a similar ideology, and his advocacy for NSP’s is well known. I am of the understanding that such parallels could be made repeatedly for many of the most ardent advocates of NSP’s.

Dr. Payne’s letter mentions the very high rates of HIV in Vancouver at present despite the operation of an NSP, having risen from 1% to 35%. It was also shown long ago in Montréal that the HIV rate amongst NSP attendees was 2.5 times that amongst non-attendees (3.1 Vs. 7.9%) .

In terms of its control of other virus transmission NSP’s seem to substantially lack power. They failed to control Hepatitis B in Amsterdam , or Hepatitis C in Australia where rates of HCV carriage amongst IVDU who have been involved in the lifestyle for longer than six months exceed 80%.

Special Situations

Some situations are special and require special consideration. We are well aware that the apparent success of harm minimization techniques in this country is frequently cited overseas and in international fora as proof of principal of the efficacy of harm minimization epidemic management techniques. What is repeatedly overlooked in such discussions is our record rates of other infections such as Hepatitis B and C, and the venereally transmitted agents Herpes, Warts and Chlamydia. Indeed recently released data shows 30-100% growth in the last five years in Queensland in Gonorrhea, Hepatitis C, Chlamydia and Syphilis . Indeed it has been estimated that the Australian health care system has now to plan for over 100,000 liver transplants required for Hepatitis C alone in the next 20 years. One also notes that the outcome after transplantation for Hepatitis C is inferior to that for other infections due to the universal early graft re-infection which invariably occurs in the first few post-operative days, and the clash between anti-rejection immunosuppressive therapy and the anti-viral needs of fighting an aggressive viral infection in the context of the immuno-suppression and likely immuno-senescence induced by drug addiction, which is reversed to an unknown extent by abstinence.

In Australia our HIV rate amongst IVDU who do not share other risk factors is very low by international standards of the order of 1%. New cases of HIV nationally in all groups have risen from about 100 in 1991 to around 300 in 2005 . There appears to be significant variation in the estimates for the number of syringes distributed to addicts in this country with estimates varying from 20,000,000 to 200,000,000 – a level of inexactitude which in itself should give us pause. The former number was more than our total population at the time, and the latter number is substantially greater than the number of sheep here (which says a lot for a nation which for a long time was said to ride on the sheep’s back!) One important feature then facing the advocates of any NSP program is exactly how many syringes do they want to distribute? One for every man woman and child in the state?

However in the case of Australia we would do well to heed Wodak’s warnings about the inability to control for other confounders. From a modeling point of view the epidemic began in certain well known high risk groups. Its spread would then have been related to the population at risk, the activity of the various risk taking behaviours, and the intersection of these behaviors with the wider general community. Still today over half of all HIV infections in this country occur amongst men who have sex with men. It should also be added that the rate of IVDU in this group is 10-20 times higher than it is in the general community. Clearly then the spread of the disease into the wider community is related to the behaviour of this reservoir of infected people. One of the obvious confounding factors which has never been studied or quantified is what might be termed the homosexualization of the Australian culture with many laws, many bureaucracies, and schools of public health completely subsumed by the new ideology accompanying the public health impetus of the HIV epidemic. In that this likely instilled major good will in the primary target community, and is likely to have very positively influenced the relevant risk taking behaviours, it is clearly an intimate confound which confuses and likely dilutes any effects which might be attributable strictly to NSP’s.

Another important confounding factor was that Australia made treatment for HIV free to all patients who would have benefited from it from the outset of the epidemic. Assuming that the most at risk individuals were infected near the beginning of the epidemic, then those that survived their infection might reasonably be expected to have had a lower viral load for most of this time making them les infectious. This can be expected to have significantly slowed the rate of progression of the epidemic in this country.

Sweden is an important case in point which must be mentioned in any intelligent discussion of the NSP movement. Sweden has very limited methadone treatment availability, until recently no NSP activity, and no legal “shooting galleries” and a very low rate of HIV in IVDU. Hence the methods of harm minimization cannot strictly be said to be required for HIV control. Clearly HIV control can occur in a very effective manner in the absence of the model harm minimalist strategies.

