Drug use-various effects

May 29, 2024  Contact: Kristen Govostes  Phone Number: (617) 557-2100

BOSTON – The U.S. Drug Enforcement Administration’s New England Field Division will team up with college esports teams from across New England to host the first of its kind, hybrid One Pill Can Kill Game Over Tournament. This event aims to meet a critical moment in time by using the esports platform to help educate young people about the dangers of fentanyl.

Twenty-two teenagers between the ages of 14 and 18 die every week from a drug poisoning or overdose death, according to a recent study by the New England Journal of Medicine.  To more effectively reach this important audience, DEA has teamed up with actress, founder of the Devon Michael Foundation, and influencer Ava Michelle and eight esports teams across the region to take an innovative new approach to fentanyl outreach and awareness.  With an overwhelming 97% of Americans between the ages of 12 and 17 engaged in video gaming, DEA is looking to reach young people where they often spend time – in the virtual world.

The One Pill Can Kill Game Over Tournament will be hosted by Clark University Esports on Thursday, June 6, 2024, from 7 to 9 p.m. ET on Twitch (twitch.tv/onepillcankill).  Access to view the tournament will also be available at DEA One Pill Can Kill Game Over Tournament | DEA.gov.  Joining Clark University for this Rocket League battle will be esports teams from Worcester Polytechnic Institute, University of Massachusetts Amherst, Boston University, Emerson College, Post University, University of New Hampshire, and the University of Southern Maine.

DEA will host an in-person pre-tournament program and live gameplay for invited guests at the state-of-the-art gaming center, All Systems Go, on Thursday, June 6, 2024, beginning at 4:30 p.m. Attendees will include high school aged students, community groups and dignitaries.  Media should plan to arrive around 5:45 p.m. for b-roll opportunities ahead of the press event, which will include remarks from DEA Associate Administrator Jon DeLena, Worcester County Sheriff Lew Evangelidis, Ava Michele and more. All Systems Go gaming center is located at 225 Shrewsbury Street, Worcester, Mass., 02604.

Fentanyl is a synthetic opioid, which is now involved in a majority of drug poisonings and overdose deaths.  Fentanyl is 50 times more potent than heroin, and just two milligrams – the amount that can fit on the tip of a pencil – can be deadly.  Often, people buy what they think is a legitimate prescription pill like Percocet or Xanax on social media, but it turns out, they’ve unknowingly purchased a fentanyl pill.  DEA laboratory testing indicates 7 out of 10 fentanyl pills seized contain a potentially deadly dose.  In 2023, DEA seized approximately 15.7 million potentially lethal doses of fentanyl in New England alone.

“I am thrilled we are able to team up with these amazing esports teams to host this One Pill Can Kill Game Over Tournament in New England and increase awareness about the dangers of fentanyl,” said DEA Associate Administrator Jon DeLena. “This event is extremely personal to me.  I know how much my own kids enjoy playing video games, so knowing they are also learning valuable, life-saving information while doing what they love is so important. I want to encourage any family with a gamer to join us – either virtually or in-person – watch the competition and then talk about what you’ve learned. It could be the most important talk you have as a family.”

“Connecting with people in an environment where they are having fun and are open to learning has been an incredible experience. Raising awareness and providing education about the fentanyl epidemic is absolutely crucial—I genuinely believe we are saving lives.” –  Ava Michelle Cota, Actress, and Founder, Devon Michael Foundation.

The One Pill Can Kill Game Over Tournament in New England will be the third tournament in this series.  The first tournament was held in the DEA’s New Orleans Field Division in January and reached more than 285,500 viewers. The second tournament was hosted by DEA Philadelphia in March and was viewed by more than 146,800. B-roll and soundbites from the previous events is available here. The New England event is the first to offer an in-person outreach event ahead of the tournament.

DEA would like to thank the participating teams, All Systems Go, The Rendon Group, and the esports community for their involvement and support of DEA’s One Pill Can Kill Game Over Tournaments.

 

Drug Enforcement Administration

Stephen Belleau, Acting Special Agent in Charge – New England

@DEANewEngland

Source: https://www.dea.gov/press-releases/2024/05/29/dea-brings-its-one-pill-can-kill-game-over-tournament-new-england-first

Associate Professor | Department Chair | Director, Forensic Science Research Center

Department of Criminal Justice, California State University

The opioid epidemic is a public health and safety emergency that is killing thousands and destroying the quality of life for hundreds of thousands of Americans and those who care about them. Fentanyl and other opioids affect all age ranges, ethnicities, and communities, including our most vulnerable population, children. Producing fentanyl is increasingly cheap, costing pennies for a fatal dose, with the opioid intentionally or unintentionally mixed with common illicit street drugs and pressed into counterfeit pills. Fentanyl is odorless and tasteless, making it nearly untraceable when mixed with other drugs. Extremely small doses of fentanyl, roughly equivalent to a few grains of salt, can be fatal, while carfentanil, a large animal tranquilizer, is 100 times more potent than fentanyl and fatal at an even smaller amount.

The Biden-Harris Administration should do even more to fund opioid-related prevention, treatment, eradication, and interdiction efforts to save lives in the United States. The 2022 Executive Order to Address the Opioid Epidemic and Support Recovery awarded $1.5 billion to states and territories to expand treatment access, enhance services in rural communities, and fund law enforcement efforts. In his 2023 State of the Union address, President Biden highlighted reducing opioid overdoses as part of his bipartisan Unity Agenda, pledging to disrupt trafficking and sales of fentanyl and focus on prevention and harm reduction. Despite extensive funding, opioid-related overdoses have not significantly decreased, showing that a different strategy is needed to save lives.

Opioid-related deaths have been estimated cost the U.S. nearly $4 trillion over the past seven years—not including the human aspect of the deaths. The cost of fatal overdoses was determined to be $550 billion in 2017. The cost of the opioid epidemic in 2020 alone was an estimated $1.5 trillion, up 37% from 2017. About two-thirds of the cost was due to the value of lives lost and opioid use disorder, with $35 billion spent on healthcare and opioid-related treatments and about $15 billion spent on criminal justice involvement. In 2017, per capita costs of opioid use disorder and opioid toxicity-related deaths were as high as $7247, with the cost per case of opioid use disorder over $221,000. With inflation in November 2023 at $1.26 compared to $1 in 2017, not including increases in healthcare costs and the significant increase in drug toxicity-related deaths, the total rate of $693 billion is likely significantly understated for fatal overdoses in 2023. Even with extensive funding, opioid-related deaths continue to rise.

With fatal opioid-related deaths being underreported, the Centers for Disease Control and Prevention (CDC) must take a primary role in real-time surveillance of opioid-related fatal and non-fatal overdoses by funding expanded toxicology testing, training first responder and medicolegal professionals, and ensuring compliance with data submission. The Department of Justice (DOJ) should support enforcement efforts to reduce drug toxicity-related morbidity and mortality, with the Department of Homeland Security (DHS) and the Department of the Treasury (TREAS) assisting with enforcement and sanctions, to prevent future overdoses. Key recommendations for reducing opioid-related morbidity and mortality include:

  • Funding research to determine the efficacy of current efforts in opioid misuse reduction and prevention.
  • Modernizing data systems and surveillance to provide real-time information.
  • Increasing overdose awareness, prevention education, and availability of naloxone.
  • Improve training of first responders and medicolegal death investigators.
  • Funding rapid and thorough toxicology testing in emergency departments and coroner/medical examiner agencies.
  • Enhancing prevention and enforcement efforts.

Challenge And Opportunity

Opioids are a class of drugs, including pain relievers that can be illegally prescribed and the illicit drug heroin. There are three defined waves of the opioid crisis, starting in the early 1990s as physicians increasingly prescribed opioids for pain control. The uptick in prescriptions stemmed from pharmaceutical companies promising physicians that these medications had low addiction rates and medical professionals adding pain levels being added to objective vital signs for treatment. From 1999 to 2010, prescription opioid sales quadrupled—and opioid-related deaths doubled. During this time frame when the relationship between drug abuse and misuse was linked to opioids, a significant push was made to limit physicians from prescribing opioids. This contributed to the second wave of the epidemic, when heroin abuse increased as former opioid patients sought relief. Heroin-related deaths increased 286% from 2002 to 2013, with about 80% of heroin users acknowledging that they misused prescription opioids before using heroin.  The third wave of the opioid crisis came in 2013 with an increase in illegally manufactured fentanyl, a synthetic opioid used to treat severe pain that is up to 100 times stronger than morphine, and carfentanil, which is 100 times more potent than fentanyl.

In 2022, nearly 110,000 people in the United States died from drug toxicity, with about 75% of the deaths involving opioids. In 2021, six times as many people died from drug overdoses as in 1999, with a 16% increase from 2020 to 2021 alone. While heroin-related deaths decreased by over 30% from 2020 to 2021, opioid-related deaths increased by 15%, with synthetic opioid-involved deaths like fentanyl increasing by over 22%. Over 700,000 people have died of opioid-related drug toxicity since 1999, and since 2021 45 people have died every day from a prescription opioid overdose. Opioid-related deaths have increased tenfold since 1999, with no signs of slowing down. The District of Columbia declared a public emergency in November 2023 to draw more attention to the opioid crisis.

In 2023, we are at the precipice of the fourth wave of the crisis, as synthetic opioids like fentanyl are combined with a stimulant, commonly methamphetamine. Speedballs have been common for decades, using stimulants to counterbalance the fatigue that occurs with opiates. The fatal combination of fentanyl and a stimulant was responsible for just 0.6% of overdose deaths in 2010 but 32.3% of opioid deaths in 2021, an over fifty-fold increase in 12 years. Fentanyl, originally used in end-of-life and cancer care, is commonly manufactured in Mexico with precursor chemicals from China. Fentanyl is also commonly added to pressed pills made to look like legitimate prescription medications. In the first nine months of 2023, the Drug Enforcement Agency (DEA) seized over 62 million counterfeit pills and nearly five tons of powdered fentanyl, which equates to over 287 million fatal doses. These staggering seizure numbers do not include local law enforcement efforts, with the New York City Police Department recovering 13 kilos of fentanyl in the Bronx, enough powder to kill 6.5 million people. 

The ease of creating and trafficking fentanyl and similar opioids has led to an epidemic in the United States. Currently, fentanyl can be made for pennies and sold for as little as 40 cents in Washington State. The ease of availability has led to deaths in our most vulnerable population—children. Between June and September 2023, there were three fatal overdoses of children five years and younger in Portland, OR. In a high-profile case in New York City, investigators found a kilogram of fentanyl powder in a day care facility after a 1-year-old died and three others became critically ill.

The Biden Administration has responding to the crisis in part by placing sanctions against and indicting executives in Chinese companies for manufacturing and distributing precursor chemicals, which are commonly sold to Mexican drug cartels to create fentanyl. The drug is then trafficked into the United States for sale and use. There are also concerns about fentanyl being used as a weapon of mass destruction, similar to the anthrax concerns in the early 2000s.

The daily concerns of opioid overdoses have plagued public health and law enforcement professionals for years. In Seattle, WA, alone, there are 15 non-fatal overdoses daily, straining the emergency medical systems. There were nearly 5,000 non-fatal overdoses in the first seven months of 2023 in King County, WA, an increase of 70% compared to 2022. In a landmark decision, in March 2023 the Food and Drug Administration (FDA) approved naloxone, a drug to reverse the effects of opioid overdoses, as an over-the-counter nasal spray in an attempt to reduce overdose deaths. Naloxone nasal spray was initially approved for prescription use only in 2015 , significantly limiting access to first responders and available to high-risk patients when prescribed opioids. In New York, physicians have been required to prescribe naloxone to patients at risk of overdose since 2022. Although naloxone is now available without a prescription, access is still limited by price, with one dose costing as much as $65, and some people requiring more than one dose to reverse the overdose. Citing budget concerns, Governor Newsom vetoed California’s proposed AB 1060, which would have limited the cost of naloxone to $10 per dose. Fentanyl testing strips that can be used to test substances for the presence of fentanyl before use show promise in preventing unwanted fentanyl-adulterated overdoses. The Expanding Nationwide Access to Test Strips Act, which was introduced to the Senate in July 2023, would decriminalize the testing strips as an inexpensive way to reduce overdose while following evidence-based harm-reduction theories.

Illicit drugs are also one of the top threats to national security. Law enforcement agencies are dealing with a triple epidemic of gun violence, the opioid crisis, and critical staffing levels. Crime prevention is tied directly to increased police staffing, with lower staffing limiting crime control tactics, such as using interagency task forces, to focus on a specific crime problem. Police are at the forefront of the opioid crisis, expected to provide an emergency response to potential overdoses and ensure public safety while disrupting and investigating drug-related crimes. Phoenix Police Department seized over 500,000 fentanyl pills in June 2023 as part of Operation Summer Shield, showing law enforcement’s central role in fighting the opioid crisis. DHS created a comprehensive interdiction plan to reduce the national and international supply of opioids, working with the private sector to decrease drugs brought into the United States and increasing task forces to focus on drug traffickers.

Prosecutors are starting to charge drug dealers and parents of children exposed to fentanyl in their residences in fatal overdose cases. In an unprecedented action, Attorney General Merrick Garland recently charged Mexican cartel members with trafficking fentanyl and indicting Chinese companies and their executives for creating and selling precursor chemicals. In November 2023, sanctions were placed against the Sinaloa cartel and four firms from Mexico suspected of drug trafficking to the United States, removing their ability to legally access the American banking system. Despite this work, criminal justice-related efforts alone are not reducing overdoses and deaths, showing a need for a multifaceted approach to save lives.

While these numbers of opioid overdoses are appalling, they are likely underreported. Accurate reporting of fatal overdoses varies dramatically across the country, with the lack of training of medicolegal death investigators to recognize potential drug toxicity-related deaths, coupled with the shortage of forensic pathologists and the high costs of toxicology testing, leading to inaccurate cause of death information. The data ecosystem is changing, with agencies and their valuable data remaining disjointed and unable to communicate across systems. A new model could be found in the CDC’s Data Modernization Initiative, which tracked millions of COVID-19 cases across all states and districts, including data from emergency departments and medicolegal offices. This robust initiative to modernize data transfer and accessibility could be transformative for public health. The electronic case reporting system and strong surveillance systems that are now in place can be used for other public health outbreaks, although they have not been institutionalized for the opioid epidemic.

Toxicology testing can take upwards of 8–10 weeks to receive, then weeks more for interpretation and final reporting of the cause of death. The CDC’s State Unintentional Drug Overdose Reporting System receives data from 47 states from death certificates and coroner/medical examiner reports. Even with the CDC’s extensive efforts, the data-sharing is voluntary, and submission is rarely timely enough for tracking real-time outbreaks of overdoses and newly emerging drugs. The increase of novel psychoactive substances, including the addition of the animal tranquilizer xylazineto other drugs, is commonly not included in toxicology panels, leaving early fatal drug interactions undetected and slowing notification of emerging drugs regionally. The data from medicolegal reports is extremely valuable for interdisciplinary overdose fatality review teams at the regional level that bring together healthcare, social services, criminal justice, and medicolegal personnel to review deaths and determine potential intervention points. Overdose fatality review teams can use the data to inform prevention efforts, as has been successful with infant sleeping position recommendations formed through infant mortality review teams.

Plan Of Action

Reducing opioid misuse and saving lives requires a multi-stage, multi-agency approach. This includes expanding real-time opioid surveillance efforts; funding for overdose awareness, prevention, and education; and improved training of first responders and medicolegal personnel on recognizing, responding to, and reporting overdoses. Nationwide, improved toxicology testing and reporting is essential for accurate reporting of overdose-involved drugs and determining the efficacy of efforts to combat the opioid epidemic.

Agency Role
Department of Education (ED) ED creates policies for educational institutions, administers educational programs, promotes equity, and improves the quality of education.

ED should increase resources for creating and implementing evidence-based preventative education for youth and provide resources for drug misuse with access to naloxone.

Department of Justice (DOJ) DOJ is responsible for keeping our country safe by upholding the law and protecting civil rights. The DOJ houses the Office of Justice Programs and the Drug Enforcement Agency (DEA), which are instrumental in the opioid crisis.

DOJ should be the principal enforcement agency, with the DEA leading drug-related enforcement actions. The Attorney General should continue to initiate new sanctions and a wider range of indictments to assist with interdiction and eradication efforts.

Department of Health and Human Services (HHS) HHS houses the Centers for Disease Control and Prevention (CDC), the nation’s health protection and preventative agency, and collects and analyzes vital data to save lives and protect people from health threats.

The CDC should be the primary agency to focus on robust real-time opioid-related overdose surveillance and fund local public health departments to collect and submit data. HHS should fund grants to enhance community efforts to reduce opioid-related overdoses and provide resources and outreach to increase awareness.

Department of Homeland Security (DHS) DHS focuses on crime prevention and safety at our borders, including interdiction and eradication efforts, while monitoring security threats and strengthening preparedness.

DHS should continue leading international investigations of fentanyl production and trafficking. Additional funding should be provided to allow DHS and its investigative agencies to focus more on producers of opioids, sales of precursors, and trafficking to assist with lessening the supply available in the United States.

Department of the Treasury (TREAS) TREAS is responsible for maintaining financial infrastructure systems, collecting revenue and dispersing payments, and creating international economic policies.

TREAS should continue efforts to sanction countries producing precursors to create opioids and trafficking drugs into the U.S. while prohibiting business ties with companies participating in drug trades. Additional funding should be available to support E.O. 14059 to counter transnational organized crime’s relation to illicit drugs.

Bureau of Prisons (BOP) The BOP provides protection for public safety by providing a safe and humane facility for federal offenders to serve their prescribed time while providing appropriate programming for reentry to ease a transition back to communities.

The BOP should provide treatment for opioid use disorders, including the option for medication-assisted treatment, to assist in reducing relapse and overdoses, coupled with intensive case management.

State Department (DOS) The DOS spearheads foreign policy by creating agreements, negotiating treaties, and advocating for the United States internationally.

The DOS should receive additional funding to continue to work with the United Nations to disrupt the trafficking of drugs and limit precursors used to make illicit opioids. The DOS also assists Mexico and other countries fight drug trafficking and production.

Recommendation 1. Fund research to determine the efficacy of current efforts in opioid misuse reduction and prevention.

DOJ should provide grant funding for researchers to outline all known current efforts of opioid misuse reduction and prevention by law enforcement, public health, community programs, and other agencies. The efforts, including the use of suboxone and methadone, should be evaluated to determine if they follow evidence-based practices, how the programs are funded, and their known effect on the community. The findings should be shared widely and without paywalls with practitioners, researchers, and government agencies to hone their future work to known successful efforts and to be used as a foundation for future evidence-based, innovative program implementation.

Recommendation 2. Modernize data systems and surveillance to provide real-time information.

City, county, regional, and state first responder agencies work across different platforms, as do social service agencies, hospitals, private physicians, clinics, and medicolegal offices. A single fatal drug toxicity-related death has associated reports from a law enforcement officer, fire department personnel, emergency medical services, an emergency department, and a medicolegal agency. Additional reports and information are sought from hospitals and clinics, prior treating clinicians, and social service agencies. Even if all of these reports can be obtained, data received and reviewed is not real-time and not accessible across all of the systems.

Medicolegal agencies are arguably the most underprepared for data and surveillance modernization. Only 43% of medicolegal agencies had a computerized case management system in 2018, which was an increase from 31% in 2004. Outside of county or state property, only 75% of medicolegal personnel had internet access from personal devices. The lack of computerized case management systems and limited access to the internet can greatly hinder case reporting and providing timely information to public health and other reporting agencies.

With the availability and use of naloxone by private persons, the Public Naloxone Administration Dashboard from the National EMS Information System (NEMSIS) should be supported and expanded to include community member administration of naloxone. The emergency medical services data can be aligned with the anonymous upload of when, where, and basic demographics for the recipient of naloxone, which can also be made accessible to emergency departments and medicolegal death investigation agencies. While the database likely will not be used for all naloxone administrations, it can provide hot spot information and notify social services of potential areas for intervention and assistance. The database should be tied to the first responder/hospital/medicolegal database to assist in robust surveillance of the opioid epidemic.

Recommendation 3. Increase overdose awareness, prevention education, and availability of naloxone.

Awareness of the likelihood of poisoning and potential death from the use of fentanyl or counterfeit pills is key in prevention. The DEA declared August 21 National Fentanyl Prevention and Awareness Day to increase knowledge of the dangers of fentanyl, with the Senate adopting a resolution to formally recognize the day in 2023. Many states have opioid and fentanyl prevention tactics on their public health websites, and the CDC has educational campaigns designed to reach young adults, though the education needs to be specifically sought out. Funding should be made available to community organizations and city/county governments to create public awareness campaigns about fentanyl and opioid usage, including billboards, television and streaming ads, and highly visible spaces like buses and grocery carts.

ED allows evidence-based prevention programs in school settings to assist in reducing risk factors associated with drug use and misuse. The San Diego Board of Supervisors approved a proposal to add education focused on fentanyl awareness after 12 juveniles died of fentanyl toxicity in 2021. The district attorney supported the education and sought funding to sponsor drug and alcohol training on school campuses. Schools in Arlington, VA, note the rise in overdoses but recognize that preventative education, when present, is insufficient. ED should create prevention programs at grade-appropriate levels that can be adapted for use in classrooms nationwide.