The situation in prisons, or penitentiaries, is a special one and well worth at least some specific consideration. I was privileged to give evidence to the Inquiry into the Impact of Illicit Drug Use on Families before the Federal House of Representatives of the Australian Parliament on 3rd April 2007 . During that interview I stated that “my blood ran cold at the thought of 500 inmates all sharing the same syringe barrel” as was recounted to me by one of my HIV positive patients. However typical harm minimalist solutions such as methadone, syringe distribution and bleach use have been found to be impractical in the prison environment, and in this country have triggered strikes and industrial disputes by the prison warders due to the creation of unsafe workplaces. Since making those comments to the committee I have considered what might best be done about this appalling situation. One approach follows below (see “Other Treatment Modalities”).

In essence it is my belief that where the crime for which a person is committed is referable to opiate drugs, the standard of care will become naltrexone implant insertion on admission to the jail (after appropriate detoxification procedures), naltrexone implant maintenance during incarceration, and naltrexone implant prior to discharge to prevent the overdose which so often accompanies discharge (and the ritualistic “get a whack, get a woman” routine which is invariably followed). Indeed in Perth patients discharged from the prison are taken by volunteer escort from the prison gates to the clinic for implantation before the whole destructive cycle can re-commence. This seems the most sensible, responsible and compassionate management of this problem.

Other Treatment Modalities

Naltrexone was fist synthesized in the USA 1963 at Endo laboratory by Matossian acting under Blumberg’s instruction . Naltrexone implants and depot preparations have recently received a lot of attention from the international addiction management literature, and have been commercially introduced in the USA. American developed depot injections typically last 3-4 weeks. A preparation recently developed in this country lasts typically 4-6 months. The results of the first formal clinical trial conducted in Perth will soon be announced, probably in a leading medical journal such as JAMA or New England Medical Journal. They have been extensively used in this clinic where we have inserted over 600 USA (Wedgewood) and Australian (Perth “Go Medical”) implants. I was asked by the Preventative and Community Medicine Committee of the Queensland Faculty of the Royal Australian College of General Practitioners to evaluate naltrexone medicine including the Perth naltrexone program in 1998, and since 2001 I have been involved with the development in Perth of their naltrexone implant.

Unofficially the abstinence rate in terms of not returning to dependent heroin use at five months was well in excess of 50% in a study which set new standards international medical literature for patient follow-up. Only 11% of the 70- patients were lost to follow-up compared to over 90% in a similar (larger) study conducted in leading centres in the USA reported by Hollister in 1977 for NIDA at the NIH . Naltrexone is also a widely recognized and used technique for reducing problem drinking in alcoholics. It has also been used for gambling addiction, with positive results on some occasions. Moreover other results reported from the Perth clinic indicate that naltrexone is likely to have a controlling effect on other chemical addiction such as benzodiazepines, cannabis and stimulants such as amphetamines.

It is my personal view that they are excellent and will soon revolutionize the treatment of opiate addiction. Opiate dependence of course is the most addictive and refractory of all drug addictions, and the possibility of gaining control of such patients in a drug free context, as opposed to the usual medical model involving the indefinite maintenance of addiction, must be one of the most exciting opportunities ever to be offered to physicians in addiction medicine.

Another medical agent which has shown enormous promise in the control of multiple addictions is the cannabinoid antagonist rimonabant (“Accomplia”; SR141716A) which has been used with success against opiate, tobacco, alcohol, amphetamine food and cocaine addictions. This drug has attracted attention from NIDA and is undergoing further testing. I am not sure what its regulatory status is in the USA. It was available in eight European nations when I enquired with the pharmaceutical company (Sanofi-Synthelabo) about four months ago. The drug is still under patent, so this impedes its being re-formulated into an implant or depot preparation.

The combination of naltrexone and rimonabant has yet to be tested but would appear to show obvious promise, and it would be a priority in a rational testing program to investigate this further.

Future Research Directions

Many studies show increased evidence of drug use in young people.

All senior authorities in the world agree that there is far too little resources put towards investigating the toxicological effects of addictive drugs in general, and in adolescents in particular.