With the legalization of over-the-counter naloxone, funding is needed to provide subsidized or free access to this life-saving medication. Powerful fentanyl analogs require higher doses of naloxone to reverse the toxicity, commonly requiring multiple naloxone administrations, which may not be available to an intervening community member. The State of Washington’s Department of Public Health offers free naloxone kits by mail and at certain pharmacies and community organizations, while Santa Clara University in California has a vending machine that distributes naloxone for free. While naloxone reverses the effects of opioids for a short period, once it wears off, there is a risk of a secondary overdose from the initial ingestion of the opioid, which is why seeking medical attention after an overdose is paramount to survival. Increasing access to naloxone in highly accessible locations—and via mail for more rural locations—can save lives. Naloxone access and basic training on signs of an opioid overdose may increase recognition of opioid misuse and empower the community to provide immediate, lifesaving action.

However, there are concerns that naloxone may end up in a shortage. With its over-the-counter access, naloxone may still be unavailable for those who need it most due to cost (approximately $20 per dose) or access to pharmacies. There is a national push for increasing naloxone distribution, though there are concerns of precursor shortages that will limit or halt production of naloxone. Governmental support of naloxone manufacturing and distribution can assist with meeting demand and ensuring sustainability in the supply chain.

Recommendation 4. Improve training of first responders and medicolegal death investigators.

Most first responders receive training on recognizing signs and symptoms of a potential overdose, and emergency medical and firefighting personnel generally receive additional training for providing medical treatment for those who are under the influence. To avoid exposure to fentanyl, potentially causing a deadly situation for the first responder, additional training is needed about what to do during exposure and how to safely provide naloxone or other medical care. DEA’s safety guide for fentanyl specifically outlines a history of inconsistent and misinformation about fentanyl exposure and treatment. Creating an evidence-based training program that can be distributed virtually and allow first responders to earn continuing education credit can decrease exposure incidents and increase care and responsiveness for those who have overdosed.

While the focus is rightfully placed on first responders as the frontline of the opioid epidemic, medicolegal death investigators also serve a vital function at the intersection of public health and criminal justice. As the professionals who respond to scenes to investigate the circumstances (including cause and manner) surrounding death, medicolegal death investigators must be able to recognize signs of drug toxicity. Training is needed to provide foundational knowledge on deciphering evidence of potential overdose-related deaths, photographing scenes and evidence to share with forensic pathologists, and memorializing the findings to provide an accurate manner of death. Causes of death, as determined by forensic pathologists, need appropriate postmortem examinations and toxicology testing for accuracy, incorporated with standardized wording for death certificates to reflect the drugs contributing to the death. Statistics on drug-related deaths collected by the CDC and public health departments nationwide rely on accurate death certificates to determine trends.

The CDC created the Collaborating Office for Medical Examiners and Coroners (COMEC) in 2022 to provide public health support for medicolegal death investigation professionals. COMEC coordinates health surveillance efforts in the medicolegal community and champions quality investigations and accurate certification of death. The CDC offers free virtual, asynchronous training for investigating and certifying drug toxicity deaths, though the program is not well known or advertised, and there is no ability to ask questions of professionals to aid in understanding the content. Funding is needed to provide no-cost, live instruction, preferably in person, to medicolegal offices, as well as continuing education hours and thorough training on investigating potential drug toxicity-related deaths and accurately certifying death certificates.

Cumulatively, the roughly 2,000 medicolegal death investigation agencies nationwide investigated more than 600,000 deaths in 2018, running on an average budget of $470,000 per agency. Of these agencies, less than 45% had a computerized case management system, which can significantly delay data sharing with public health and allied agencies and reduce reporting accuracy, and only 75% had access to the internet outside of their personally owned devices. Funding is needed to modernize and extend the infrastructure for medicolegal agencies to allow basic functions such as computerized case management systems and internet access, similar to grant funding from the National Network of Public Health Institutes.

Recommendation 5. Fund rapid and thorough toxicology testing in emergency departments and coroner/medical examiner agencies.

Rapid, accurate toxicology testing in an emergency department setting can be the difference between life and death treatment for a patient. Urine toxicology testing is fast, economical, and can be done at the bedside, though it cannot quantify the amount of drug and is not inclusive for emerging drugs. Funding for enhanced accurate toxicology testing in hospitals with emergency departments, including for novel psychoactive substances and opioid analogs, is necessary to provide critical information to attending physicians in a timely manner to allow reversal agents or other vital medical care to be performed.

With the limited resources medicolegal death investigation agencies have nationally and the average cost of $3000 per autopsy performed, administrators need to triage which deaths receive toxicology testing and how in-depth the testing will be. Advanced panels, including ever-changing novel psychoactive substances, are costly and can result in inaccurate cause of death reporting if not performed routinely. Funding should be provided to medicolegal death investigating agencies to subsidize toxicology testing costs to provide the most accurate drugs involved in the death. Accurate cause of death reporting will allow for timely public health surveillance to determine trends and surges of specific drugs. Precise cause of death information and detailed death investigations can significantly contribute to regional multidisciplinary overdose fatality review task forces that can identify potential intervention points to strengthen services and create evidence to build future life-saving action plans.

Recommendation 6. Enhance prevention and enforcement efforts.

DOJ should fund municipal and state law enforcement grants to use evidence-based practices to prevent and enforce drug-related crimes. Grant applications should include a review of the National Institute of Justice’s CrimeSolutions.gov practices in determining potential effectiveness or using foundational knowledge to build innovative, region-specific efforts. The funding should be through competitive grants, requiring an analysis of local trends and efforts and a detailed evaluation and research dissemination plan. Competitive grant funding should also be available for community groups and programs focusing on prevention and access to naloxone.

An often overlooked area of prevention is for justice-involved individuals who enter jail or prison with substance use disorders. Approximately 65% of prisoners in the United States have a substance abuse order, and an additional 20% of prisoners were under the influence of drugs or alcohol when they committed their crime. About 15% of the incarcerated population was formally diagnosed with an opioid use disorder. Medications are available to assist with opioid use disorder treatments that can reduce relapses and post-incarceration toxicity-related deaths, though less than 15% of correctional systems offer medication-assisted opioid use treatments. Extensive case management coupled with trained professionals to prescribe medication-assisted treatment can help reduce opioid-related relapses and overdoses when justice-involved individuals are released to their communities, with the potential to reduce recidivism if treatment is maintained.

DEA should lead local and state law enforcement training on recognizing drug trends, creating regional taskforces for data-sharing and enforcement focus, and organizing drug takeback days. Removing unused prescription medications from homes can reduce overdoses and remove access to unauthorized users, including children and adolescents. Funding to increase collection sites, assist in the expensive process of properly destroying drugs, and advertising takeback days and locations can reduce the amount of available prescription medications that can result in an overdose.

DHS, TREAS, and DOS should expand their current efforts in international trafficking investigations, create additional sanctions against businesses and individuals illegally selling precursor chemicals, and collaborate with countries to universally reduce drug production.

Budget Proposal

A budget of $800 million is proposed to evaluate the current efficacy of drug prevention and enforcement efforts, fund prevention and enforcement efforts, improve training for first responders and medicolegal death investigators, increase rapid and accurate toxicology testing in emergency and medicolegal settings, and enhance collaboration between law enforcement agencies. The foundational research on the efficacy of current enforcement, preventative efforts, and surveillance should receive $25 million, with findings transparently available and shared with practitioners, lawmakers, and community members to hone current practices.

DOJ should receive $375 million to fund grants; collaborative enforcement efforts between local, state, and federal agencies; preventative strategies and programs; training for first responders; and safe drug disposal programs.

CDC should receive $250 million to fund the training of medicolegal death investigators to recognize and appropriately document potential drug toxicity-related deaths, modernize data and reporting systems to assist with accurate surveillance, and provide improved toxicology testing options to emergency departments and medicolegal offices to assist with appropriate diagnoses. Funding should also be used to enhance current data collection efforts with the Overdose to Action program34 by encouraging timely submissions, simplifying the submission process, and helping create or support overdose fatality review teams to determine potential intervention points.

ED should receive $75 million to develop curricula for K-12 and colleges to raise awareness of the dangers of opioids and prevent usage. The curriculum should be made publicly available for access by parents, community groups, and other organizations to increase its usage and reach as many people as possible.

BOP should receive $25 million to provide opioid use disorder medication-assisted treatments by trained clinicians and extensive case management to assist in reducing post-incarceration relapse and drug toxicity-related deaths. The policies, procedures, and steps to create medication-assisted programming should be shared with state corrections departments and county jails to build into their programming to expand use in carceral settings and assist in reducing drug toxicity-related deaths at all incarceration levels.

DOS, DHS, and TREAS should jointly receive $50 million to strengthen their current international investigations and collaborations to stop drug trafficking, the manufacture and sales of precursors, and combating organized crime’s association with the illegal drug markets.

Conclusion

Opioid-related overdoses and deaths continue to needlessly and negatively affect society, with parents burying children, sometimes infants, in an unnatural order. With the low cost of fentanyl production and the high return on investment, fentanyl is commonly added to illicit drugs and counterfeit, real-looking prescription pills. Opioid addiction and fatal overdoses affect all genders, races, ethnicities, and socioeconomic statuses, with no end to this deadly path in sight. Combining public health surveillance with enforcement actions, preventative education, and innovative programming is the most promising framework for saving lives nationally.

 

As the workplace evolves, so do the challenges that organizations face in maintaining a safe and productive environment.

 

A Surge in Drug Test Tampering

 

According to Quest Diagnostics’ latest report, the percentage of employees in the general U.S. workforce showing signs of tampered drug tests increased dramatically in 2023. Instances of substituted urine specimens surged by over 600%, while invalid urine specimens rose by 45.2%. These unprecedented numbers indicate a significant increase in efforts to circumvent drug testing protocols.

 

Suhash Harwani, Ph.D., Senior Director of Science for Workforce Health Solutions at Quest Diagnostics, noted, “The increased rate of both substituted and invalid specimens indicates that some American workers are going to great lengths to attempt to subvert the drug testing process.” This trend underscores a growing issue where the normalization of drug use may be influencing employees to believe they can bypass drug tests without considering the consequences for workplace safety.

 

Historic Highs in Drug Positivity Rates

 

The overall drug positivity rate in the general U.S. workforce (those who do not work federally mandated, safety-sensitive positions) remained steady at 5.7% in 2023, maintaining historically high levels. The combined U.S. workforce (general workforce + federal mandated, safety-sensitive positions) also showed a persistent drug positivity rate of 4.6%, the highest in over two decades. Post-accident marijuana positivity has climbed sharply, with an increase of 114.3% between 2015 and 2023.

 

Marijuana Use and Legalization

 

Marijuana positivity tests continued to increase, particularly in states where recreational use is legal. In the general workforce, marijuana positivity increased by 4.7% in 2023, reaching a new peak. Over the past five years, this rate has risen by 45.2%. Despite the decrease in marijuana positivity among federally mandated, safety-sensitive workers, the data suggests that broader legalization might be contributing to increased usage and associated workplace risks.

 

Rising Drug Use in Office-Based Industries

 

Interestingly, the Quest Diagnostics report also highlights a rise in drug positivity rates within traditionally office-based industries. Real estate, lending, professional services, and education sectors all saw significant increases in drug positivity. This trend may reflect the broader impacts of the pandemic, such as increased stress and isolation from work-from-home policies, potentially leading to higher drug use.

 

Sam Sphar, Vice President and General Manager of Workforce Health Solutions at Quest Diagnostics, pointed out the importance of mental health support and drug education programs in these sectors: “The results underscore the growing need for mental health support and drug education programs to ensure employees are safe and productive, whether working at home or in the office.”

 

The Need for Comprehensive Drug Testing Programs

 

The findings from the Quest Diagnostics Drug Testing Index highlight the critical importance of effective drug testing programs. Such programs not only help maintain a safer work environment but also act as a deterrent against drug use. Dr. Harwani noted that the mere expectation of drug testing can dissuade individuals from using drugs or applying for positions where testing is standard practice.

 

In conclusion, as drug use continues to evolve and adapt to societal changes, organizations must remain vigilant. Implementing robust drug testing and support programs is essential to ensure a safe, healthy, and productive workplace.

 

Source: Workforce drug test cheating surged in 2023, finds Quest Diagnostics Drug Testing Index analysis of nearly 10 million drug tests. (2024, May 15). Quest Diagnostics Newsroom. https://newsroom.questdiagnostics.com/2024-05-15-Workforce-Drug-Test-Cheating-Surged-in-2023,-Finds-Quest-Diagnostics-Drug-Testing-Index-Analysis-of-Nearly-10-Million-Drug-Tests

There are several principal pathways to inheritable genotoxicity, mutagenicity and teratogenesis induced by cannabis which are known and well established at this time including the following. These three papers discuss different aspects of these effects.

1. Stops Brain Waves and Thinking
The brain has both stimulatory and inhibitory pathways.  GABA is the main brain inhibitory pathway. Brain centres talk to each other on gamma (about 40 cycles/sec) and theta frequencies (about 5 cycles/sec), where the theta waves are used as the carrier waves for the gamma wave which then interacts like harmonics in music.  The degree to which the waves are in and out of phase carries information which can be monitored externally.  GABA (γ-aminobutyric acid) inhibition is key to the generation of the synchronized firing which underpins these various brain oscillations. These GABA transmissions are controlled presynaptically by type 1 cannabinoid receptors (CB1R’s) and CB1R stimulation shuts them down. This is why cannabis users forget and fall asleep.

2. Blocks GABA Pathway and Brain Formation
GABA is also a key neurotransmitter in brain formation in that it guides and direct neural stem cell formation and transmission and development and growth of the cerebral cortex and other major brain areas. Gamma and theta brain waves also direct neural stem cell formation, sculpting and connectivity. Derangements then of GABA physiology imply that the brain will not form properly.  Thin frontal cortical plate measurements have been shown in humans prenatally exposed to cannabis by fMRI. This implies that their brains can never be structurally normal which then explains the long lasting and persistent defects identified into adulthood.

3. Epigenetic Damage
DNA not only carries the genetic hardware of our genetic code but it also carries the software of the code which works like traffic lights along the sequence of DNA bases to direct when to switch the genes on and off. This is known as the “epigenetic code”. Fetal alcohol syndrome is
believed to be due to damage to the software epigenetic code. The long lasting intellectual, mood regulation, attention and concentration defects which have been described after in utero cannabis exposure in the primary, middle and high schools and as college age young adults
are likely due to these defects. Epigenetics “sets in stone” the errors of brain structure made in (2) above.

4. Arterial Damage
Cannabis has a well described effect to damage arteries through (CB1R’s) (American Heart Association 2007) which they carry in high concentration (Nature Reviews Cardiology 2018). In adults this causes heart attack (500% elevation in the first hour after smoking), stroke,
severe cardiac arrhythmias including sudden cardiac death; but in developing babies CB1R’s acting on the developing heart tissues can lead to at least six major cardiac defects (Atrial- ventricular- and mixed atrioventricular and septal defects, Tetralogy of Fallot, Epstein’s deformity amongst others), whilst constriction of various babies’ arteries can lead to serious side effects such as gastroschisis (bowels hanging out) and possibly absent limbs (in at least one series).

5. Disruption of Mitotic Spindle
When cells divide the separating chromosomes actually slide along “train tracks” which are long chains made of tubulin. The tubulin chains are called “microtubules” and the whole football-shaped structure is called a “mitotic spindle”. Cannabis inhibits tubulin formation,
disrupting microtubules and the mitotic spindle causing the separating chromosomes to become cut off in tiny micronuclei, where they eventually become smashed up and pulverized into “genetic junk”, which leads to foetal malformations, cancer and cell death. High rates of
Down’s syndrome, chromosomal anomalies and cancers in cannabis exposed babies provide clinical evidence of this.

6. Defective Energy Generation & Downstream DNA Damage
DNA is the crown jewel of the cell and its most complex molecule. Maintaining it in good repair is a very energy intensive process. Without energy DNA cannot be properly maintained. Cannabis has been known to reduce cellular energy production by the cell’s power plants,
mitochondria, for many decades now. This has now been firmly linked with increased DNA damage, cancer formation and aging of the cells and indeed the whole organism. As it is known to occur in eggs and sperm, this will also damage the quality of the germ cells which go into forming the baby and lead directly to damaged babies and babies lost and wasted through spontaneous miscarriage and therapeutic termination for severe deformities.

7. Cancer induction
Cannabis causes 12 cancers and has been identified as a carcinogen by the California Environmental Protection agency (2009). This makes it also a mutagen. 4 of these cancers are inheritable to children; i.e. inheritable carcinogenicity and mutagenicity. All four studies in
testicular cancer are strongly positive (elevation by three fold). Carcinogen = mutagen = teratogen.

8. Colorado’s Teratology Profile
From the above described teratological profile we would expect exactly the profile of congenital defects which have been identified in Colorado(higher total defects and heart defects, and chromosomal defects) and Ottawa in Canada (long lasting and persistent brain
damage seen on both functional testing and fMRI brain scans in children exposed in utero) where cannabis use has become common. Gastroschisis was shown to be higher in all seven studies looking at this; and including in Canada, carefully controlled studies. Moreover in
Australia, Canada, North Carolina, Colorado, Mexico and New Zealand, gastroschisis and sometimes other major congenital defects cluster where cannabis use is highest. Colorado 2000-2013 has experienced an extra 20,152 severely abnormal births above the rates prior to
cannabis liberalization which if applied to the whole USA would equate to more than 83,000 abnormal babies live born annually (and probably about that number again therapeutically aborted); actually much more since both the number of users and concentration of cannabis have risen sharply since 2013, and cannabis has been well proven to be much more severely genotoxic at higher doses.

9. Cannabidiol is also Genotoxic
Cannabidiol tests positive in many genotoxicity assays, just as tetrahydrocannabinol does.

10. Births defects registry data needs to be open and transparent and public.
At present it is not. This looks too much like a cover up.

 

Source:  By Professor Dr. A. S Reece
(Edith Cowan University & University of Western Australia) 2019

 

 

Description:

Browse state-level percentage estimates based on the 2021-2022 National Surveys on Drug Use and Health (NSDUH). The 37 tables include estimates for 35 measures of substance use and mental health, by age group, along with 95% confidence intervals. The percentages are based on small area estimation (SAE) methods, in which state-level NSDUH data are combined with other data from smaller geographies. The combined data are used to create modeled state estimates of the civilian, noninstitutionalized population ages 12 and older, or adults 18 and older for mental health measures. Each table covers a single measure by state, region, and age group.

The indicators are presented in the following 37 tables:

Drug use and Perceived Risk

  1. Illicit Drug Use in the Past Month
  2. Marijuana Use in the Past Year
  3. Marijuana Use in the Past Month
  4. Perceptions of Great Risk from Smoking Marijuana Once a Month
  5. First Use of Marijuana in the Past Year (among those at risk for initiation)
  6. Illicit Drug Use Other than Marijuana in the Past Month
  7. Cocaine Use in the Past Year
  8. Perceptions of Great Risk from using Cocaine Once a Month
  9. Heroin Use in the Past Year
  10. Perceptions of Great Risk from Trying Heroin Once or Twice
  11. Hallucinogen Use in the Past Year
  12. Methamphetamine Use in the Past Year
  13. Prescription Pain Reliever Misuse in the Past Year
  14. Opioid Misuse in the Past Year

Alcohol

  1. Alcohol Use in the Past Month
  2. Binge Alcohol Use in the Past Month
  3. Perceptions of Great Risk from Having Five or More Drinks of an Alcoholic Beverage Once or Twice a Week
  4. Alcohol Use, Binge Alcohol Use in the Past Month, and Perceptions of Great Risk from Having Five or More Drinks of an Alcoholic Beverage Once or Twice a Week (among people aged 12 to 20)

Tobacco

  1. Tobacco Product Use in the Past Month
  2. Cigarette Use in the Past Month
  3. Perceptions of Great Risk from Smoking One or More Packs of Cigarettes per Day

Substance Use Disorders

  1. Substance Use Disorder in the Past Year
  2. Alcohol Use Disorder in the Past Year
  3. Alcohol Use Disorder in the Past Year (among people aged 12 to 20)
  4. Drug Use Disorder in the Past Year
  5. Pain Reliever Use Disorder in the Past Year
  6. Opioid Use Disorder in the Past Year

Substance Use Treatment

  1. Received Substance Use Treatment in the Past Year
  2. Classified as Needing Substance Use Treatment in the Past Year
  3. Did Not Receive Substance Use Treatment in the Past Year among those Classified as Needing Substance Use Treatment

Mental Illness

  1. Any Mental Illness in the Past Year
  2. Serious Mental Illness in the Past Year
  3. Received Mental Health Treatment in the Past Year
  4. Major Depressive Episode in the Past Year

Suicidality

  1. Had Serious Thoughts of Suicide in the Past Year
  2. Made Any Suicide Plans in the Past Year
  3. Attempted Suicide in the Past Year
Publication Date: February 15, 2024
Collection Date: 2021-2022
Report Type: Data Table
Source:  https://www.samhsa.gov/data/report/2021-2022-nsduh-state-prevalence-estimates

ORLANDO, Fla.Jan. 24, 2024 /PRNewswire/ — Victoria’s Voice Foundation, a nonprofit providing evidence-based drug education and addiction prevention support for families, marked a major milestone yesterday, surpassing one million children and parents impacted through its education programs – with a school assembly in Nashville on the dangers of vaping and drug use. The event was held at Davidson Academy for 375 students in grades 7-12.

During the assembly, Michael DeLeon – director of youth outreach and school programs for Victoria’s Voice and founder of Steered Straight, a drug prevention program for school systems nationwide – discussed vaping, stressing the escalating incidence of overdose deaths from vapes laced with fentanyl, as well as drug use information, associated risks, and tools for prevention. DeLeon also shared his personal story of addiction, incarceration and recovery, and reinforced with students the importance of making responsible, informed choices.

“We are very proud to achieve this important milestone,” said Victoria’s Voice co-founders Jackie and David Siegel, who were on hand at the Davidson assembly. “This marks a significant step in our ongoing efforts to educate and empower families about drug use and addiction. It is our life’s work to spare other parents the pain and grief we experienced.”

Victoria’s Voice has created a diverse and versatile collection of education and prevention programming to meet the needs of communities and at-risk populations nationwide. The foundation’s live school speaker series encourages students to live drug-free. The series also includes prevention resources and activities to engage students year-round, programming tailored for parents and educators, and complimentary copies of Victoria’s Voice, the powerful, personal diary of the Siegels’ late daughter, Victoria.

The foundation also offers Vital Signs, a free program that prepares parents to recognize the early signs of drug use in their children; a community speaker program; free video programming for life skills and drug prevention; and Victoria’s Voice, which the foundation provides for free to schools and other organizations.

About Victoria’s Voice Foundation
Victoria’s Voice Foundation was established in 2019 by Jackie and David Siegel after losing their 18-year-old daughter to an accidental drug overdose. Victoria’s Voice is dedicated to providing evidence-based drug education and addiction prevention support for families, including access to Naloxone. Since its founding, Victoria’s Voice has positively impacted more than one million parents and children through its education programs. For more information about Victoria’s Voice, please visit www.victoriasvoice.org.

Source: https://finance.yahoo.com/news/victorias-voice-foundation-marks-milestone-194100724.html?

The United States is knee-deep in what some experts call the opioid epidemic’s “fourth wave,” which is not only placing drug users at greater risk but is also complicating efforts to address the nation’s drug problem.

These waves, according to a report from Millennium Health, were the crisis in prescription opioid use, followed by a significant jump in heroin use, then an increase in the use of synthetic opioids like fentanyl.
The latest wave involves using multiple substances at the same time, combining fentanyl mainly with either methamphetamine or cocaine, the report found. “And I’ve yet to see a peak,” said one of the co-authors, Eric Dawson, vice president of clinical affairs at Millennium, a specialty laboratory that provides drug-testing services to monitor use of prescription medications and illicit drugs.
The report, which takes a deep dive into the nation’s drug trends and breaks usage patterns down by region, is based on 4.1 million urine samples collected from January 2013 to December 2023 from people receiving some kind of drug-addiction care.
Its findings offer staggering statistics and insights. Its major finding is how common polysubstance use has become. According to the report, an overwhelming majority of fentanyl-positive urine samples — nearly 93% — contained additional substances. “That is huge,” said Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health.
The most concerning, Volkow and other addiction experts said, is the dramatic increase in the combination of methamphetamine and fentanyl use. Meth, a highly addictive drug often in powder form that poses several serious cardiovascular and psychiatric risks, was found in 60% of fentanyl-positive tests last year. That is an 875% increase since 2015.
“I never, ever would have thought this,” Volkow said.
Among the report’s other key findings:

  • The nationwide spike in methse alongside fentanyl marks a change in drug use patterns.
  • Polydrug use trends complicate overdose treatments. For instance, naloxone, an opioid-overdose reversal medication, is widely available, but there isn’t an FDA-approved medication for stimulant overdose.
  • Both heroin and prescribed-opioid use alongside fentanyl have dipped. Heroin detected in fentanyl-positive tests dropped by 75% since peaking in 2016. Prescription opioids were found at historic low rates in fentanyl-positive tests in 2023, down 89% since 2013.

But Jarratt Pytell, an addiction medicine specialist and assistant professor at the University of Colorado’s School of Medicine, warned these declines shouldn’t be interpreted as a silver lining.
A lower level of heroin use “just says that fentanyl is everywhere,” Pytell said, “and that we have officially been pushed by our drug supply to the most dangerous opioids that we have available right now.”
“Whenever a drug network is destabilizing and the product changes, it puts the people who use the drugs at the greatest risk,” he said. “That same bag or pill that they have been buying for the last several months now is coming from a different place, a different supplier, and is possibly a different potency.”
In the illicit drug industry, suppliers are the controllers. It may not be that people are seeking out methamphetamine and fentanyl but rather that they’re what drug suppliers have found to be the easiest and most lucrative product to sell.
“I think drug cartels are kind of realizing that it’s a lot easier to have a 500-square-foot lab than it is to have 500 acres of whatever it takes to grow cocaine,” Pytell said.
Dawson said the report’s drug use data, unlike that of some other studies, is based on sample analysis with a quick turnaround — a day or two.
Sometimes researchers face a months-long wait to receive death reports from coroners. Under those circumstances, you are often “staring at today but relying on data sources that are a year or more in the past,” said Dawson.
Self-reported surveys of drug users, another method often used to track drug use, also have long lag times and “often miss people who are active for substance use disorders,” said Jonathan Caulkins, a professor at Carnegie Mellon University. Urine tests “are based on a biology standard” and are good at detecting when someone has been using two or more drugs, he said.
But using data from urine samples also comes with limitations. For starters, the tests don’t reveal users’ intent.
“You don’t know whether or not there was one bag of powder that had both fentanyl and meth in it, or whether there were two bags of powder, one with fentanyl in it and one with meth and they took both,” Caulkins said. It can also be unclear, he said, if people intentionally combined the two drugs for an extra high or if they thought they were using only one, not knowing it contained the other.
Volkow said she is interested in learning more about the demographics of polysubstance drug users. “Is this pattern the same for men and women, and is this pattern the same for middle-age or younger people? Because again, having a better understanding of the characteristics allows you to tailor and personalize interventions.”
All the while, the nation’s crisis continues. According to the Centers for Disease Control and Prevention, more than 107,000 people died in the U.S. in 2021 from drug overdoses, most because of fentanyl.
Caulkins said he’s hesitant to view drug use patterns as waves because that would imply people are transitioning from one to the next.
“Are we looking at people whose first substance use disorder was an opioid use disorder, who have now gotten to the point where they’re polydrug users?” he said. Or, are people now starting substance use disorders with methamphetamine and fentanyl, he asked.
One point was clear, Dawson said: “We’re just losing too many lives.”

 

Source: https://lexingtonky.news/2024/02/24/opioid-epidemic-is-in-a-fourth-wave-with-multiple-substances-being-used-at-the-same-time-and-fentanyl-is-the-most-common/

Washington tribal leaders are looking at an overseas model to combat the rise in opioid use among teens.

It’s called the Icelandic Prevention Model, and it’s helped slash alcohol use among Icelandic 15- and 16-year-olds from 77% to 35% in 20 years.

“There’s no other model in the world that has that kind of turnaround in the community,” said Nick Lewis, councilmember of the Lummi Nation and chairman of the Northwest Portland Area Indian Health Board.

Washington has dubbed its effort the “Washington Tribal Prevention System” and the Health Care Authority, along with five tribes, will partner with Planet Youth, a non-profit bringing the Icelandic Prevention Model to other places.

The model involves re-thinking how to discourage drug use by placing responsibility on the community, rather than the individual. Instead of asking kids to “just say no,” the Icelandic Prevention Model calls on the adults in a child’s life to create an environment without drugs and alcohol, said Margrét Lilja Guðmundsdóttir, chief knowledge officer at Planet Youth.

“The child should never be responsible for the situation in the community,” Guðmundsdóttir said.

The Washington Tribal Prevention System officially kicked off its ten-year pilot program with the ceremonial signing of contracts on Feb. 14. The five tribal governments participating are Jamestown S’Klallam Tribe, Lummi Nation, Tulalip Tribes, Swinomish Indian Tribal Community and Colville Tribes.

In Washington, American Indian and Alaska Native residents have the highest rate of death from opioid overdoses, far outpacing other races and ethnicities, according to state Department of Health data. 

“Our stories might be different,” Lewis said. “But if they can turn things around, we can too.”

The first two years, the Health Care Authority officials said, are just administrative planning, which will cost $2 million to $3 million a year. Gov. Jay Inslee has called for $1 million for the project in his supplemental budget proposal this year, and the rest of the money would come from federal grants.

Whether lawmakers will provide the $1 million Inslee requested or some other amount for the program will become clearer in the days ahead as the Legislature irons out budget legislation.

When the program moves out of the planning phase – scheduled to happen in its third year – costs are expected to go up dramatically. But Aren Sparck, tribal affairs administrator for the Health Care Authority, said he’s optimistic about finding funding from both private and public entities because of how much interest there is in the model.

Sparck also said the program could be adopted by other tribes and communities. “I think this is going to be a test for the entire state,” he said.

What exactly is the Icelandic model?

In Iceland, youth, parents, schools, the government and other community members work in tandem to create an environment that discourages drug use.

For example, the country has free after-school activities funded by the government. Kids are bussed directly to those activities. Youth councils help shape what activities happen, so teens are actually interested. It’s about making drug-use prevention a lifestyle, said Loni Greninger, tribal vice chair at Jamestown.

Last year, Health Care Authority officials and several tribal delegations visited Iceland to see the model for themselves. Sparck said he was skeptical at first — but when he saw the model in person, “jaws were on the floor.” The way Iceland has managed to make its model just a part of daily life, Sparck said, is exactly what he wants to see in Washington.

“I was talking to some of the youth and asking them, ‘What’s it like to be in the world’s most successful prevention model? And they asked us, ‘What’s the Icelandic Prevention Model?’” Sparck said.

Sparck said one of the things he learned about was a large dance party that young people in Iceland helped plan. Students invited one of the well-known DJs in Europe and policed each other, ensuring there were no drugs and alcohol at the event.

“What we saw was empowering the youth to make their decisions together. So they own this, and they’re a part of it and invested in it,” Sparck said.

Putting trust in youth to help create an alcohol and drug-free environment is also a big part of the model, officials said.

“A child wants a healthy environment,” Lewis said. “A child wants to grow up and be healthy. You never hear a child say ‘I want to grow up and be a drug addict.’”

The tribal model

The Icelandic Prevention Model relies on cultural practices within Iceland. Planet Youth works with its partners to translate the model into their own cultures, Guðmundsdóttir said.

While this is the first time Planet Youth has worked with tribal governments, Guðmundsdóttir and tribal leaders said Iceland and Washington’s tribes share a lot of values in common — namely the belief that it takes a community to raise a child.

“You’re literally wrapping your arms around these kids in everything prevention and wellness,” Greninger said about Iceland’s model.

“That’s what we tribes aspire to do,” she said. “But when you are working with separate entities, we all have our own visions and missions and agendas, we’re all busy every single day. It’s hard to line up all of that.”

Planet Youth — and efforts to implement Iceland’s model in other places — are relatively new, and it took Iceland decades to get where it is now. But there’s already research suggesting Iceland’s model is transferable.

“It’s not a quick fix,” Guðmundsdóttir said. “It’s a never-ending story. You will always have new kids, new parents, new kinds of substances.”

“It’s not a one-year project. It’s a long-term way of thinking,” she added.

When Lummi Nation policymakers presented the Iceland Prevention Model to Lewis, he said he recognized it as just another name for what his tribe is already doing, but without the resources they need to implement it at the level Iceland has.

According to Lewis, it’s often difficult to get funding for tribal drug treatment practices because they aren’t always considered evidence-based — and it’s almost impossible to gather enough proof that a tribal practice works because tribal populations are so small.

The Icelandic Prevention Model, to Lewis, proves that what tribes have already been trying to do works when it’s fully resourced. He hopes using Iceland’s model will help raise the funding needed and remove the silos between different efforts in Washington.

“If we’re going to break this cycle, we need to go back to creating healthy environments and get back to the values that bring people together,” Lewis said.

Source: https://www.anacortesnow.com/news/health/5285-washington-tribes-look-to-iceland-for-help-getting-teens-off-drugs

US DRUG CZAR EXPLAINS CAUSES AND RSDT TOOL TO PREVENT TEEN DRUG USE AND OVERDOSE DEATH INTERVIEW WITH U.S. DRUG CZAR JOHN WALTERS

Introduction:  In response to recent news of a huge increase in drug overdose deaths and arrests for drug trafficking among Fairfax County youths, Fox News TV5 reporter Sherri Ly interviewed U.S. Drug Czar John Walters for his expert views on the cause and potential cure for these horrific family tragedies.  Following is a transcript of that half-hour interview with minor editing for clarity and emphasis added.  The full original interview is available through the 11/26/08 Fox5 News broadcast video available at link:

WALTERS:  Well, as this case shows, while we’ve had overall drug use go down, we still have too many young people losing their lives to drugs, either through overdoses, or addiction getting their lives off track.  So there’s a danger.  We’ve made progress, and we have tools in place that can help us make more progress, but we have to use them

Q 1:  You meet with some of these parents whose children have overdosed.  What do they tell you, and what do you tell them?

WALTERS:  It’s the hardest part of my job; meeting with parents who’ve lost a child.  Obviously they would give anything to go back, and have a chance to pull that child back from the dangerous path they were on.  There are no words that can ease their grief.  That’s something you just pray that God can give them comfort.  But the most striking thing they say to me though is they want other parents to know, to actAnd I think this is a common thing that these terrible lessons should teach us.

Many times, unfortunately, parents see signs: a change in friends, sometimes they find drugs; sometimes they see their child must be intoxicated in some way or the other.  Because it’s so frightening, because sometimes they’re ashamed – they hope it’s a phase, they hope it goes away – they try to take some half measures.  Sometimes they confront their child, and their child tells them – as believably as they ever can – that it’s the first time.  I think what we need help with is to tell people; one, it’s never the first time.  The probability is low that parents would actually recognize these signs – even when it gets visible enough to them – because children that get involved in drugs do everything they can to hide it.  It’s never the first time.  It’s never the second time.  Parents need to act, and they need to act quickly.  And the sorrow of these grieving parents is, if anything, most frequently focused on telling other parents, “Don’t wait: do anything to get your child back from the drugs.”

Secondly, I think it’s important to remember that one of the forces that are at play here is that it’s their friends.  It’s not some dark, off-putting stranger – it’s boyfriends, girlfriends.  I think that was probably a factor in this case.  And it’s also the power and addictive properties of the drug.  So your love is now being tested, and the things you’ve given your child to live by are being pulled away from them on the basis of young love and some of the most addictive substances on earth.  That’s why you have to act more strongly.  You can’t count on the old forces to bring them back to safety and health.

Q 2:  When we talk about heroin – which is what we saw in this Fairfax County drug ring, alleged drug ring – what are the risks, as far as heroin’s concerned?  I understand it can be more lethal, because a lot of people don’t know what they’re dealing with?

WALTERS:  Well it’s also more lethal because one, the drug obviously can produce cardiac and respiratory arrest.  It’s a toxic substance that is very dangerous.  It’s also the case that narcotics, like heroin – even painkillers like OxyContin, hydrocodone, which have also been a problem – are something that the human body gets used to.  So what you can frequently get on the street is a purity that is really blended for people who are addicted and have been long time addicted.  So a person who is a new user or a naïve user can more easily be overdosed, because the quantities are made for people whose bodies have adjusted to higher purities, and are seeking that effect that only the higher purity will give them in this circumstance.  So it’s particularly dangerous for new users.  But we also have to remember, it almost never starts with heroin.  Heroin is the culmination here.  I think some of the – and I’ve only seen press stories on this — some of these young people may have gotten involved as early as middle school.

We have tools so that we don’t have to lose another young woman like this– or young men.  We now have the ability to use Random Student Drug Testing (RSDT) because the Supreme Court has, in the last five years, made a decision that says it can’t be used to punish.  It’s used confidentially with parents.  We have thousands of schools now doing it since the president announced the federal government’s willingness to fund these programs in 2004.  And many schools are doing it on their own.  Random testing can do for our children what it’s done in the military, what it’s done in the transportation safety industry– significantly reduce drug use.

First, it is a powerful reason not to start.  “I get tested, I don’t have to start.”  We have to remember, it’s for prevention and not a “gotcha!”  But it’s a powerful reason for kids to say, even when a boyfriend or girlfriend says come and do this with me, “I can’t do it, I get tested.  I still like you, I still want to be your friend; I still want you to like me, but I just can’t do this,” which is very, very powerful and important.  And second, if drug use is detected the child can be referred to treatment if needed.

Q 3:  Is the peer pressure just that much that without having an excuse, that kids are using drugs and getting hooked?

WALTERS:  Well one of the other unpleasant parts of my job is I visit a lot of young people in treatment; teenagers, sometimes as young as 14, 15, but also 16, 17, 18.  It is not uncommon for me to hear from them, “I came from a good family.  My parents and my school made clear what the dangers were of drugs.  I was stupid.  I was with my boyfriend (or girlfriend) and somebody said hey, let’s go do this.  And I started, and before I knew it, I was more susceptible.

We have to also understand the science, which has told us that adolescents continue to have brain development up through age 20-25.  And their brains are more susceptible to changes that we can now image from these drugs.  So it’s not like they’re mini-adults.  They’re not mini-adults.  They’re the particularly fragile and susceptible age group, because they don’t have either the experience or the mental development of adults.  That’s why they get into trouble, that’s why it happens so fast to them, that’s why it’s so hard for them to see the ramifications.

So what does RSDT do?  It finds kids early–­ if prevention fails.  And it allows us to intervene, and it doesn’t make the parent alone in the process.  Sometimes parents don’t confront kids because kids blackmail them and say “I’m going to do it anyway, I’m going to run away from home.”  The testing brings the community together and says we’re not going to lose another child.  We’re going to do the testing in high school – if necessary, in middle school.  We’re going to wrap our community arms around that family, and get those children help.  We’re going to keep them in school, not wait for them to drop out.  And we’re certainly not going to allow this to progress until they die.

Q 4:  And in a sense, if you catch somebody early, since you’re saying the way teenagers seem to get into drug use is a friend introduces it to a friend, and then next thing you know, you have a whole circle of friends doing it.  Are you essentially drying that up at the beginning, before it gets out of hand?

WALTERS:  That is the very critical point.  It’s not only helping every child that gets tested be safer, it means that the number of young people in the peer group, in the school, in the community that can transfer this dangerous behavior to their friends shrinks.  This is communicated like a disease, except it’s not a germ or a bacillus.  It’s one child who’s doing this giving it behaviorally to their friends, and using their friendship as the poison carrier here.  It’s like they’re the apple and the poison is inside the apple.  And they trade on their friendship to get them to use.  They trade on the fact that people want acceptance, especially at the age of adolescence.  So what you do is you break that down, and you make those relationships less prone to have the poison of drugs or even underage drinking linked to them.  And of course we also lose a lot of kids because of impaired driving.

Q 5:  And how does the drug testing program work, then, in schools– the schools that do have it.  Is it completely confidential?  Are you going to call the police the minute you find a student who’s tested positive for heroin or marijuana or any other illicit drug?

WALTERS:  That’s what is great about having a Supreme Court decision.  It is settled – random testing programs cannot be used to punish, to call law enforcement; they have to be confidential.  So we have a uniform law across the land.  And what the schools that are doing RSDT are seeing is that it’s an enormous benefit to schools for a relatively small cost.  Depending on where you are in the country, the screening test is $10-40.  It’s less than what you’re going to pay for music downloads in one month for most teenage kids in most parents’ lives.  And it protects them from some of the worst things that can happen to them during adolescence.  Not only dying behind the wheel, but overdose death and addiction.

 Schools that have done RSDT have faced some controversy; so you have to sit down and talk to people; parents, the media, young people.  You have to engage the community resources.  You’re going to find some kids and families that do have treatment needs.  But with RSDT you bring the needed treatment to the kids.

I tell, a lot of times, community leaders – mayors and superintendents, school board members – that if you want to send less kids into the criminal justice system and the juvenile justice system, drug test — whether you’re in a suburban area or in an urban area.

What does the testing do?  It takes away what we know is an accelerant to self-destructive behavior: crime, fighting in school, bringing a weapon, joining a gang.  We have all kinds of irrefutable evidence now – multiple studies showing drugs and drinking at a young age accelerate those things, make them worse, make them more violent, as well as increasing their risks of overdose deaths and driving under the influence.  So drug testing makes all those things get better.  And it’s a small investment to make everything else we do work better.