If we are ever going to do more than shut the door after the horse has bolted, clearly the issue of the true toxicity of addiction must be much better investigated, and the results of such studies broadcast far and wide to our young people, to de-glamourize the dreadfully seductive marketing program to which the rock music and popular culture misleadingly subjects them. If we are ever going to contain the monster of rampant destructive drug use in our younger people, then their dangers must be better emphasized.

Given the obvious multi-system damage of long term chemical addiction which is immediately apparently to even the untrained observer, one can only conclude which a Science which espouses the relative benignity of addiction must be grossly and egregariously deficient.

I have formulated a detailed plan by which such a strategy can be put in place, based around the accumulated ageing changes evident in the skin, teeth, hair, blood vessels, bones, immune system, stem cells and brains of addicts. It invites international collaboration and multi-system multilevel cooperation and the application of state of the art techniques to classical clinical problems. That however, is another story.


In summary NSP’s incur great social cost and are clearly part of the problem rather than part of the solution. Their scientific literature is remarkable for its lack of compelling evidence and methodological rigor, not to mention the prominence of adverse findings, when properly adjudicated. Rather the global penetration of NSP’s is an indicator of the strength of the marketing strategy of the ideology they enshrine. They are in any case about to be phased out like old dinosaurs by the cutting edge technologies which are moving ever closer to being a real market alternative, particularly the revolutionary long lasting Australian naltrexone implant.

I have been advised that now methadone is worth $150/week to dispensing hospitals in Federal hospital subsidies. As some of the most famous institutions in the USA have 10,000 – 20,000 patients enrolled on it, this income source forms a major stream of hospital funding. As such it is not likely to be disrupted. What the management of the Australian HIV epidemic does teach us is that it is best to get on and treat the HIV infection as soon as medically appropriate. In addiction medicine we have up until now largely done the reverse, for there we have deliberately continued indefinitely maintenance treatment designed to not to confront the addicted physiology, but rather to postpone indefinitely the definitive redress of that medical condition. The Australian success with HIV management tends to rather emphasize the reverse approach. This is the therapeutic route suggested by naltrexone implant maintenance. In all the discussion we would appear to have forgotten that in the early 1960’s New York was in urgent need of a treatment for addicted GI’s returning home from Vietnam. Methadone as the only medical solution then available was adopted and quickly came to command tremendous official support to the point where it became in time, the established industry. We have now a far more exciting opportunity to launch naltrexone implants and other new treatments in a similar and innovative manner. In would be my sincere hope that nations can move speedily to deliver proven and safe medical treatments to vulnerable populations without incurring undue, unnecessary and officious regulatory obstruction.

This would appear to be the visionary, drug free and health enhancing approach. As these concepts are more widely understood it is hoped that regulators and administrators will cooperate to mobilize international best medical practice on behalf of those with whose care they have been entrusted. I would invite the legislators of New Jersey to work with us on these issues of major cultural importance.

Yours Sincerely,

A. Stuart Reece, MBBS (Hons.), FRCS (Ed.), FRCS (Glas.), MD, FRACGP.
Family Physician, Highgate Hill Brisbane,
Senior Lecturer, Medical School, University of Queensland,
Fellow, Drug Watch International,
Fellow, Drug Free Australia,
Member, Society for Neuroscience,
Member, International Cannabinoid Research Society,
Attendee, College of the Problems of Drug Dependence Conferences 2002-2006.
Awardee, National Institute of Drug Abuse, International, 2003, 2004, 2006.

Abstainers Are Not Maladjusted, but Lone Users Face Difficulties

Key findings:
• Although some consider experimenting with marijuana normal behavior for adolescents, those adolescents who abstain are not maladjusted as others have reported.
• Young abstainers do better than experimenters into young adulthood.
• Even strict abstainers — youth who avoid all drugs — fare well in life.
• Solitary substance use is not uncommon among youth.
• Young solitary users are an overlooked at-risk group who face a wide range of psychosocial and behavioral difficulties as teens and young adults.

A lot of adolescents experiment with marijuana — the National Institute on Drug Abuse estimates that 46% of high school seniors have tried this drug at some time. Pushing boundaries is what young people do, and some researchers believe that trying marijuana is a normal part of growing up. Does that mean that young people who do not indulge are somehow maladjusted?