Again, drug testing is not a substitute for drug education or good parenting or paying attention to healthy options for your kid.  It just makes all those things work better.

Q 6:  And I know you’ve heard this argument before, but isn’t that big brother?  Aren’t there parents out there who say to you, “I’m the parent: why are you going to test my child for drugs in school; that’s my job?” 

WALTERS:  I think that is the critical misunderstanding that we are slowly beginning to change by the science that tells us substance abuse is a disease.  It’s a disease that gets started by using the drug, and then it becomes a thing that rewires our brain and makes us dependent.  So instead of thinking of this as something that is a moral failing, we have to understand that this is a disease that we can use the kind of tools for public health – screening and interventions – to help reduce it.

Look, let me give you the counter example.  It’s really not big brother.  It’s more like tuberculosis.  Schools in our area require children to be tested for tuberculosis before they come to school.  Why do they do that?  Because we know one, they will get sicker if they have tuberculosis and it’s not treated.  And we can treat them, and we want to treat them.  And two, they will spread that disease to other children because of the nature of the contact they will have with them and spreading the infectious agent.  The same thing happens with substance abuse.  Young people get sicker if they continue to use.  And they spread this to their peers.  They’re not secretive among their peers about it; they encourage them to use them with them.  Again, it’s not spread by a bacillus, but it’s spread by behavior.

If we take seriously the fact that this is a disease and stop thinking of it as something big brother does because it’s a moral decision that somebody else is making, we can save more lives.  And I think the science is slowly telling us that we need to be able to treat this in our families, for adults and young people.  We have public health tools that we’ve used for other diseases that are very powerful here, like screening – and that’s really what the random testing is.  We’re trying to get more screening in the health care system.  So when you get a check up, when you bring your child to a pediatrician, we screen for substance abuse and underage drinking.  Because we know we can treat this, and we know that we can make the whole problem smaller when we do. 

Q 7:  You have said there were about 4,000 schools across the country now that are doing this random drug testing.  What can we see in the numbers since the Supreme Court ruling in 2002, as far as drug use in those schools, and drug use in the general population?

WALTERS:  Well, what a number of those schools have had is of course a look at the harm from student drug and alcohol use.  Some of them have put screening into place, random testing, because they’ve had a terrible accident; an overdose death; death behind the wheel.  What’s great is when school districts do this, or individual schools do this, without having to have a tragedy that triggers it.  But if you have a tragedy, I like to tell people, you don’t have to have another one.  The horrible thing about a tragic event is that most people realize those are not the only kids that are at risk.

There are more kids at risk, obviously, in our communities in the Washington, DC area where this young woman died.  We know there’s obviously more children who are at risk of using in middle school and high school.  The fact is those children don’t have to die.  We cannot bring this young lady back.  Everybody knows that.  But we can make sure others don’t follow her.  And the way we can do that is to find, through screening, who’s really using.  And then let’s get them to stop – let’s work with their families, and let’s make sure we don’t start another generation of death.  So what you see in these areas is an opportunity to really change the dynamic for the better.

Q 8:  Now, although nationally drug use among our youth is going down – what does it say to you – when I look at the numbers specific to Virginia, the most recent that I could find tells me that 3% of 12th graders, over their lifetime, have used a drug like heroin?  What does it say to you?  To me, that sounds like a lot.

WALTERS:  Yeah, and it’s absolutely true.  I think the problem here is that when you tell people we are taking efforts that are making progress nationwide, they jump to the conclusion that that means that we don’t have a problem anymore.  We need to continue to make this disease smaller.  It afflicts our young people.  It obviously also afflicts adults, but this is a problem that starts during adolescence — and pre-adolescence in some cases — in the United States.  We can make this smaller.  We not only have the tools of better prevention but also better awareness and more recognition of addiction as a disease.  We need to make that still broader.  We need to use random testing.  If we want to continue to make this smaller, and make it smaller in a permanent way, random testing is the most powerful tool we can use in schools.

We want screening in the health care system.  We have more of that going on through both insurance company reimbursement and public reimbursement through Medicare and Medicaid for those who come into the public pay system.  That needs to grow.  It needs to grow into Virginia, it’s already being looked at in DC; it needs to grow into Maryland and the other states that don’t have it.  We are pushing that, and it’s relatively new, but it’s consistent with what we’re seeing – the science and the power of screening across the board.

We need to continue to look at this problem in terms of also continuing to push on supply.  We’re working to reduce the poisons coming into our communities, which is not the opposite of demand; that we have to choose one or the other.  They work together.  Keeping kids away from drugs and keeping drugs away from kids work together.  And where we see that working more effectively, we’ll save more lives.  So again, we’ve seen that a balanced approached works, real efforts work, but we need to follow through.  And the fact that you still have too many kids at risk is an urgent need.  Today, you have kids that could be, again, victims that you have to unfortunately tell about on tonight’s news, that we can save.  It’s not a matter we don’t know how to do this.  It’s a matter of we need to take what we know and make it reality as rapidly as possible.

Q 9:  Where are these drugs coming from?  Where’s the heroin that these kids allegedly got coming from?

WALTERS:  We do testing about the drugs to figure out sources for drugs like heroin.  Principally, the heroin in the United States today has come from two sources.  Less of it’s coming out of Colombia.  Colombia used to be a source of supply on the East Coast, but the Colombian government, as a part of our engagement with them on drugs, has radically reduced the cultivation of poppy and the output of heroin.  There still is some, but it’s dramatically down from what it was even about five years ago.  Most of the rest of the heroin in the United States comes from Mexico.  And the Mexican government, of course, is engaged in a historic effort to attack the cartels.  You see this in the violence the cartels have had as a reaction.  So we have promising signs.  There are dangerous and difficult tasks ahead, but we can follow through on that as well.

Most of the heroin in the world comes from Afghanistan; 90% of it.  And we are working there, of course, as a part of our effort against the Taliban and the forces of terror and Al Qaeda, to shrink that.  The good news is that last year we had a 20% decline in cultivation and a 30% decline in output there.  Most of that does not come here, fortunately.  But it has been funding the terrorists.  It’s been drained out of most of the north and the east of the country.  It’s focused on the area where we have the greatest violence today, in the southwest.  We’re working now – you see Secretary Gates talking to the NATO allies about bringing the counter-insurgency effort together with the counter-narcotics effort to attack both of these cancers in Afghanistan.  We have a chance to change heroin availability in the world in a durable way by being successful in Afghanistan.  We’ve started that path in a positive way.  Again, it’s a matter of following through as rapidly as possible.

Q 10:  Greg Lannes, the father of the girl in Fairfax County who died, told me that one of his main efforts, as you imagined, was to let people know that those drugs, they’re coming from where it is produced, outside our country; that they’re getting all the way down to the street level and into our neighborhoods– something that people don’t realize.  So when you hear that they busted a ring of essentially teenagers who have been dealing, using and buying heroin, what does that say to you as the man in charge of combating drugs in our country?

WALTERS:  Well again, we have tools that can make this smaller.  But we have to use those tools.  And we have multiple participants here.  Yes we need to educate.  And we need to make sure that parents know they need to talk to their children, even when their children look healthy and have come from a great home.  Drugs – we’ve learned, I think, over the last 25 years or more, drugs affect everybody; rich or poor, middle class, lower class or upper class.  Every family’s been touched by this, in my experience, by alcohol or drugs.  They know that reality– we don’t need to teach them that.

What we need to teach them is the tools that we have that they can help accelerate use of.  Again, I think – there is no question in my mind that had this young woman been in a school, middle school or high school that had random testing – since that’s where this apparently started, based on the information I’ve seen in the press – she would not be dead today.  So again, we can’t go back and bring her to life.  But we can put into place the kind of screening that makes the good will and obvious love that she got from her parents, the obvious good intentions that I can’t help but believe were a part of what happened in the school, the opportunities that the community has to have a lot of resources that she didn’t get when she needed them.  And now she’s dead.  Again, we can stop this: we just have to make sure we implement that knowledge in the reality of more of our kids as fast as possible.

Q 11:  Should anyone be surprised by this case?  And that such a hardcore drug like heroin is being used by young people?

WALTERS:  We should never stop being surprised when a young person dies.  They shouldn’t die.  They shouldn’t die at that young age, and we should always demand of ourselves, even while we know that’s sometimes going to happen today, that every death is a death too many.  I think that it is very important not to say we’re going to accept a certain level.  Never accept this.  Never!  That’s my attitude, and I know that’s the president’s  attitude as well here.  Never accept that heroin’s going to get into the lives of our teenagers.  Never accept that our children are going to be able to use and not be protected.  It’s our job to protect themThey have a role, also, obviously in helping to protect themselves.  But we need to give them the tools that will help protect them.

When I talk to children and young adults in high school or college, they know what’s going on among their peers.  And in some ways, when you get them alone and they feel they can talk candidly, they tell us they don’t understand why we, as adults who say this is serious, don’t act.  They know that we see children who are intoxicated; they know that we must see signs of this, because as kid’s lives get more out of control, they show signs of it.  They want to know why we don’t act.

We can use the tools of screening, and we can use the occasion of a horrible event like this to bring the community together and say it’s time for us to use the shock and the sorrow for something positive in the future.  I haven’t met a parent of a child who’s been lost who doesn’t say I just want to use this now for something positive.  And that’s understandable, and I think we ought to honor that wish.

Q 12:  Well, I guess I’m not asking should we accept that this is in our schools, but is it naïve for people not to understand or realize that these hardcore drugs are in our schools, and in our communities, and in our neighborhoods. 

WALTERS:  Yeah.  Where it is naïve, I think, is to not recognize the extent and access that young people have to drugs and alcohol.  I think we sometimes think that because they come from a home where this isn’t a part of their lives now, that it’s not ever going to be part of their lives.  Look, your viewers should go on the computer.  Type marijuana into the Google search engine and see how many sites encourage them to use marijuana, how to get marijuana, how to grow marijuana, the great fun of marijuana.  Go on YouTube and type in marijuana, and see how many videos come up using marijuana, joking around about marijuana.  And then when you start showing one, of course the system is designed to show you similar things.  Type in heroin.  See what kind of sites come up, and see what kind of videos come up on these sites.  Young people spend more time on these sites than they do, frequently, watching television.  Remember, there is somebody telling your children things about drugs.  And if it’s not you, the chances are they’re telling them things that are false and dangerous.  So there is a kind of naiveté about what the young peoples’ world, as it presents itself to them, tells them about these substances.  It minimizes the danger, it suggests that it’s something that you can do to be more independent, not be a kid anymore. 

We, from my generation — because I’m a baby boomer — unfortunately have had an association of growing up in America with the rebellion that’s been associated with drug use.  That’s been very dangerous, and we’ve lost a lot of lives.  We have to remember that it’s alive and well, and has become part of the technological sources of information that young people have.  I also see young people in treatment centers who got in a chat room and somebody offered them drugs or offered them to come and buy them alcohol and flattered them, and got them involved in incredibly self-destructive behavior.  The computer brings every predator and every dangerous influence into your own child’s home – into their bedroom in some cases, if that’s where that computer exists.  You wouldn’t let your kids go out and play in the park with drug dealers.  If you have a computer and it’s not supervised, those drug dealers are in that computer.  Remember that.  And they’re only a couple of keystrokes away from your child.

Q 13:  And you talk about the YouTube and the computers and all those things.  What about just the overall societal image?  Because we have this whole image with heroin, of heroin chic.  How much does that contribute to the drug use, and how difficult does it make your job, when a drug is being made out to be cool in society by famous people?

WALTERS:  There are still some elements of that.  It was more prominent a number of years ago.  I would say you see less of that now glamorized in the entertainment industry, or among people who are celebrities in and out of entertainment.  You see more cases of real harm.  But it’s still out there.  The one place that I think is replacing that, just to get people ahead of the game here, is prescription pharmaceuticals.  Those have been marketed to kids on the internet as a safe high.  They falsely suggest that you can overcome the danger of an overdose because you can predict precisely the dosage of OxyContin, hydrocodone, Vicodin.  And there are sites that suggest what combination of drugs to use.  We’ve seen prescription drug use as the one counter example of a category of drug use going up among teens.  We’re trying to work on that as well, but that’s something that’s in your own home, because many people get these substances for legitimate medical care.  Young people are going to the medicine cabinet of family or friends, taking a few pills out and using those.  And those are as powerful as heroin, they’re synthetic opioids, and they have been a source of overdose deaths. 

So let’s not forget – while this Fairfax example reminds us of the issues of heroin chic and of the heroin that’s in our communities, the new large problem today is a similar dangerous substance in pill form in our own medicine cabinets.  Barrier to access is zero.  They don’t have to find a drug dealer; they just go find the medicine cabinet.  They don’t have to pay a dime for it because they just take it and they share that with their friends.  We need to remember, that’s another dimension here.  Keep these substances out of reach – under our control when we have them in our home.  Throw them away when we’re done with them.  Make sure we talk to kids about pills.  Because people, again, are telling them that’s the place to go to avoid overdose death, is to take a pill.

Q 14:  When you see a lot of these celebrities checking in and out of rehab, does it sort of glamorize it for kids?  And teach them hey, you can use, you can check into rehab, you can come back, you can – you know.  Is there a mixed message there?

WALTERS:  There is.  Some young people interpret it the way you describe; of it’s something you do and you can get away with it by going into rehab.  We do a lot of research on young people’s attitudes for purposes of helping shape prevention programs in the media, as well as in schools and for parents.  We do a lot with providing material to parents.  I would say that compared to where we’ve been in the last 15 or 20 years, there’s less glamorization today.

I think we should also remember the positive, because we reinforce that.  A lot of young people – obviously not all or we wouldn’t have this death – believe that taking drugs makes you a loser.  They’ve seen that a lot of those celebrities are showing their careers going down the toilet because they can’t get away from the pills and the drugs and the alcohol.  And I think they see that even among some of their peers.  That’s a good thing.  We should reinforce that as parents: teaching our kids that drug and alcohol use may be falsely presented to you as something you do that would make you popular, make you seem like you should have more status in society generally.  But actually, look at a lot of these people; they’ve had enormous opportunities, enormous gifts, and they can’t stop themselves from throwing them away.  And they may not stop themselves from throwing away their lives. 

I think you could use these events as a teachable moment.  It can go two ways.  Help your child understand what the truth is here.  And I tell young people – and I think parents have to start this more directly – this is the way this is going to come to you:  Somebody you really, really want to like you; somebody you really, really like; someone you may even love — or think you love — they’re going to say come and do this with me.  If you can’t find any other reason to not do this with them, say, “Before we do this, let’s go to a treatment center.  Let’s go talk to people who stood where we stood and said it’s not going to happen to me.”  If everybody, when they got the chance to start, thought of an addict or somebody who was dead, they wouldn’t start.  The fact is that does not enter their mind. 

Many people in treatment centers understand that part of the task of recovery is helping other people avoid this.  So they’re willing to talk about it.  In fact, that’s part of their path of staying clean and sober, which not many kids are going to be able to do on their own.  But it makes them think that what presents itself as something overwhelmingly attractive has behind it a horrible dimension, for their friends as well as for themselves.  And more and more, I think kids understand this.

We can use the science of this as a disease, and the experience of many families.  Remember, uncle Joe didn’t used to be like this.  Especially Thanksgiving, when we have families getting together and all of a sudden mom’s going to get loaded and become ugly in the corner.  We also have to remember we have an obligation to reach out to those people, and to get them help.  We can treat them.  Nobody gets sober, in my experience, by themselves.  They have to take responsibility.  But you have to overcome the pushback, and addiction and alcoholism have, as a part of the disease, denial.  When you tell somebody they have a problem, they get angry with you.  They don’t say hey thanks, I want your help.  They don’t hit bottom and become nice.  That’s a myth.  They need to be grabbed and encouraged and pushed.  Almost everybody in treatment is coerced – by a family member, by an employer, sometimes by the criminal justice system.

So remember that, when you find your child using and they want to lie to you up down and sideways saying, “It’s the first time I’ve ever done it.”  No, no, no, no, no, that’s the drugs talking.  That shows you, if anything, you have a bigger problem than you realized and you need to reach out, get some professional help.  But don’t wait!

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

DeForest Rathbone, Chairman, Great Falls, Virginia, 703-759-2215, DZR@prodigy.net

Abstract

3,4-Methylenedioxymethamphetamine (MDMA, Ecstasy) tablets are widely used recreationally, and not only vary in appearance, but also in MDMA content. Recently, the prevalence of high-content tablets is of concern to public health authorities. To compare UK data with other countries, we evaluated MDMA content of 412 tablets collected from the UK, 2001-2018, and investigated within-batch content variability for a sub-set of these samples. In addition, we investigated dissolution profiles of tablets using pharmaceutical industry-standard dissolution experiments on 247 tablets. All analyses were carried out using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Our data supported other studies, in that recent samples (2016-2018) tend to have higher MDMA content compared to earlier years. In 2018, the median MDMA content exceeded 100 mg free-base for the first time. Dramatic within-batch content variability (up to 136 mg difference) was also demonstrated. Statistical evaluation of dissolution profiles at 15-minutes allowed tablets to be categorized as fast-, intermediate-, or slow-releasing, but no tablet characteristics correlated with dissolution classification. Hence, there would be no way of users knowing a priori whether a tablet is more likely to be fast or slow-releasing. Further, within-batch variation in dissolution rate was observed. Rapid assessment of MDMA content alone provides important data for harm reduction, but does not account for variability in (a) the remainder of tablets in a batch, or (b) MDMA dissolution profiles. Clinical manifestations of MDMA toxicity, especially for high-content, slow-releasing tablets, may be delayed or prolonged, and there is a significant risk of users re-dosing if absorption is delayed.

Source: https://pubmed.ncbi.nlm.nih.gov/31009168/ August 2019

Colorado appears doomed to repeat failure

After two fouled attempts to sway the Colorado Legislature that these sites will curb the state’s overdose crisis, harm reduction advocates persuaded a majority in the House Health and Human Services Committee to pass the bill on a 9-4 party-line vote.

These sites are illegal under federal law; the bill, however, appears poised to pass the House in the same party-line fashion.

While persistence may be on the proponents’ side, the facts, when thoroughly considered, are not in their corner.

Bill advocates use a sole metric of “effectiveness” to support their claim that these sites will reduce overdose deaths.

In the North American communities where these sites have been piloted, including Vancouver, British Columbia, San Francisco, and New York’s Harlem neighborhood, there are virtually no reported overdose deaths on the sites themselves. Conveniently omitted is the data showing that drug overdose rates have soared in the communities surrounding the pilot sites.

In Vancouver, where the normalization of such behavior over 20 years is likely to have had some effect, deaths due to illicit drug toxicity have risen by 840% since its first site opened in 2004. Heroin possession and trafficking incidents increased by nearly 170% from 2004 to 2018.

Still, a more thorough look at the overdose death rate should not be the sole metric used by the Colorado Legislature to evaluate comprehensive effectiveness.

One consideration is whether these sites reduce overall harm to a person struggling with addiction.

The Centers for Disease Control and Prevention classifies addiction as a medical condition, a brain disease that needs treatment.

San Francisco’s site experiment revealed that “revived” drug abusers often continue to take the drugs and overdose. There are documented cases of the same person being revived from an overdose more than 30 times, making them further subject to toxic brain injury, according to the Brain Injury Association. Repeated drug abuse destroys frontal lobe tissue, the source of motor function and judgment, and can lead to further injury to the brain, including hypoxia or brain anoxia, in which the body forgets how to breathe. Enabling the disease is hardly a benign effort.

Further, legislators should evaluate the impact on the surrounding neighborhoods. The neighbors of the sites in Harlem reported an uprising of drug markets where dealers have unlimited access to customers. At the same time, Harlem’s children are forced to navigate used syringes along the sidewalks. In San Francisco, the neighbors endured a similar experience, which led the city to shut down the site within one year of operations.

The linking of site visitors to treatment programs must also be considered. In Vancouver, less than 2% of the site visitors access treatment of any sort. In the San Francisco pilot program, it was less than 1%. Notably, the site operators in Harlem don’t measure this indicator.

Finally, Colorado legislators must consider last week’s bipartisan repeal of Oregon’s Measure 110 by its Legislature. In 2020, Measure 110 was overwhelmingly passed by Oregon voters, who were told that the decriminalization of drugs would “reduce stigma” and reduce use for those struggling with addiction. In three short years, Oregon is now one of the nation’s leaders in addiction and overdose death rates and now has the second-highest increase in homelessness in the country.

More than 1 in 10 Coloradoans struggle with addiction — one of the highest rates in the nation. Colorado’s homeless population grew by nearly 40% in 2023 over 2022. Colorado can ill afford another public policy experiment that rejects recovery and restoration that is not only possible for the individual struggling with addiction but also necessary for a functioning society.

Colorado lawmakers must serve as the backstop to this failed policy. They must look through the portal of experience versus through the narrow lens imparted by the bill’s authors to see the broad implications to all Coloradoans if HB 24-1028 were to pass.