Jonathan Shedler and Jack Block[1] raised this possibility in a report in 1990. They suggested that adolescents who experimented with marijuana were better adjusted emotionally and socially than their counterparts who avoided all drugs. Specifically, abstainers were observed to be anxious, emotionally constricted, and lacking in social skills compared with experimenters. Not surprisingly, these findings caused widespread comment in the drug-prevention community.

Now, RAND Corporation researchers have revisited Shedler and Block’s classic study and have uncovered evidence that challenges those initial findings. Kids who abstained from marijuana through the last year of high school were not socially or emotionally troubled. And they had better outcomes as young adults.

A second study looked at a largely ignored group of adolescents: kids who go off by themselves to use marijuana and other harmful substances. The researchers documented a wide range of psychosocial and behavioral difficulties faced by youth who use harmful substances while alone, rather than only in social settings like parties. And the troubles followed them into young adulthood.

For policymakers, these two studies help clarify the picture of youthful marijuana use: Marijuana abstainers do well, solitary users do poorly, and kids who use marijuana only in social settings are in between.

Digging for Clues About Youthful Marijuana Use
To re-examine the provocative findings of Shedler and Block, the RAND researchers, led by Joan Tucker, a social psychologist, mined a wealth of data on youthful substance use accumulated since 1985 by the RAND Adolescent/Young Adult Panel Study. This database contains survey responses from thousands of individuals who answered questions about their use of harmful substances, about their social and emotional well-being and behavior, and about school. The survey was given in grades 7, 8, 9, 10, and 12, and again at ages 23 and 29. The database was used to evaluate the effectiveness of the Project ALERT drug use prevention program that RAND developed for middle-school students. For their study, the researchers examined responses to the surveys given in 12th grade and at age 23. They divided the responders into abstainer and experimenter categories, which replicate as closely as possible those used in the 1990 Shedler and Block study:

Abstainers — those who had never tried marijuana or any other illicit drug.

Experimenters — those who had used marijuana less than 10 times in the year before being surveyed and less than three times in the preceding month, and none or only one other illicit drug in their lifetime.

A different picture emerges of youth and marijuana
From their analyses of survey responses, the RAND researchers pieced together a picture of marijuana abstainers and experimenters as teens and as young adults that contradicts that painted by earlier studies. Their key findings, some of which are shown in the figure, include

Youth who stayed away from marijuana through their senior year of high school functioned better overall than did seniors who experimented with the drug. Compared with experimenters, abstainers

• had more parental support
• devoted more time to homework
• spent more time in extracurricular school activities
• earned better grades
• got into less trouble
• were emotionally better off.

Both groups were similar in that

• on average, they rarely felt lonely
• they reported similar levels of peer support and ease in interacting with the opposite sex.

The one exception was that,

• although abstainers were socially active, they went to parties and dances significantly less frequently than did experimenters.

By the time they turned 23, those who had avoided marijuana in high school functioned better overall as young adults than those who had experimented with it in their youth. Compared with experimenters, abstainers

• were better educated
• were happier with their friends
• were less involved in deviant behavior (stealing and drug selling).

Both groups were similar in that

• they showed no differences in their satisfaction with family life and with general mental health, or with limitations due to emotional problems.

The emotional and social well-being of strict marijuana abstainers — those who had tried neither marijuana nor cigarettes and had not used alcohol in the past year — was also compared with that of experimenters, both in high school and as young adults:

• Even this more-stringent subgroup of marijuana abstainers did not show the adjustment problems suggested by earlier studies.

Why did two different pictures emerge?
The conflicting findings may be due to methodological factors. For example, the RAND team examined longitudinal data for more than 3,000 individuals who were originally recruited from 30 California and Oregon schools. These schools were chosen to represent a wide range of community types, socioeconomic status, and racial/ethnic composition. Thus, the RAND sample was considerably larger and more diverse than the 100 or so youth from the San Francisco Bay area whom Shedler and Block followed.

Young Solitary Substance Users: An Overlooked, At-Risk Group
Surprisingly little research looks at t