 

Source: https://www.iwf.org/2024/03/29/safe-injection-sites-are-no-answer-to-addiction/

How families can help prevent teen substance use disorder

If you or someone you know is in immediate need of help for substance use, or any mental health crisis, the national 988 Lifeline is the best place to start. You can call or text 988 from any phone, or connect via webchat.

Recent studies, both nationally and at Michigan Medicine, report that alcohol, cannabis and nicotine vaping are the most commonly used substances among teens.

Aside from cannabis and prescription drug misuse, teens report relatively low use of illicit substances. Despite this, teen drug overdose deaths have been on the rise in recent years. Monthly overdose deaths among youth aged 10-19 more than doubled from 2019 to 2021.

Parents and caregivers should actively be on the lookout for signs and symptoms of substance use. Addressing substance use early on can help prevent addiction or other problems later in life.

An expert from the University of Michigan Addiction Center recently spoke about the impacts of teen substance use and what families can do to help youth who may be at risk or showing signs of addiction.

Trends in teen substance use

Meghan Martz, Ph.D., a research assistant professor of psychiatry, explains concerning trends surrounding adolescent substance use. Although levels have stabilized in recent years, there are new factors for parents to consider.

When it comes to alcohol use, binge drinking remains the leading concern. This harmful consumption pattern can lead to blackouts, vomiting, overdose and mental and physical health problems.

Vaping nicotine products also remains popular among teens. Martz says the flavored products cater directly to its young audience, posing a serious risk of addiction for adolescents.

As cannabis legalization has become widespread, perceptions of harm have decreased, and rates of cannabis use have increased tremendously. In 2023, 29% of 12th graders reported cannabis use in the past year.

“The level of THC is much stronger in cannabis products used today, and there is a direct link between higher potency and risk for disordered use,” Martz said, describing the substance in cannabis that causes most of the “high” sensation that users feel.

Parents should particularly monitor for opioids, even if the use rates are lower than other substances. Due to drugs laced with fentanyl, a highly potent synthetic opioid, there has been a recent surge in overdose deaths.

Risk factors

The exact reasons for substance use can vary, “but teens are the most vulnerable population for disordered use,” Martz said.

It all starts with a curiosity about substances. Ten percent of 9- and 10-year-olds reported curiosity to use alcohol and nicotine, according to research Martz led. The desire to fit in socially can significantly influence the decision to try substances, and teens tend to overestimate the prevalence of substance use among their peers.

Factors that can lead to substance use in teens include:

  • A family history of substance use.
  • Associating with substance using peers.
  • Coping with mental health issues like anxiety, depression or ADHD.
  • Low parental monitoring.
  • Lack of school connectedness.

The adolescent brain

It’s important to remember that “the risk factors present in teens are associated with the development of the adolescent brain,” said Martz.

Three key functions of the brain are associated with substance use: reward, emotion and cognitive control.

The reward circuit involves the release of dopamine, a naturally occurring chemical attributed to feelings of pleasure. People become hooked to this false sense of happiness and develop an addiction to the drug supplying it.

Similarly, drugs can influence the emotion circuit by reducing feelings of anxiety, irritability and unease. The addiction is reinforced through a cycle of withdrawal symptoms that can range from mild discomfort to life-threatening complications.

But for adolescents, it is the cognitive control circuit that makes them most susceptible to substance use. This brain function is responsible for thinking, planning and problem solving.

“The cognitive control circuit is the last part of the brain to mature,” Martz said.

“This makes youth more prone to act on impulse and engage in risky behaviors, including substance use.”

Teens are also less likely to experience immediate consequences of substance use – such as hangovers – leading to greater consumption and more damaging neurotoxic effects.

Advice for families

Substance use and addiction prevention starts in the home. Parents are the first line of defense against potential drug use disorders.

There is no guarantee that your child won’t use substances, but it is less likely to happen if you:

  • Bring it up early – kids are curious from a young age.
  • Talk early and often about the dangers of substance use.
  • Set rules about substance use.
  • Focus on the biological impact to the brain and body, rather than moral or legal considerations.

As a parent, you may not be able to control the external influences, but you can certainly start the conversation early and set firm boundaries to protect your child from substance use,” Martz said.

 

Source: https://www.michiganmedicine.org/health-lab/what-parents-should-know-about-teen-drug-and-alcohol-use

 

Cannabis and cannabinoids are implicated in multiple genotoxic, epigenotoxic and chromosomal-toxic mechanisms and interact with several morphogenic pathways, likely underpinning previous reports of links between cannabis and congenital anomalies and heritable tumours. However the effects of cannabinoid genotoxicity have not been assessed on whole populations and formal consideration of effects as a broadly acting genotoxin remain unexplored. Our study addressed these knowledge gaps in USA datasets. Cancer data from CDC, drug exposure data from National Survey of Drug Use and Health 2003–2017 and congenital anomaly data from National Birth Defects Prevention Network were used. We show that cannabis, THC cannabigerol and cannabichromene exposure fulfill causal criteria towards first Principal Components of both: (A) Down syndrome, Trisomies 18 and 13, Turner syndrome, Deletion 22q11.2, and (B) thyroid, liver, breast and pancreatic cancers and acute myeloid leukaemia, have mostly medium to large effect sizes, are robust to adjustment for ethnicity, other drugs and income in inverse probability-weighted models, show prominent non-linear effects, have 55/56 e-Values > 1.25, and are exacerbated by cannabis liberalization (P = 9.67 × 10 –43 ,2.66 × 10 –15 ). The results confirm experimental studies showing that cannabinoids are an important cause of community-wide genotoxicity impacting both birth defect and cancer epidemiology at the chromosomal hundred-megabase level.

Source: https://www.nature.com/articles/s41598-021-93411-5.epdf July 2021

Kratom, in powder form, can be taken in capsules or brewed into a tea.

A kratom leaf, the source of an herbal supplement that users say can provide pain relief and relieve insomnia, among other uses.

Vivian Allen sought chronic pain relief.

A car wreck left the 55-year-old grandmother immobilized. Six subsequent back surgeries led to severe nerve damage. A doctor advised implanting a morphine pump but Allen, from Walker, Louisiana, worried about the southern climate. A morphine pump implant could not withstand 90-degree heat and could kill her.

She felt desperate.

When a friend from a Facebook group suggested kratom, the herbal supplement derived from leaves of a Southeast Asian tree, Allen decided to try it.

“I couldn’t believe it,” she said. “It alleviated my symptomatic problems and it helped me have a functional life without having to get the implant.”

Kratom, which she began taking in 2015, also allowed her to wean herself from the Xanax pills she’d been prescribed for more than two decades.

“People take kratom because they need it,” she said. “It’s that simple. Very few people take it recreationally.”

But if lawmakers have their way, Allen and other kratom users throughout Louisiana could be out of luck.

A bill set to criminalize kratom in Louisiana was passed several weeks ago.

The legislation, prompted by a Louisiana Department of Health (LDH) report and pushed through by state Rep. Chris Turner, R-Ruston, was passed unanimously by the Senate and the House and signed into law June 11 by Gov. John Bel Edwards.

Kratom will be banned under the act if the U.S. Drug Enforcement Administration (DEA) categorizes it as a Schedule I drug. The category, which includes drugs like heroin, ecstasy and peyote, indicates a lack of medical use and suggests a high potential for abuse.

This move to classify kratom as Schedule I has been attempted before. In 2016, the DEA listed kratom as a “drug and chemical of concern” and temporarily banned it. It’s currently illegal in Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin. Other states, including Colorado, Nevada, Illinois and Florida, have outlawed kratom in certain jurisdictions.

The U.S. Food and Drug Administration (FDA) hasn’t approved kratom for human consumption either. In June, the FDA expressed disdain when addressing kratom distributors in Folsom, California and Wilmington, North Carolina for making false medical assertions.

“Despite our warnings, companies continue to sell this dangerous product and make deceptive medical claims that are not backed by science or any reliable scientific evidence,” FDA Commissioner Ned Sharpless said in a statement. “As we work to combat the opioid crisis, we cannot allow unscrupulous vendors to take advantage of consumers by selling products with unsubstantiated claims that they can treat opioid addiction or alleviate other medical conditions.”

The FDA continued to state that “substances” in kratom have opioid properties “that expose users to the risks of addiction, abuse and dependence.”

“There are no FDA-approved uses for kratom, and the agency has received concerning reports about the safety of kratom,” the statement said. “The FDA encourages more research to better understand kratom’s safety profile, including the use of kratom combined with other drugs.”

The FDA also has recommended classifying kratom as a Schedule I drug.

So what exactly is kratom?

Originating from a Southeast Asian evergreen tree, kratom (Mitragyna speciosa) leaves contain mitragynine and 7-a-hydroxymitragynine, organic compounds that target opioid receptors in the brain. It can be taken in capsule or powder form or brewed into a tea. There are several strains including Maeng Da, which is said to boost energy; Red Vein Kali, commonly taken for sedation; and Green Vein Kali, known to treat pain.

Although they work on the same receptors as opiates, they don’t have the same chemical properties.

Wesley Nance, 26, a singer who lives in New Orleans and works at The Herb Import Company in Mid-City, said he used two strains of kratom to ease scoliosis pain.

He took 2 grams of Green Vein Kali in the morning for his aching, and 2 grams of Red Vein Kali at night so he could sleep without discomfort.

“It made my pain go away,” he said. “I was amazed.”

Nance was wary of pharmaceutical drugs after seeing his mother’s addiction to opioids, he said. “Kratom helped me change the family history,” he said. “It helped me heal naturally.”

Scott Ploof, 35, publisher of Big Easy Magazine, began using it after the death of his grandfather.

“It helped me alleviate anxiety and depression in a natural way,” he said.

Ploof believes a partisan political climate is undermining the reality of the drug’s benefits and possible risks. “Politics is getting in the way of reason,” he said. “Kratom is a safe, natural, herbal alternative supplement that can be used to treat a variety of issues and is better than a lot of what else is out there.”

Kratom also has been praised by former opioid users.

Neal Catlett, 39, of Lexington, Kentucky, became hooked on oxycodone and morphine in 2015 after a shoulder injury. He credits kratom with helping him kick the prescription medications by easing withdrawal symptoms and physical pain.

“It’s a lifesaver for those who suffer from drug addiction,” he told Gambit. “It’s an amazing plant.”

The LDH, however, outlined different results of kratom use. The department’s 14-page report, released in February, points to dangers.

In 2017, the FDA reported 44 to 47 deaths related to kratom use, with one caused by “pure kratom.” The rest resulted from mixing other drugs with kratom, including fentanyl, diphenhydramine, caffeine, and morphine. Kratom also was associated with a national salmonella outbreak from January 2017 to May 2018 that affected 199 people ranging from 1 to 75 years old. No deaths were recorded but one-third of the individuals needed hospitalization, the report said.

“Heavy users of kratom often lose weight, become tired and suffer constipation,” the report said. “Facial redness may also occur. Repeated doses of 10 to 25 grams of dried leaves cause perspiration, dizziness, nausea, and dysphoria (a state of unease or generalized dissatisfaction with life), which become quickly replaced by a state of calm, euphoria and a dreaming state which may last up to six hours. The LDH concluded by advocating for a ban.

“Kratom currently has no accepted medical uses,” it goes onto say. “Therefore, the Louisiana Department of Health recommends that kratom be banned from general consumption in the state, with exceptions made only in the context of well-designed scientific studies with appropriate oversight, data safety monitoring boards and regulatory approval.”

LDH spokeswoman Mindy Faciane told Gambit the decision was made with consumer well-being in mind. “The Louisiana Department of Health supports any efforts that help make Louisiana residents safer,” Faciane said.

Kratom has been a boon for New Orleans businesses that sell it, despite any risks. Uxi Duxi in Mid-City and Mushroom New Orleans in Uptown sell kratom products to loyal customers.

Ashley Daily, who owns the Euphorbia Kava Bar in Riverbend, said kratom accounts for more than 50 percent of her business. A ban “wouldn’t shut me down,” she said, “but it would make me very broke and it would affect my employees.”

After five years in business, she is making a profit for the first time, largely because of kratom — but Daily said it’s about more than commerce. “It’s what [a ban] would do to my customers who depend on kratom,” she said. “Twenty percent of my clientele use it as a natural painkiller. Other ex-users get off opioids with it and it truly helps them.”

Christopher Hummel, owner of Mushroom New Orleans, began selling kratom about seven years ago but only saw a sales uptick in the past two years.

“People are now trying to avoid prescription painkillers, and they take kratom so they don’t have to [take them],” he says. “Banning it would cause a major health issue.”

Reza Hardinata, 20, a native of Pontianak, Indonesia, told Gambit kratom is his family’s main source of income. His father harvests it and Hardinata sells kratom to local companies that export the substance each month. “Kratom is very helpful in terms of health, addiction and pain relief and also improves the economy of my family and also the community,” he said. “This [ban] is very unfortunate.”

Others who study the science behind kratom believe the FDA is amplifying adverse effects while ignoring empirical data. Marc T. Swogger, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center, conducted peer-reviewed research on kratom. Although no clinical trials to examine kratom’s benefits have been directed in America, he said, “observational studies” in the United States and Southeast Asia have been “compelling.”

“Across samples, people report pain relief, relief of anxiety or depressed mood, and the utility of kratom to serve as an opioid replacement, easing symptoms of opioid withdrawal,” he said.

Swogger believes criminalization would set up a “new and vibrant black market” for kratom.

“In addition to being ineffective, a kratom ban would be wrong,” he said. “People are using kratom to help with difficult conditions and reporting success. For some of them, lack of access to kratom would lead to the increased use of classical opioids, setting the stage for yet more overdoses.”

The Kratom Information & Resource Center (KIRC) last week launched a campaign to get journalists to cover kratom with “fair and balanced” reporting. 

“This is a legal product that is being used by informed adults in the privacy of their homes and dedicated commercial establishments,” KIRC spokesman Max Karlin said in a statement. “If kratom were as much of a problem as it has been made out by some organizations engaging in reckless ‘Leafer Madness’ rhetoric, America’s hospitals and ERs would be choked. … Instead, experts can’t agree whether there has been even one kratom-related death in the U.S.”

McClain “Mac” Haddow, senior fellow on public policy at the American Kratom Association (AKA), agrees, and believes the approximately 5 million kratom users in the U.S. should have access to a regulated product.

That’s why Haddow and the AKA are working with politicians to enact the Kratom Consumer Protection Act, which aims “to regulate preparation, distribution, and sale of kratom products” to prohibit adulterated or contaminated kratom. He believes selling to people over 18 and ensuring the purity of the kratom would be more helpful than a ban.

“If you ban it, people in the kratom community will die,” he says.

Instead, he believes in regulatory measures and thinks kratom advocates in Louisiana will prevail in the end.

“The Louisiana ban is not as bad as it sounds,” he said. “We’re pretty comfortable on the federal side that there is movement. We’re more and more confident that we’re being heard.”

Haddow said he plans to work with Rep. Turner’s office to enact the Kratom Consumer Protection Act in Louisiana during the next legislative session.

Allen, who testified in a June judiciary hearing in Baton Rouge about kratom use, said passing the act would be the most effective compromise. “Having the Kratom Consumer Protection Act is the best thing for Louisiana,” she says. “Consumers need to be protected but they shouldn’t lose what helps them. Mine is only one of 5 million stories. People shouldn’t be denied the ability to heal.”

Source:  https://www.theadvocate.com/gambit/new_orleans/news/the_latest/article_b6261ece-b23e-11e9-8739-6f4af0786d5a.html   5 Aug. 2019

Summary

Background

Adolescence represents a crucial developmental period in shaping mental health trajectories. In this study, we investigated the effect of the COVID-19 pandemic on mental health and substance use during this sensitive developmental stage.

Methods

In this longitudinal, population-based study, surveys were administered to a nationwide sample of 13–18-year-olds in Iceland in October or February in 2016 and 2018, and in October, 2020 (during the COVID-19 pandemic). The surveys assessed depressive symptoms with the Symptom Checklist-90, mental wellbeing with the Short Warwick Edinburgh Mental Wellbeing Scale, and the frequency of cigarette smoking, e-cigarette use, and alcohol intoxication. Demographic data were collected, which included language spoken at home although not ethnicity data. We used mixed effects models to study the effect of gender, age, and survey year on trends in mental health outcomes.

Findings

59 701 survey responses were included; response rates ranged from 63% to 86%. An increase in depressive symptoms (β 0·57, 95% CI 0·53 to 0·60) and worsened mental wellbeing (β −0·46, 95% CI −0·49 to −0·42) were observed across all age groups during the pandemic compared with same-aged peers before COVID-19. These outcomes were significantly worse in adolescent girls compared with boys (β 4·16, 95% CI 4·05 to 4·28, and β −1·13, 95% CI −1·23 to −1·03, respectively). Cigarette smoking (OR 2·61, 95% CI 2·59 to 2·66), e-cigarette use (OR 2·61, 95% CI 2·59 to 2·64), and alcohol intoxication (OR 2·59, 95% CI 2·56 to 2·64) declined among 15–18-year-olds during COVID-19, with no similar gender differences.

Interpretation

Our results suggest that COVID-19 has significantly impaired adolescent mental health. However, the decrease observed in substance use during the pandemic might be an unintended benefit of isolation, and might serve as a protective factor against future substance use disorders and dependence. Population-level prevention efforts, especially for girls, are warranted.

Funding

Icelandic Research Fund.
Source: Depressive symptoms, mental wellbeing, and substance use among adolescents before and during the COVID-19 pandemic in Iceland: a longitudinal, population-based study – The Lancet Psychiatry June 2021

  • Neither the cause of autism nor the effects of cannabis on a developing fetus are entirely clear 
  • Researchers at the Ottawa Hospital and University of Ottawa studied 2,200 Canadian women who reported using marijuana while pregnant 
  • The rate of autism among their children was four per 1,000 person-years, compared to 2.42 among children whose mothers did not use marijuana  

Pregnant women who smoke cannabis almost double the risk of their baby being born autistic, warns a new study.

In the largest ever study of its kind, researchers found that children whose mothers reported using cannabis during pregnancy were at greater risk of autism.

The incidence of autism was four per 1,000 person-years among children exposed to cannabis in pregnancy, compared to 2.42 among unexposed children.

‘There is evidence that more people are using cannabis during pregnancy,’ said senior study author Professor Mark Walker, of the University of Ottawa in Canada.

‘This is concerning, because we know so little about how cannabis affects pregnant women and their babies.

‘Parents-to-be should inform themselves of the possible risks, and we hope studies like ours can help.’

A Canadian study found that rates of autism were twice as high among the children of women who used marijuana during pregnancy, compared to rates among children of mothers  who did not use the drug (file)

The researchers reviewed data from every birth in Ontario between 2007 and 2012, before recreational cannabis was legalised in Canada.

Of the half a million women in the study, about 3,000 (0.6 per cent) reported using cannabis during pregnancy.

Importantly, these women reported using only cannabis.

The team had previously found that cannabis use in pregnancy was linked to an increased risk of premature birth.

In that study, they found that women who used cannabis during pregnancy often used other substances including tobacco, alcohol and opioids.

The findings, published in the medical journal Nature Medicine. showed that babies born to this group still had an increased risk of autism compared to those who didn’t use cannabis.

The researchers do not know exactly how much cannabis the women were using, how often, at what time during their pregnancy, or how it was consumed.

But as cannabis becomes more socially acceptable, doctors are concerned that some parents-to-be might think it can be used to treat morning sickness.

Dr Daniel Corsi, an epidemiologist at The Ottawa Hospital, said: ‘In the past, we haven’t had good data on the effect of cannabis on pregnancies.’

He added: ‘This is one of the largest studies on this topic to date.

‘We hope our findings will help women and their health-care providers make informed decisions.’

Autism is fairly common, but still poorly understood.

In the US, about one in every 59 children born will fall somewhere on the autism spectrum.

About one in every 66 children in Canada are autistic and, globally, the rate is approximately one in every 160 children.

Research suggests that there is likely some genetic basis for autism,  which is about four-times more common among boys than girls.

But scientists believe exposures in the womb likely play a role as well.

The effects of cannabis are similarly poorly understood to the origins of autism.

Although doctors caution against it, cannabis use has not been linked to miscarriages in humans (though animal studies have suggested an increased risk) and evidence on the link between weed and low birth-weight is mixed.

Marijuana use during pregnancy has been linked, however, to up to 2.3 times greater risks of stillbirth.

The Ottawa Hospital study did not investigate how exactly marijuana use in pregnancy might lead to autism in a child, but scientists believe that the drug’s interaction with the so-called endocannabinoid system within the nervous system could play a role in the development of the behavioral condition.

Source: Autism is twice as common in children whose mothers used cannabis in pregnancy | Daily Mail Online

Research suggests that smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco.

Credit…Gracia Lam

Do you have the heart to safely smoke pot? Maybe not, a growing body of medical reports suggests.

Currently, increased smoking of marijuana in public, even in cities like New York where recreational use remains illegal (though no longer prosecuted), has reinforced a popular belief that this practice is safe, even health-promoting.

“Many people think that they have a free pass to smoke marijuana,” Dr. Salomeh Keyhani, professor of medicine at the University of California, San Francisco, told me. “I even heard a suggestion on public radio that tobacco companies should switch to marijuana because then they’d be selling life instead of selling death.”

But if you already are a regular user of recreational marijuana or about to become one, it would be wise to consider medical evidence that contradicts this view, especially for people with underlying cardiovascular diseases.

Compared with tobacco, marijuana smoking causes a fivefold greater impairment of the blood’s oxygen-carrying capacity, Dr. Keyhani and colleagues reported.

In a review of medical evidence, published in January in the Journal of the American College of Cardiology, researchers described a broad range of risks to the heart and blood vessels associated with the use of marijuana.

The authors, led by Dr. Muthiah Vaduganathan, cardiologist at Brigham and Women’s Hospital in Boston, point out that “marijuana is becoming increasingly potent, and smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco.”

Edible forms of marijuana have also been implicated as a possible cause of a heart attack, especially when high doses of the active ingredient THC are consumed.

With regard to smoking marijuana, Dr. Vaduganathan explained in an interview, “The combustion products a tobacco smoker inhales have a very similar toxin profile to marijuana, so the potential lung and heart effects can be comparable. When dealing with patients, we really have to shift our approach to the use of marijuana.”

His team reported, “Although marijuana is smoked with fewer puffs, larger puff volumes and longer breath holds may yield greater delivery of inhaled elements.” In other words, when compared to tobacco smoking, exposure to chemicals damaging to the heart and lungs may be even greater from smoking marijuana.

Dr. Vaduganathan said he was especially concerned about the increasing number of heart attacks among marijuana users younger than 50. In a registry of cases created by his colleagues, in young patients suffering a first heart attack, “marijuana smoking was identified as one factor that was more common among them.” The registry revealed that, even when tobacco use was taken into account, marijuana use was associated with twice the hazard of death among those under age 50 who suffered their first heart attack.

Other medical reports have suggested possible reasons. A research team headed by Dr. Carl J. Lavie of the John Ochsner Heart and Vascular Institute in New Orleans, writing in the journal Missouri Medicine, cited case reports of inflammation and clots in the arteries and spasms of the coronary arteries in young adults who smoke marijuana.

Another damaging effect that has been linked to marijuana is disruption of the heart’s electrical system, causing abnormal heart rhythms like atrial fibrillation that can result in a stroke. In one survey of marijuana smokers, the risk of stroke was increased more than threefold.

These various findings suggest that a person need not have underlying coronary artery disease to experience cardiovascular dysfunction resulting from the use of marijuana. There are receptors for cannabinoids, the active ingredients in marijuana, on heart muscle cells and blood platelets that are involved in precipitating heart attacks.

Cannabinoids can also interfere with the beneficial effects of various cardiovascular medications, including statins, warfarin, antiarrhythmia drugs, beta-blockers and calcium-channel blockers, the Boston team noted.

The researchers found that in an analysis of 36 studies among people who suffered heart attacks, the top three triggers were use of cocaine, eating a heavy meal and smoking marijuana. And 28 of 33 systematically analyzed studies linked marijuana use to an increased risk of what are called acute coronary syndromes — a reduction of blood flow to the heart that can cause crushing chest pain, shortness of breath or a heart attack.

“In settings of an increased demand on the heart, marijuana use may be the straw on the back, the extra load that triggers a heart attack,” Dr. Vaduganathan said. He suggested that the recent decline in cardiovascular health and life expectancy among Americans may be related in part to the increased use of marijuana by young adults.

“We should be screening and testing for marijuana use, especially in young patients with symptoms of cardiovascular disease,” Dr. Vaduganathan urged.

He expressed special concern about two recent practices: the vaping of marijuana and the use of more potent forms of the drug, including synthetic marijuana products.

“Vaping delivers the chemicals in marijuana smoke more effectively, resulting in increased doses to the heart and potentially adverse effects that are more pronounced,” the cardiologist said. “Marijuana stimulates a sympathetic nervous system response — an increase in blood pressure, heart rate and demands on the heart that can be especially hazardous in people with preexisting heart disease or who are at risk of developing it.”

Dr. Vaduganathan’s team estimated that more than two million American adults who say they have used marijuana also have established cardiovascular disease, according to data from the National Health and Nutrition Examination Surveys in 2015 and 2016.

According to Dr. Keyhani, who works at the San Francisco VA Medical Center, the combination of marijuana smoking and pre-existing heart disease is especially concerning because inhaling particulate matter of any kind can harm the heart and blood vessels.

“Marijuana is a leafy green, and combustion of any plant is probably toxic to human health if the resulting products are inhaled,” she explained. “Unfortunately, the research base is inadequate because marijuana hasn’t been studied in randomized clinical trials.”

A major problem in attempts to clarify the risks of marijuana is its classification by the U.S. Drug Enforcement Administration as a Schedule I drug, making it illegal to study it rigorously in controlled clinical trials.

Scientists must then resort to the next best research method: prospective cohort studies in which large groups of people with known habits and risk factors are followed for long periods to assess their health status. “The challenge is to recruit a cohort of daily cannabis users,” Dr. Keyhani said. “It’s absolutely important to look at the health effects of cannabis now that the prevalence of daily use is increasing. The absence of evidence is not evidence of absence.”

While there are currently no official guidelines, Dr. Vaduganathan’s team urged that anyone known to be at increased risk of cardiovascular disease should be advised to minimize the use of marijuana or, better yet, quit altogether.

Source:  https://www.nytimes.com/2020/10/26/well/live/marijuana-heart-health-cardiovascular-risks.html October 2020

Despite stereotypical images of addicts injecting heroin and then dying, new government research finds that smoking drugs such as fentanyl is now the leading cause of fatal overdoses.

In the new research, published Thursday in Morbidity and Mortality Weekly Report, scientists from the U.S. Centers for Disease Control and Prevention found the percentage of overdose deaths between January 2020 and December 2022 linked to smoking increased 73.7% — going from from 13.3% to 23.1% — while the percentage of overdose deaths linked to injection decreased 29.1% — going from from 22.7% to 16.1%.

These changes were most pronounced when fentanyl was the drug of choice: In those cases, the percentage with evidence of injection decreased 41.6%, while the percentage with evidence of smoking increased 78.9%.

CDC officials explained in their report that they decided to tackle the topic after seeing reports from California suggesting that smoking fentanyl was becoming the preferred way to use the deadly drug.

Fentanyl accounts for nearly 70% of overdose deaths in the United States, they noted.

Some early research has suggested that smoking fentanyl is somewhat less deadly than injecting it, and any reduction in injection-related overdose deaths is a positive, report author Lauren Tanz, a CDC senior scientist who studies overdoes, told the Associated Press.

However, “both injection and smoking carry a substantial overdose risk,” and it’s not clear if a shift toward smoking fentanyl will lower the number of U.S. overdose deaths, Tanz said.

Fentanyl is a powerful drug that, in powder form, is cut into heroin or other drugs. In recent years, it’s been fueling the U.S. overdose epidemic. Drug overdose deaths climbed slightly in 2022 after two big leaps during the pandemic, and provisional data for the first nine months of 2023 suggests it inched up again last year, the AP reported.

For years, fentanyl has been injected, but drug users often smoke it now. Users put the powder on tin foil or in a glass pipe, heated from below, and inhale the vapor, Alex Kral, a RTI International researcher who studies drug users in San Francisco, told the AP.

Smoked fentanyl is not as concentrated as fentanyl in a syringe, but some users see upsides to smoking, Kral explained, including the fact that people who inject drugs often deal with pus-filled abscesses on their skin and risk infections with hepatitis and other diseases.

“One person showed me his arms and said, ‘Hey, look at my arm! It looks beautiful! I can now wear T-shirts and I can get a job because I don’t have these track marks,’” Kral said.

In the new report, investigators were able to cull data from the District of Columbia and 27 states for the years 2020 to 2022. From there, they tallied how drugs were taken in about 71,000 of the more than 311,000 total U.S. overdose deaths over those three years.

By late 2022, 23% of the deaths occurred after smoking, 16% after injections, 16% after snorting and 14.5% after swallowing, the researchers reported.

Tanz said she feels the data is nationally representative because it came from states in every region of the country, and all showed increases in smoking and decreases in injecting. Smoking was the most common route in the West and Midwest, and roughly tied with injecting in the Northeast and South, the report found.

Kral noted the study has some limitations.

It can be difficult to determine the exact cause of an overdose death, especially if no witness was present, he said, and injections might be more reported more often because it is easy to spot needle marks on the body. To detect smoking as a cause of death, “they likely would need to find a pipe or foil on the scene and decide whether to write that down,” he said.

Kral added that many people who smoke fentanyl use a straw, and it’s possible investigators saw a straw and assumed it was snorted.

By Robin Foster HealthDay Reporter

SOURCE: Morbidity and Mortality Weekly Report, Feb. 16, 2024; Associated Press

More information

The National Institute on Drug Abuse has more on drug overdose deaths.

Copyright © 2024 HealthDay. All rights reserved.

To Whom it may concern

On behalf of Drug Free Australia and our coalition of drug prevention researchers, we wish to commend to you, research that could well be a game-changer in informing and preventing a large proportion of Australia’s substance use issues.

The research is in various stages of development and a synopsis of current and emerging research, being done by Dr Stuart Reece and Professor Gary Hulse should be of genuine interest for all Australian Health Professionals. However, it appears that, to date, too many of the world’s researchers have placed this important research in the ‘too hard’ basket, similar to the way the NHS in the United Kingdom did with research into Pandemics.

At present the COVID-19 pandemic and how it is being addressed, should be a ‘wakeup call’ to Australian health authorities that prevention is the single most important goal. A ‘Harm Minimisation’ only approach, fails to achieve best-practice primary prevention outcomes. The passive discounting of the primary pillar of the National Drug Strategy – Demand Reduction over the last 30 years (and particularly the last 10) has seen a very large increase in illegal drug use in this nation.

The only exception to this has been seen in the correct and full use of both demand and supply reduction on the drug Tobacco. There has been little or no use of harm reduction mechanisms and a relentless and unified approach to abstinent/cessation modelling and it has worked spectacularly well, seeing Australia with, arguably, the lowest daily tobacco use in the world.

The research, that we now summarise, should not be placed in Australia’s ‘too hard’ basket. Rather, it warrants recognition by all Australian Health authorities for the world break-through that it is. Such evidence-based data offers timely insights that should promote and resource primary prevention and demand reduction.

Synopsis of the research:
1. Canadian Cannabis Consumption and Patterns of Congenital Anomalies: An Ecological Geospatial Analysis Albert Stuart Reece, MBBS(Hons), FRCS(Ed), FRCS(Glas), FRACGP, MD(UNSW), and Gary Kenneth Hulse, BBSc(Hons), MBSc, PhD
https://journals.lww.com/journaladdictionmedicine/Abstract/publishahead/Canadian_Cannabis_Consumption_and_Patterns_of.99248.aspx

Status
Mapping showed cannabis use was more common in the northern Territories of Canada in the Second National Survey of Cannabis Use 2018. Total congenital anomalies, all cardiovascular defects, orofacial clefts, Downs syndrome and gastroschisis were all found to be more common in these same regions and rose as a function of cannabis exposure.

When Canada was dichotomized into high and low cannabis use zones by Provinces v Territories the Territories had a higher rate of total congenital anomalies 450.026 v 390.413 (O.R.=1.16 95%C.I. 1.08-1.25, P=0.000058; attributable fraction in exposed 13.25%, 95%C.I. 7.04–19.04%). In geospatial analysis in a spreml spatial error model cannabis was significant both alone as a main effect (P<2.0×10-16) and in all its first and second order interactions with both tobacco and opioids from P<2.0×10-16.

Conclusion:

These results show that the northern Territories of Canada share a higher rate of cannabis use together with elevated rates of total congenital anomalies, all cardiovascular defects, Down’s syndrome and gastroschisis. This is the second report of a significant association between cannabis use and both total defects and all cardiovascular anomalies and the fourth published report of a link with Downs syndrome and thereby direct major genotoxicity.

The correlative relationships described in this paper are confounded by many features of social disadvantage in Canada’s northern territories. However, in the context of a similar broad spectrum of defects described both in animals and in epidemiological reports from Hawaii, Colorado, USA and Australia they are cause for particular concern and indicate further research.

139 References – click on this link to access.
https://journals.lww.com/journaladdictionmedicine/Abstract/publishahead/Canadian_Cannabis_Consumption_and_Patterns_of.99248.aspx

2. Cannabis Consumption Patterns Parallel the East-West Gradient in Canadian Neural Tube Defect Incidence – An Ecological Study
https://www.researchgate.net/publication/337911618_Cannabis_Consumption_Patterns_Explain_the_East-West_Gradient_in_Canadian_Neural_Tube_Defect_Incidence_An_Ecological_Study

Status:
Whilst a known link between prenatal cannabis exposure (PCE) and anencephaly exists, the relationship of PCE with neural tube defects (NTD’s) generally has not been defined. Published data from Canada Health and Statistics Canada was used to assess this relationship. Both cannabis use and NTDs were shown to follow an east-west and north-south gradient. Last year cannabis consumption was significantly associated (P<0.0001; Cannabis use: time interaction P<0.0001). These results were confirmed when estimates of termination for anomaly were used. Canada Health population data allowed the calculation of an NTD O.R.=1.27 (95%C.I. 1.19-1.37; P<10-11) for high risk provinces v. the remainder with an attributable fraction in exposed populations of 16.52% (95%C.I. 12.22-20.62). Data show a robust positive statistical association between cannabis consumption as both a qualitative and quantitative variable and NTDs on a background of declining NTD incidence. In the context of multiple mechanistic pathways these strong statistical findings implicate causal mechanisms.

82 References – click on this link to access.
https://www.researchgate.net/publication/337911618_Cannabis_Consumption_Patterns_Explain_the_East-West_Gradient_in_Canadian_Neural_Tube_Defect_Incidence_An_Ecological_Study

3. Cannabis exposure as an interactive cardiovascular risk factor and accelerant of organismal ageing: a longitudinal study. Response to Lane
https://bmjopen.bmj.com/content/6/11/e011891.responses

Status:
We wish to thank Dr Lane for his interest in our study. We are pleased to see statistical input to the issues of cannabis medicine as we feel that sophisticated statistical methodologies have much to offer this field.

Most of the concerns raised are addressed in our very detailed report. As described our research question was whether, in our sizeable body of evidence (N=13,657 RAPWA studies), we could find evidence for the now well-described cannabis vasculopathy and what such implications might be. As this was the first study of its type to apply formal quantitative measures of vascular stiffness to these questions it was not clear at study outset if there would be any effect, much less an estimate of effect size. In the absence of this information power calculations would be mere guesswork. Nor indeed are they mandatory in an exploratory study of this type. Similarly the primary focus of our work was on whether cannabis exposure was an absolute cardiovascular risk factor in its own right, and how it compared to established risk factors. Hence Table 2 contains our main results. The role of Table 1 is to illustrate the bivariate (uncorrected) comparisons which can be made, show the various groups involved, and compare the matching of the groups. It is not intended to be a springboard for effect-size-power calculations which are of merely esoteric interest.
Calculations detailing the observed effect size are clearly described in our text being 11.84% and 8.35% age advance in males and females respectively.

Mixed-effects models are the canonical way to investigate longitudinal data given a usual random error structure 1. We agree with Lane that unusual error structures can affect significance conclusions. Diagnostic tests run on our models confirm that the residuals had the usual spheroidal error structure so that the application of mixed-effects models in the classical way is quite satisfactory. Another way to investigate this issue is that of incremental model building comparing models with and without cannabis exposure terms. If one considers regression equations from our data with cannabis use treated either as a categorical (RA/CA ~ Days_Post-Cannabis * BMI + * Cannabis_Category) or a continuous (RA/(CA*BMI) ~ Cigs*SP + * Cannabis_Use +Chol+DP+HDL+HR+CRH) variable one notes firstly that terms including cannabis use remain significant in final models (after model reduction) and secondly that models which include cannabis exposure are significantly better than ones without (Categorical: AIC = 1088.56 v. 1090.22, Log.Ratio = 19.62, P = 0.0204; Continuous: AIC = 412.33 v. 419.73, Log.Ratio = 9.37, P = 0.0022). Unfortunately formatting rules for BMJ Rapid Responses do not allow us to include a detailed table of regression results in each model in the present reply. We also note that AIC’s are little used in our report, and simply indicate the direction of the ANOVA results comparing models linear, quadratic and cubic in chronological age. They also appear routinely in the display of mixed-effects model results. Their use in such contexts is methodologically unremarkable. Control groups are also spelled out in fine detail in Table 1, in all our Figures and in the text.

We are aware that various algorithms for vascular age have been reported in the literature. The list proposed by Lane is correct but non-exhaustive. Such algorithms are generally derived from known cardiovascular risk factors. As clearly stated in our report the algorithm for vascular age we employed is derived from the proprietary software used. As such its details have not been publicized and indeed are commercially protected information.

We have however been assured by AtCor on many occasions that it includes measures of chronological age, sex, arterial stiffness and height (which is important as it dictates distance and thus speed parameters for the reflected and augmented central arterial pressure waves) and is very well validated and tested. AtCor recently advised that their algorithm is based on a very large series of studies done with arterial stiffness published in 2005 2. As such it has distinct advantages over algorithms which do not include indices of arterial stiffness. The AtCor website includes a very interesting, informative and educative animated loop which clearly illustrates the complex relationship between chronological and vascular age as a function of arterial stiffness and vascular tone 3

We are keen to see advanced statistical methods applied to such questions. We are becoming interested in geospatial and spacetime analyses and its application to the important questions of cannabis epidemiology 4. We find the very breadth of the organ systems impacted by cannabis to be quite remarkable with effects on the brain, cardiovasculature, liver, lungs, testes, ovaries, gastrointestinal, endocrine, reproductive and immune systems being well described and constituting most of the body’s major systems 5 6. Testicular and several pediatric cancers have also been described as being cannabis-associated 5. Such a multisystem generality of toxicity suggests to us that some basic cellular functions may be deleteriously affected – as implied by its well described mitochondriopathy 7, its heavy epigenetic footprint 8, accelerated aging as described in our present report 9 or some multi-way interaction between these and other processes. Given that the cannabis industry is presently entering a major commercialization growth phase, and given the multigenerational implications of mitochondriopathy-epigenotoxicity (by direct: substrate supply including ATP, NAD+ and acetate; and indirect: RNA transfer and malate-aspartate and glycerol-3-phosphate shuttle; pathways 10) further study and elucidation of these points is becoming an increasingly imperative international research priority.

Apropos of the recent Covid-19 pandemic emergency it is also worth noting that since cannabis is immunosuppressive, is known to be damaging to lungs and airways and often carries chemical, microbial and fungal contaminants cannabis use and cannabis vaping is also likely to have a deleterious effect on the coronavirus epidemic. Such data implies an untoward convergence of two public health epidemics. Appropriate controls on cannabis use imply improved public health management of SARS-CoV-2.

10 References – click on this link to access. https://bmjopen.bmj.com/content/6/11/e011891.responses

4. Cannabis Teratology Explains Current Patterns of Coloradan Congenital Defects: The Contribution of Increased Cannabinoid Exposure to Rising Teratological Trends.
https://www.researchgate.net/publication/334368364_Cannabis_Teratology_Explains_Current_Patterns_of_Coloradan_Congenital_Defects_The_Contribution_of_Increased_Cannabinoid_Exposure_to_Rising_Teratological_Trends/link/5d2d4d39a6fdcc2462e3097c/download

Status
Rising Δ9-tetrahydrocannabinol concentrations in modern cannabis invites investigation of the teratological implications of prenatal cannabis exposure.

Data from Colorado Responds to Children with Special Needs (CRCSN), National Survey of Drug Use and Health, and Drug Enforcement Agency was analyzed. Seven, 40, and 2 defects were rising, flat, and falling, respectively, and 10/12 summary indices rose. Atrial septal defect, spina bifida, microcephalus, Down’s syndrome, ventricular septal defect, and patent ductus arteriosus rose, and along with central nervous system, cardiovascular, genitourinary, respiratory, chromosomal, and musculoskeletal defects rose 5 to 37 times faster than the birth rate (3.3%) to generate an excess of 11 753 (22%) major anomalies. Cannabis was the only drug whose use grew from 2000 to 2014 while pain relievers, cocaine, alcohol, and tobacco did not. The correlation of cannabis use with major defects in 2014 (2019 dataset) was R = .77, P = .0011. Multiple cannabinoids were linked with summary measures of congenital anomalies and were robust to multivariate adjustment.

66 References – click on this link to access
https://www.researchgate.net/publication/334368364_Cannabis_Teratology_Explains_Current_Patterns_of_Coloradan_Congenital_Defects_The_Contribution_of_Increased_Cannabinoid_Exposure_to_Rising_Teratological_Trends/link/5d2d4d39a6fdcc2462e3097c/download

5. Impacts of cannabinoid epigenetics on human development: reflections on Murphy et. al. ‘cannabinoid exposure and altered DNA methylation in rat and human sperm’ epigenetics 2018; 13: 1208-1221.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773386/pdf/kepi-14-11-1633868.pdf
Status

ABSTRACT Recent data from the Kollins lab (‘Cannabinoid exposure and altered DNA methylation in rat and human sperm’ Epigenetics 2018; 13: 1208–1221) indicated epigenetic effects of cannabis use on sperm in man parallel those in rats and showed substantial shifts in both hypo- and hyper-DNA methylation with the latter predominating. This provides one likely mechanism for the transgenerational transmission of epigenomic instability with sperm as the vector. It therefore contributes important pathophysiological insights into the probable mechanisms underlying the epidemiology of prenatal cannabis exposure potentially explaining diverse features of cannabis-related teratology including effects on the neuraxis, cardiovasculature, immune stimulation, secondary genomic instability and carcinogenesis related to both adult and pediatric cancers. The potentially inheritable and therefore multigenerational nature of these defects needs to be carefully considered in the light of recent teratological and neurobehavioural trends in diverse jurisdictions such as the USA nationally, Hawaii, Colorado, Canada, France and Australia, particularly relating to mental retardation, age-related morbidity and oncogenesis including inheritable cancerogenesis.

Increasing demonstrations that the epigenome can respond directly and in real time and retain memories of environmental exposures of many kinds implies that the genome-epigenome is much more sensitive to environmental toxicants than has been generally realized. Issues of long-term multigenerational inheritance amplify these concerns. Further research particularly on the epigenomic toxicology of many cannabinoids is also required. 

206 References – click on this link to access

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773386/pdf/kepi-14-11-1633868.pdf

6. Canadian Cannabis Consumption and Patterns of Congenital Anomalies: An Ecological Geospatial Analysis.
https://www.ncbi.nlm.nih.gov/pubmed/32187114

Status:
These results show that the northern Territories of Canada share a higher rate of cannabis use together with elevated rates of total congenital anomalies, all cardiovascular defects, Down’s syndrome and gastroschisis. This is the second report of a significant association between cannabis use and both total defects and all cardiovascular anomalies and the fourth published report of a link with Downs syndrome and thereby direct major genotoxicity. The correlative relationships described in this paper are confounded by many features of social disadvantage in Canada’s northern territories. However, in the context of a similar broad spectrum of defects described both in animals and in epidemiological reports from Hawaii, Colorado, USA and Australia they are cause for particular concern and indicate
further.

139 references – click on this link to access https://www.ncbi.nlm.nih.gov/pubmed/32187114

7. The Potential Association Between Prenatal Cannabis use and Congenital Anomalies
https://journals.lww.com/journaladdictionmedicine/Citation/9000/The_Potential_Association_Between_Prenatal.99243.aspx

Status:
Rates of prenatal cannabis use are likely to rise with legalization, increasing social tolerability, and promotion in social media. Cannabis consumption does not appear to be a benign activity, and there may be significant risk factors to the developing fetus when used in pregnancy. Even as epidemiological data continue to emerge, The American College of Obstetricians and Gynecologists and The Society of Obstetricians and Gynecologists of Canada recommend that women avoid the use of cannabis during pregnancy.14 Whether we will definitively establish the risk of prenatal cannabis use on congenital anomalies using epidemiological approaches remains unclear; however, combing data from ecological and patient-level approaches will be crucial. Patient engagement and increasing awareness of the health implications of cannabis are critical first steps to highlight the potential risks of cannabis use in pregnancy.

14. References – click on this link to access
https://journals.lww.com/journaladdictionmedicine/Citation/9000/The_Potential_Association_Between_Prenatal.99243.aspx

8. America Addresses Two Epidemics – Cannabis and Coronavirus and their Interactions: An Ecological Geospatial Study
Status: Embargoed until publication.

Question: Since cannabis is immunosuppressive and is frequently variously contaminated, is its use associated epidemiologically with coronavirus infection rates?

Findings: Geospatial analytical techniques were used to combine coronavirus incidence, drug and cannabinoid use, population, ethnicity, international flight and income data. Cannabis use and daily cannabis use were associated with coronavirus incidence on both bivariate regression and after multivariable spatial regression with high levels of statistical significance. Cannabis use quintiles and cannabis legal status were also highly significant.

Meaning: Significant geospatial statistical associations were shown between cannabis use and coronavirus infection rates consistent with mechanistic reports and environmental exposure concerns.

Extracts from Abstract:

Results. Significant associations of daily cannabis use quintile with CVIR were identified with the highest quintile having a prevalence ratio 5.11 (95%C.I. 4.90-5.33), an attributable fraction in the exposed (AFE) 80.45% (79.61-81.25%) and an attributable fraction in the population of 77.80% (76.88-78.68%) with Chi-squared-for-trend (14,782, df=4) significant at P<10-500. Similarly when cannabis legalization was considered decriminalization was associated with an elevated CVIR prevalence ratio 4.51 (95%C.I. 4.45-4.58), AFE 77.84% (77.50-78.17%) and Chi-squared-for-trend (56,679, df=2) significant at P<10-500. Monthly and daily use were linked with CVIR in bivariate geospatial regression models (P=0.0027, P=0.0059). In multivariable additive models number of flight origins and population density were significant. In interactive geospatial models adjusted for international travel, ethnicity, income, population, population density and drug use, terms including last month cannabis were significant from P=7.3×10-15, daily cannabis use from P=7.3×10-11 and last month cannabis was independently associated (P=0.0365).

Conclusions and Relevance. Data indicate CVIR demonstrates significant trends across cannabis use intensity quintiles and with relaxed cannabis legislation. Recent cannabis use is independently predictive of CVIR in both bivariate and multivariable adjusted models and intensity of use is significant in several interactions. Cannabis thus joins tobacco as a SARS2-CoV-2 risk factor.

Summary and Conclusions

The above research clearly shows the links with substance use and Mental illness, Autism, Congenital anomalies and Paediatric cancer including testicular cancer with marijuana use and abuse. Drug Free Australia respectfully and urgently requests a Position Statement and proposed actions from your Department regarding this research and how it can be further promoted and supported within Australia. We look forward to your timely response.

You can find a list of list of Ngo’s and Medical Professional who written support for Drug Free Australia’s Response to the commercialization of Cannabis/Marijuana/CBD in Australia

https://drugfree.org.au/images/pdf-files/homepagepdf/DRReeceSupport2020_updated6May2020.pdf.

Yours sincerely
Major Brian Watters AO B.A.
President
Drug Free Australia
PO Box 379
Seaford, SA 516

 

The sale and use of illegal drugs are among the most serious problems facing the UK, indeed, the entire world, right now. This issue is particularly prevalent within Britain’s night-time economy, where even the most stringently law-abiding and responsibly run premises are not guaranteed to be completely free from the presence of drugs and/or drug dealers.

As a security operative, especially a door supervisor, you are in a unique position to spot potential drug deals and put a stop to them. This is of benefit to both the venue as well as its patrons. Overall, it also helps to keep the public safe.

In this feature, we’ll show you to spot a probable drug deal, identify a likely drug dealer and offer advice on what to do once you’ve confirmed your suspicions. We will also examine the laws around drugs, including what is and isn’t allowed and who is liable if those laws are broken on the premises you’re guarding.

Drug Dealers in Popular Culture

The sale of drugs has, of course, existed for thousands of years. However, in prehistory and antiquity drug use probably had at least some religious or spiritual connotations.

Nevertheless, recreational drug use dates back at least as far as Ancient Mesopotamia (and probably a lot further than that). Ancient Sumerians freely traded opium along with other commodities, while the ancient Egyptians prized blue water lotus flowers for their hallucinogenic properties (King Tutankhamun was even buried with some). These drugs were not illicit or illegal in their respective eras and traders would have bought and sold them openly.

Notable books concerning drug use and purchase include Thomas De Quincey’s autobiographical account ‘Confessions of an English Opium Eater’ (1821) and William Burroughs’ 1953 debut ‘Junkie: Confessions of an Unredeemed Drug Addict’.

In 1966, The Beatles released their ‘Revolver’ album, which featured a song called ‘Dr. Robert’. The song, inspired by real-life figure Dr. Robert Freymann, tells the story of a supposedly legitimate medical doctor who abuses his prescription pad in order to get his ‘patients’ any kind of drug they want. The song is notable for being one of the first times a drug dealer was depicted overtly, as well as in a generally positive light.

One year later, New York alternative band ‘The Velvet Underground’ released their debut album, which featured the songs ‘Waiting for the Man’ (which described a drug deal) and ‘Heroin’, the meaning of which ought to be self-explanatory. These songs were even more explicit and frank about illegal drugs and the people that use them.

The popular culture of the early 21st century is replete with examples of drug dealers. The 1983 gangster film ‘Scarface’ starring Al Pacino tells the story of Tony Montana, a Cuban refugee and petty criminal who becomes a wealthy drug baron in America. Today, ‘Scarface’ looms large in popular culture, with its themes and iconography being referenced in everything from other movies and TV shows to poster art, video games and even song lyrics.

Drug use and the sale of drugs are staples of gangster movies, with the sale of illicit materials often being contrasted with the basic assumptions of American capitalism as a way to comment upon society in general.

Another good example of these themes can be seen in the 2007 film ‘American Gangster’ starring Denzel Washington and Russell Crowe. This film also depicts drug dealing as a pathway to riches among the downtrodden and dispossessed.

‘American Gangster’s story, essentially, mirrors that of both ‘Scarface’ and any number of other movies of the genre, as well as, not incidentally, the typical experience of any addict. Drugs are initially seen as empowering and fun before becoming uncontrollable and eventually leading to the central character’s downfall.

The media treats street-level drug dealers, however, in a variety of different ways.

The 1993 movie ‘Trainspotting’ (an adaptation of the novel of same name by Irvine Welsh), starring Ewan McGregor, was praised for its frank and hard-hitting discussion of heroin addiction. The movie depicts a blurred line between using and dealing.

Perhaps popular culture’s best-loved drug dealers are Jay & Silent Bob. Beginning with the debut of comedy writer/director Kevin Smith, 1994’s ‘Clerks’, Jay (Jason Mewes) and his ‘hetero life-mate’ Silent Bob (Kevin Smith) appear in almost all of Smith’s movies, occasionally as central characters.

The pair, who mainly deal marijuana, are depicted as loveable, if crass, figures, who often attempt to resolve the issues of other characters via either heartfelt advice (‘Clerks’, ‘Chasing Amy’) or direct action (‘Mallrats’, ‘Dogma’). The pair appear to be stereotypical 1990’s-era drug dealers, usually peddling their wares outside the local convenience store, but their behaviour frequently upends audience expectations for comic effect.

The AMC TV series ‘Breaking Bad’, which began in 2008, depicts a grittier take on drug dealing. In the series, chemist Walter White (Bryan Cranston) is diagnosed with inoperable lung cancer and resorts to manufacturing and selling methamphetamines as a way of securing his family’s finances after his death. This decision leads him down a bad road, which sees the character becoming progressively darker as the show continues.

Similarly, the Starz black comedy series ‘Weeds’ (beginning in 2005) details the misadventures of widowed mother-of-two Nancy Botwin (Mary-Louise Parker), who takes to dealing marijuana as a way of supporting her family.

The legal drama series ‘Suits’, which began in 2011, features a drug dealer by the name of Trevor (Tom Lipinski), who is, at the series’ outset, best friend of main character Mike Ross (Patrick J. Adams). Unlike a stereotypical dealer, Trevor wears expensive suits and poses as a software developer to peddle his wares to a rich clientele. A failed drug deal involving Mike is the series’ inciting incident.

So, the portrayal of drug dealers in popular culture tends to vary, usually according to what drugs they are selling. Those selling marijuana are often depicted in a positive or comedic light (such as the episode of ‘Curb Your Enthusiasm’ wherein Larry David buys marijuana for his father), while those selling cocaine, heroin and other, harder drugs are usually seen as villainous, or at least more complicated, characters.

On television, drug dealers (that are not main characters) are usually seen as scruffy, but still attired in the urban fashions of the period (punk style in the 80’s and early 90’s, Hip Hop fashions from the mid-90’s – 2000’s, etc). They are traditionally young males.

Sadly, a disproportionate number of television drug dealers are cast as ethnic minorities, which does not reflect reality and only serves to fuel any number of negative stereotypes.

Such stylistic choices are part of a visual shorthand that encourages the audience to make a quick ‘snap judgement’ about a character in order not to waste any time setting up the joke or scene. So, if a young man, dressed in urban wear approaches a character, the audience will understand that he is likely a drug dealer. By contrast, if an older woman, dressed perhaps in an evening gown, approached the character, they would have to remark on the perceived incongruity of this alleged dealer in order for the scene to work.

These sorts of visual codes may be very useful for the TV and film industries, but they don’t do any favours to the security operative that is hoping to spot -and stop – a real-life drug deal taking place.

So, what are drug dealers like in real life?

Drug Dealers in Real Life

After surveying 243 self-identified drug dealers, researchers from the American Addiction Centers created the following profile of the ‘average’ drug dealer.

According to this fascinating and insightful study, a drug dealer is slightly more likely to be male than female (their numbers were 63% male and 37% female) and is likely to start dealing at around the age of 19 and stop by 23. Drug dealing is much rarer over the age of 30, but it definitely does happen.

The principal motivations for drug dealing are apparently needing money (40%), wanting extra money (29%) and the dealers desiring popularity with their peers (19%). Other motivations include the idea that drug dealers live glamorous lives (5%), peer pressure (5%) and supporting their own addictions (2%).

Most dealers got started through a friend (57%), or else through their own dealer (27%), while 10% stated that they were introduced to drug dealing through a family member.

The average drug dealer’s clientele is primarily students (34%) and working professionals (28%), although high school students (remember that this study is American, so these students could be as old as 18) also featured prominently. 2% even claimed to have dealt drugs to law enforcement offers.

The study revealed that 43% of the average drug dealer’s clients were considered by them to be addicts, but that only 11% of females and 9% of males denied their wares to those they considered at risk of death.

In hindsight, 61% said that they felt regret for their actions, while 39% were at peace with them. Only 45% admitted to feeling guilty, however, with a 55% majority stating that they did not. A small percentage stated that their actions had resulted in the deaths of some friends or clients.

The data is clear. Whilst a drug dealer is statistically slightly more likely to be young and male, they can (and do) look like anyone. Where TV’s drug dealers often wear loud clothes and openly publicise their products like foul-mouthed market vendors, real-life drug dealers are usually very adept at simply ‘blending in’ to their surroundings and not drawing undue attention to themselves.

Pop culture often assumes that drug dealers must resemble stereotypical drug users, however this is also rarely the case. A lot of dealers don’t use any drugs themselves and sell their products after working all day at a regular, 9-5 job.

Drug dealers can range from relatively innocuous-seeming people who sell ‘soft’ drugs to a small group of friends and/or family, to individuals of considerable wealth and influence, who sell, indirectly, to large numbers of people.

Some dealers sell prescription pain medication for those who are addicted to it, or experience chronic pain, some sell drugs that they consider harmless (but are, in fact, quite dangerous) and others do not consider themselves to be drug dealers at all.

Drug dealers can be any sex, gender, age, race, or class. So how can they be spotted?

How to Spot a Drug Deal

Knowing what we now know, we must consider that drug dealers are likely to be hard to spot. A drug deal, on the other hand, usually displays certain distinguishing characteristics that can be readily identified.

One trait common to most drug dealers is that they tend to set up in the same place each time they visit a venue. They do this so that customers know where to find them. A drug dealer’s preferred location is usually somewhere dark, slightly away from prying eyes, as well as a place that is likely to always be available. In most cases, dealers will not set themselves up in direct view of bar staff or door supervisors.

Be aware of any regular who sets themselves up in one specific place all or most of the time and is visited by multiple, seemingly unrelated, patrons or makes regular trips to the toilet. This person is very possibly a drug dealer.

Watch also for conspiratorial behaviour, such as two or more people huddling together as if sharing a secret. More experienced dealers will avoid this type of behaviour, but some dealers can still be identified this way.

Some dealers use accomplices known as ‘runners’ or ‘minders’ who actually carry the drugs and/or money. In this way, if the dealer is searched, security operatives or police will find nothing on them. A runner may not liaise with the dealer directly, but if a suspected dealer is visited several times by the same person, you may be inclined to search that person as well.

Dealers will often have a larger-than-average amount of cash about their person (although online payment methods are making this trait less common than it was). If a person has an abundance of cash on them (and you don’t work security in a strip club), this could be a sign that they are a dealer.

In person, dealers are often friendly and amiable, many are even charming. They are, after all, salespeople. With many customers that are probably nervous, it stands to reason that a dealer would want to be somewhat approachable.

Drug dealers are often very uncomfortable around the subject of drugs, however. When spoken to on the subject, many dealers will assume that they’ve been found out and will avoid the subject before leaving in a hurry. If you approach a suspected dealer and ask them about drugs while dressed in your uniform, their reaction can be a good indicator of either innocence or guilt.

What the Law Says

The main laws surrounding illegal drugs, at least for the purposes of this feature, are the Misuse of Drugs Act 1971 and the Licensing Act 2003. The Misuse of Drugs Act 1971 states that heavy penalties can be imposed upon any premises found to be permitting the sale or use of illegal drugs

The act, which was created to ensure the UK’s adherence to various international treaty conditions, made it illegal to possess, sell, offer to sell, or supply without charge any controlled drug or substance.

Oddly enough, despite the act’s title, the Misuse of Drugs Act 1971 does not cover the actual use of illegal drugs, nor does it immediately define which drugs it is referring to. Instead, the act defines 4 classes of controlled substances.

Class A’ drugs (heroin, cocaine, MDMA, LSD, methadone, methamphetamines, and magic mushrooms) are the most dangerous and therefore carry the harshest sentences under the act.

Class B’ drugs (amphetamines, codeine, barbiturates, ketamine, cannabis, and related cannabinoids) and ‘Class C’ drugs (anabolic steroids, diazepam, piperazines) are seen as less dangerous and carry lesser sentences. The ‘4th’ class is a temporary class, intended for more specific requirements than the broad classifications found elsewhere in the legislation.

Alcohol and tobacco are subject to separate legislation and are not affected by the terms of the act.

Under the terms of the Licensing Act 2003, if any licensed premises is found to be permitting the sale or use of illegal drugs, either interim steps toward the suspension of the license will be taken, or else the outright suspension of the license will occur.

A premises can also be closed under the Anti-Social Behaviour, Crime and Policing Act 2014.

The Misuse of Drugs Act 1971 was preceded by both the Dangerous Drugs Act 1964 (which dealt primarily with the use of cannabis and was itself preceded by the Dangerous Drug Act 1951) and the Medicines Act 1968, this second law primarily discussed the prescriptions, quality control and advertising of legal medicine. Prior to this, the laws around drugs and drug use were somewhat lax and insufficient.

Also of note is the Psychoactive Substances Act 2016, which was created to stop the spread of so-called ‘legal highs’. ‘Legal highs’ were drugs created to exploit loopholes in the terms of the Misuse of Drugs Act.

These legal drugs gained popularity in the 2000’s and 2010’s and were readily available from a variety of sources. Despite their easy availability, they were also very dangerous, killing almost 100 people in 2012 alone. The Psychoactive Substances Act was created to make their manufacture, sale and use illegal.

At present, Home Office guidelines (specific to, but not limited to raves and other ‘dance events’) allow for free cold water to be given to patrons as requested, the availability of a space to cool down and rest, monitoring of temperatures and air quality, provision of information and advice regarding drugs, and door staff to be trained to handle drug-related issues that may arise. 

Is the Law Effective?

According to the government’s latest figures, drug offences are on the rise in the UK. From 2020-21, drug-related offences jumped up by a massive 19% from 2019 – 20.

However, while this data may indicate a worsening trend, we must also consider the effect of the current coronavirus pandemic on the data. During lockdown, while the sale of illegal substances no doubt occurred, it would have been at least partially diminished, gaining more momentum once lockdowns were lifted.

Historically, British authorities have taken multiple approaches to preventing the sale and use of illegal drugs.

In 1954, the Metropolitan Police set up the Dangerous Drugs Office. It comprised of just 4 officers. In fact, a 1961 report on drug addiction in the UK concluded that

“the incidence of addiction to dangerous drugs is still very small… no cause to fear that any real increase is at present occurring”.

By 1963, however, the Metropolitan Police had learned that some doctors were overordering medicinal drugs and selling the surplus for personal profit, as well as overprescribing to addicts. After the number of arrests for drug-related offences began to climb, Parliament passed the Dangerous Drugs Act 1964 and the Medicines Act 1968.  

Further legislation was passed in the 1970’s and 1980’s, as new drugs began to be featured in the national discourse. Solvent abuse began in earnest in the 1980’s, which prompted the passage of the Intoxicating Substances (Supply) Act 1985, while barbiturates, which had been a serious problem since the mid-late 1970’s, were added to the Misuse of Drugs Act in 1984.

By 1985, MDMA was beginning to appear, claiming its first life in 1986. Police were given extra powers of search and interrogation, with particular emphasis on drug-related crimes by the Police and Criminal Evidence Act 1984.

1985’s Controlled Drug (Penalties) Act increased sentences for drug-related offences and the arrival of AIDS (which had existed since the 70’s, but was formally labelled an epidemic  in the 80’s) issued a public crackdown on needle sharing. Accordingly, the Drug Trafficking Offences Act 1986 came into effect in 1987. This act was partially intended to help recover the profits from drug trafficking. 

As we have seen, the issue of drugs exploded between the 1960’s and the 1990’s. By 1994, drug use was being seen as a global epidemic. The government published its ‘green paper’, titled ‘Tackling Drugs Together: A consultation document on a strategy for England 1995–1998′. This document outlined a ‘new approach to strategic thinking on drugs issues’, with an emphasis on reducing the availability of illegal drugs and keeping communities safer from drug-related offences.

The government also passed the Criminal Justice and Public Order Act 1994, which attempted to control drug use in prisons, as well as at raves.

Some of these measures have been reasonably effective, others appear not to have worked at all. However, the problem continues to persist, at times worsening.

The law is certainly effective when it comes to arresting and detaining some dealers, but the fact that drug use continues to be so persistent and prevalent shows that no measure has ever been 100% successful.

Critics of the Misuse of Drugs Act 1971, for example, have suggested that the classification system is inadequate because it does not consider the relative dangers of the drugs it classifies. This argument was key to the decision to reclassify cannabis as a ‘Class C’ drug in 2004. Nevertheless, the drug was moved back to ‘Class B’ in 2009.

In this case, the law would appear to be somewhat out-of-step with public opinion. The Liberal Democrat Party has supported the legalisation and taxation of Cannabis since 2015, making them the first mainstream British political party to do so.

Public support has also drifted more towards sympathy with hard-drug users in recent years, as mental health issues and the nature of addiction become better understood by the public.

Britain’s anti-drug policies and legislation may appear harsh to some, but there are many other countries that are far less tolerant. In Malaysia, China, Vietnam, Iran, Thailand, Saudi Arabia, Singapore, Indonesia and The Philippines, drug dealers can be (and often are) executed by the state.  

Despite these brutal punishments, drug trafficking, dealing and use still occurs in all these countries. According to the U.N., domestic drug abuse in Vietnam has risen sharply since the 1990’s, while a 2020 review found that mental health conditions, arising from chronic drug use, are a problem in Saudi Arabia.

In addition to heroin and opium use, Thailand is currently facing the rise of a popular street drug known as ‘Yaba’, which is a mixture of caffeine and methamphetamine.

The notion that harsher punishments for crimes will somehow eliminate those crimes from occurring is a faulty one. It has been tried – and has failed, many times throughout history. The death penalty for murder, for example, does not prevent murder.

Is the law effective? Yes and no. As with drugs themselves and basically everything else, it depends on the individual.

Preventing Drug Dealing/Use on the Premises

There are a number of preventative methods that a bar, pub, club or venue can take if it wants to actively discourage drug dealers. Door supervisors are the first line of defence against these activities, so it is of vital importance that they remain vigilant at all times.

Firstly, we advise that proprietors keep their venues clean and tidy, with security cameras in clear view. A drug dealer is probably looking for a place with lax security. If it looks like the management can’t be bothered to clean up at the end of the night, a drug dealer may well feel more confident about ‘setting up shop’ there.

Ensuring that all CCTV, alarms, and other security equipment is up-to-date and functioning well is also a great way to deter drug dealers. 

We also recommend putting up notices that drug dealing on the premises will not be tolerated under any circumstances.  The venue should create a drugs policy and make every employee (including door staff) aware of it. All signage should reflect this policy.

Joining a local ‘Pubwatch‘ scheme is a great way for venues to share intel on specific troublemakers and get a sense of how widespread the problem is in the local area.

It is advisable also to always refuse entry to any known or suspected drug dealers. This can be part of the venue’s drugs policy. For example, it can be venue policy that any patron caught dealing drugs on the premises may be the recipient of a ‘lifetime ban’ and reported to other venues as well.

We also suggest that all security operatives keep an eye out for signs of drug use. Signs of drug use can include payment with tightly wound banknotes (occasionally showing a small amount of powder or blood at the edges), traces of powder left on surfaces (particularly in restrooms), as well as other ‘tell-tale trash’ left behind by drug users, such as small ‘sealie’ bags, torn beermats, empty pill bottles and sweet or chewing gum wrappers.

If the toilets turn up incongruous items such as burned spoons or tinfoil, drinking straws, lighters, razor blades, make-up mirrors, small squares of cling film, syringes or discarded tubes of glue, the venue has probably been visited by a drug user. Surfaces that have been wiped entirely clean before closing time can also be a giveaway.

You may also be alert to the signs of a person using drugs at the venue. These can include the more obvious behaviours (vacant expression, a sense of the person not truly being ‘present’, bloodshot eyes, dilated pupils, excessive chattering, giggling or noise for example), to ordering excessive amounts of water, sporting white marks around the nostrils, and appearing to be either hyperactive or extremely lethargic.

If your venue or premises appears to have a serious problem with drug dealing and/or use, we recommend contacting local police or drug squads. If these problems persist, the venue could lose its license, or be closed entirely. More importantly, lives could even be at stake.

A police licensing officer who has been informed of a potential situation at the venue will be far more likely to show compassion and sympathy to a venue that reaches out for help than they will if they must investigate it of their own volition. Where possible, we advise security staff and venue proprietors to liaise with police at regular intervals.

Door searches, though not always popular, may also be necessary in the more severe cases.

Of course, all drug-related instances, even small ones, must be recorded in the venue’s incident books and, where appropriate, referred to police.

Stopping a drug deal may seem like a small victory. Indeed, many security operatives simply deem it ‘part of the job’ and don’t give it much attention beyond that. However, there is no such thing as an inconsequential action. As the zen proverb has it, “the man who would move a mountain begins by carrying away small stones”.

Each drug deal thwarted contributes toward making Britain’s streets, establishments, and businesses safer, which in turn helps to ensure the safety of people everywhere – and that, more than anything else, is the reason security operatives do what they do in the first place.

Source: Drug Dealers: Dealing with Drugs and Dealers – Working The Doors

Source: 20-Reasons-to-Vote-NO-in-2020-SAM-VERSION-Cannabis.pdf (saynopetodope.org.nz) May 2020

A meta-analysis of all studies worldwide showing association between marijuana use and schizophrenia:

Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370:319–328.
http://dirwww.colorado.edu/alcohol/downloads/Cannabis_and_behavior.pdf

“There was an increased risk of any psychotic outcome in individuals who had ever used cannabis…with greater risk in people who used cannabis most frequently. There is now sufficient evidence to warn young people that using cannabis could increase their risk of
developing a psychotic illness later in life.”

The most recent study conducted in the United States (Columbia University, New York), showing a high risk (odds ratio, “OR”) for schizophrenia spectrum disorders, particularly in those who become cannabis-dependent:

Davis GP, Compton MT, Wang S, Levin FR, Blanco C. Association between cannabis use, psychosis, and schizotypal personality disorder: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Schizophr Res. 2013 Dec;151(1-3):197-202.
“There was a similar dose-response relationship between the extent of cannabis use and schizotypal personality disorder (OR=2.02 for lifetime cannabis use, 95% CI 1.69-2.42; OR=2.83 for lifetime cannabis abuse, 95% CI 2.33-2.43; OR=7.32 for lifetime cannabis dependence, 95% CI 5.51-9.72). Likelihood of individual schizotypal features increased significantly with increased extent of cannabis use in a dose-dependent manner.”

Studies that corrected for general genetic background effects and many non-cannabis environmental variables by comparing siblings. The risk ratios are somewhat lower than general population studies, because genetic predisposition is more or less controlled for:

McGrath J, Welham J, Scott J, Varghese D, Degenhardt L, Hayatbakhsh MR, Alati R, Williams GM, Bor W, Najman JM. Association between cannabis use and psychosis-related outcomes using sibling pair analysis in a cohort of young adults. Arch Gen Psychiatry. 2010; 67(5):440-7.
“Longer duration since first cannabis use was associated with multiple psychosis-related outcomes in young adults… the longer the duration since first cannabis use, the higher the risk of psychosis-related outcomes…
Compared with those who had never used cannabis, young adults who had 6 or more years since first use of cannabis (i.e., who commenced use when around 15 years or younger) were twice as likely to develop a nonaffective psychosis…
This study provides further support for the hypothesis that early cannabis use is a risk-modifying factor for psychosis-related outcomes in young adults.”

Giordano GN, Ohlsson H, Sundquist K, Sundquist J, Kendler KS. The association between cannabis abuse and subsequent schizophrenia: a Swedish national co-relative control study.
Psychol Med. 2014 Jul 3:1-8. [Epub ahead of print]
http://journals.cambridge.org/download.php?file=%2FPSM%2FS0033291714001524a.pdf&code=79f795824a92c8eead870197ef071dd8

“Allowing 7 years from initial CA registration to later diagnosis, the risk for schizophrenia in discordant full sibling pairs remained almost twofold….The results of this study therefore lend support to the etiologic hypothesis, that CA is one direct cause of later schizophrenia.”

Those diagnosed with schizophrenia who also use recreational drugs are much more likely to be violent, including those who use cannabis:

Fazel S, Långström N, Hjern A, Grann M, Lichtenstein P. Schizophrenia, substance abuse, and violent crime. JAMA. 2009 May 20;301(19):2016-23.
“The risk was mostly confined to patients with substance abuse comorbidity (of whom 27.6% committed an offense), yielding an increased risk of violent crime among such patients (adjusted OR, 4.4; 95% CI,3.9-5.0), whereas the risk increase was small in schizophrenia patients without substance abuse comorbidity (8.5% of whom had at least 1 violent offense; adjusted OR,1.2; 95% CI, 1.1-1.4; P<0.001 for interaction).”

Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009 Aug;6(8):e1000120. doi: 10.1371/journal.pmed.1000120. Epub 2009 Aug 11.
“The effect of comorbid substance abuse was marked with….. an OR of 8.9” (as compared to the general population)

Arseneault L, Moffitt TE, Caspi A, Taylor PJ, Silva PA. Mental disorders and violence in a total birth cohort: results from the Dunedin Study. Arch Gen Psychiatry. 2000;57(10):979-86.
“for having more than two of these disorders at once…..the OR (odds ratio for violence) was, …..for marijuana dependence plus schizophrenia spectrum disorder, 18.4”

Harris AW, Large MM, Redoblado-Hodge A, Nielssen O, Anderson J, Brennan J. Clinical and cognitive associations with aggression in the first episode of psychosis. Aust N Z J Psychiatry. 2010 Jan;44(1):85-93.
‘The use of cannabis with a frequency of more than fourfold in the previous month was the only factor that was found to be associated with serious aggression’

Self-report of psychotic symptoms by otherwise healthy users (12% to 15%):

Thomas H. A community survey of adverse effects of cannabis use. Drug Alcohol Depend. 1996 Nov;42(3):201-7.
“This survey estimates the frequency of various adverse effects of the use of the drug cannabis. A sample of 1000 New Zealanders aged 18-35 years were asked to complete a self-administered questionnaire on cannabis use and associated problems. The questionnaire was derived from criteria for the identification of cannabis abuse which are analagous to criteria commonly used to diagnose alcoholism. Of those who responded 38% admitted to having used cannabis. The most common physical or mental health problems, experienced by 22% of users were acute anxiety or panic attacks following cannabis use. Fifteen percent reported psychotic symptoms following use.”

Smith MJ, Thirthalli J, Abdallah AB, Murray RM, Cottler LB. Prevalence of psychotic symptoms in substance users: a comparison across substances. Compr Psychiatry. 2009 May-Jun;50(3):245-50. doi: 10.1016/j.comppsych.2008.07.009. Epub 2008 Sep 23.
“Among all users of substances without a diagnosis of abuse or dependence, cannabis users reported the highest prevalence of psychotic symptoms (12.4%).”

Barkus EJ, Stirling J, Hopkins RS, Lewis S.. Cannabis-induced psychosis-like experiences are associated with high schizotypy Psychopathology 2006;39(4):175-8.
“In the sample who reported ever using cannabis (72%) the means for the subscales from the CEQ were as follows: ……Psychotic-Like Experiences (12.98%).”

Rates of psychotic symptoms in those with cannabis dependence as compared to non-dependent users and nonusers:

Fergusson DM, Horwood LJ, Swain-Campbell NR. Cannabis dependence and psychotic symptoms in young people. Psychol Med. 2003 Jan;33(1):15-21.
“Young people meeting DSM-IV criteria for cannabis dependence had elevated rates of psychotic symptoms at ages 18 (rate ratio = 3.7; 95% CI 2.8-5.0; P < 0.0001) and 21 (rate ratio = 2.3; 95% CI 1.7-3.2; P < 0.0001).”

Smith MJ, Thirthalli J, Abdallah AB, Murray RM, Cottler LB. Prevalence of psychotic symptoms in substance users: a comparison across substances. Compr Psychiatry. 2009 May-Jun;50(3):245-50. doi: 10.1016/j.comppsych.2008.07.009. Epub 2008 Sep 23.
“more than half of the respondents who were dependent on cocaine (80%), cannabis (63.5%), amphetamines (56.1%), and opiates (53.1%) reported psychotic symptoms. Among all users of substances without a diagnosis of abuse or dependence, cannabis users reported the highest prevalence of psychotic symptoms (12.4%)……. There was also a marked increase in the risk for psychotic symptoms when dependence became moderate or severe for cannabis (OR=25.1, OR=26.8; respectively).”

Studies on the psychotomimetic properties of THC administered to healthy individuals in the clinic:

D’Souza DC, Perry E, MacDougall L, Ammerman Y, Cooper T, Wu YT, Braley G, Gueorguieva R, Krystal JH. The psychotomimetic effects of intravenous delta-9-tetrahydrocannabinol in healthy individuals: implications for psychosis. Neuropsychopharmacology. 2004 Aug;29(8):1558-72.
“∆-9-THC (1) produced schizophrenia-like positive and negative symptoms; (2) altered perception;(3) increased anxiety; (4) produced euphoria; (5) disrupted immediate and delayed word recall, sparing recognition recall; (6) impaired performance on tests of distractibility, verbal fluency, and working memory (7) did not impair orientation; (8) increased plasma cortisol. These data indicate that D-9-THC produces a broad range of transient symptoms, behaviors, and cognitive deficits in healthy individuals that resemble some aspects of endogenous psychoses.”

Morrison PD, Nottage J, Stone JM, Bhattacharyya S, Tunstall N, Brenneisen R, Holt D, Wilson D, Sumich A, McGuire P, Murray RM, Kapur S, Ffytche DH. Disruption of frontal θ coherence by ∆9-tetrahydrocannabinol is associated with positive psychotic symptoms. Neuropsychopharmacology. 2011;;36(4):827-36.
“Compared with placebo, THC evoked positive and negative psychotic symptoms, as measured by the positive and negative syndrome scale (p<0.001)…… The results reveal that the pro-psychotic effects of THC might be related to impaired network dynamics with impaired communication between the right and left frontal lobes.”

Bhattacharyya S, Crippa JA, Allen P, Martin-Santos R, Borgwardt S, Fusar-Poli P, Rubia K, Kambeitz J, O’Carroll C, Seal ML, Giampietro V, Brammer M, Zuardi AW, Atakan Z, McGuire PK. Induction of psychosis by ∆9-tetrahydrocannabinol reflects modulation of prefrontal and striatal function during attentional salience processing. Arch Gen Psychiatry. 2012 Jan;69(1):27-36. doi: 10.1001/archgenpsychiatry.2011.161.
“Pairwise comparisons revealed that 9-THC significantly increased the severity of psychotic symptoms compared with placebo (P<.001) and CBD (P<.001).”,

Freeman D, Dunn G, Murray RM, Evans N, Lister R, Antley A, Slater M, Godlewska B, Cornish R, Williams J, Di Simplicio M, Igoumenou A, Brenneisen R, Tunbridge EM, Harrison PJ, Harmer CJ, Cowen P, Morrison PD. How Cannabis Causes Paranoia: Using the Intravenous Administration of ∆9-Tetrahydrocannabinol (THC) to Identify Key Cognitive Mechanisms Leading to Paranoia. Schizophr Bull. 2014 Jul 15. pii: sbu098. [Epub ahead of print]
“THC significantly increased paranoia, negative affect (anxiety, worry, depression, negative thoughts about the self), and a range of anomalous experiences, and reduced working memory capacity.”

For data on dose-response (a very large study by Zammit et al., and another by van Os et al.) and the greater risk for psychosis posed by high strength marijuana (DiForti et al.):

Zammit S, Allebeck P, Andreasson S, Lundberg I, Lewis G, 2002, Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study. BMJ. 2002 Nov 23;325(7374):1199. http://www.bmj.com/content/325/7374/1199.full.pdf
“We found a dose dependent relation between frequency of cannabis use and risk of schizophrenia, with an adjusted odds ratio for linear trend across the categories of frequency of cannabis use used in this study of 1.2 (1.1 to 1.4, P < 0.001). The adjusted odds ratio for subjects with a history of heaviest use of cannabis ( > 50 occasions) was 3.1 (1.7 to 5.5)………………Cannabis use is associated with an increased risk of
developing schizophrenia, consistent with a causal relation. This association is not explained by use of other psychoactive drugs or personality traits relating to social integration.”

van Os J, Bak M, Hanssen M, Bijl RV, de Graaf R, Verdoux H. Cannabis use and psychosis: a longitudinal population-based study. Am J Epidemiol. 2002 Aug 15;156(4):319-27.
“…..further evidence supporting the hypothesis of a causal relation is demonstrated by the existence of a dose-response relation.. between cumulative exposure to cannabis use and the psychosis outcome……. About 80 percent of the psychosis outcome associated with exposure to both cannabis and an established vulnerability to psychosis was attributable to the synergistic action of these two factors. This finding indicates that, of the subjects exposed to both a vulnerability to psychosis and cannabis use, approximately 80 percent had the psychosis outcome because of the combined action of the two risk factors and only about 20 percent because of the action of either factor alone.”

DiForti M, Morgan C, Dazzan P, Pariante C, Mondelli V, Marques TR, Handley R, Luzi S, Russo M, Paparelli A, Butt A, Stilo SA, Wiffen B, Powell J, Murray RM. High-potency cannabis and the risk of psychosis. Br J Psychiatry. 2009,195(6):488-91.
“78% (n = 125) of the cases group preferentially used sinsemilla (skunk) compared with only 31% (n = 41) of the control group (unadjusted OR= 8.1, 95% CI 4.6–13.5). This association was only slightly attenuated after controlling for potential confounders (adjusted OR= 6.8, 95% CI 2.6–25.4)………. Our most striking finding is that patients with a first episode of psychosis preferentially used high-potency cannabis preparations of the sinsemilla (skunk) variety…… our results suggest that the potency and frequency of cannabis use may interact in further increasing the risk of psychosis.”

DiForti M, Marconi A, Carra E, Fraietta S, Trotta A, Bonomo M, Bianconi F, Gardner-Sood P, O’Connor J, Russo M, Stilo SA, Marques TR, Mondelli V, Dazzan P, Pariante C, David AS, Gaughran F, Atakan Z, Iyegbe C, Powell J, Morgan C, Lynskey M, Murray RM. Proportion of
patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study. Lancet Psychiatry, online February 18, 2015, http://dx.doi.org/10.1016/S2215-0366(14)00117-5.
“In the present larger sample analysis, we replicated our previous report and showed that the highest probability to suffer a psychotic disorder is in those who are daily users of high potency cannabis. Indeed, skunk use appears to contribute to 24% of cases of first episode psychosis in south London. Our findings show the importance of raising awareness among young people of the risks associated with the use of high-potency cannabis. The need for such public education is emphasised by the worldwide trend of liberalisation of the legal constraints on cannabis and the fact that high potency varieties are becoming much more widely available.”

For data on percent of those with marijuana-induced psychosis who go on to receive a diagnosis of a schizophrenia spectrum disorder:

Arendt M, Mortensen PB, Rosenberg R, Pedersen CB, Waltoft BL. Familial predisposition for psychiatric disorder: comparison of subjects treated for cannabis-induced psychosis and schizophrenia. Arch Gen Psychiatry. 2008;65(11):1269-74. http://archpsyc.ama-assn.org/cgi/reprint/65/11/1269
“Approximately half of the subjects who received treatment of a cannabis induced psychosis developed a schizophrenia spectrum disorder within 9 years after treatment…… The risk of schizophrenia after a cannabis-induced psychosis is independent of familial predisposition……. cannabis-induced psychosis may not be a valid diagnosis but an early marker of schizophrenia……. Psychotic symptoms after cannabis
use should be taken extremely seriously.”

Niemi-Pynttäri JA, Sund R, Putkonen H, Vorma H, Wahlbeck K, Pirkola SP. Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases. J Clin Psychiatry. 2013 74(1):e94-9.
“Eight-year cumulative risk to receive a schizophrenia spectrum diagnosis was 46% for persons with a diagnosis of cannabis-induced psychosis ….. chances for amphetamine-, hallucinogen-, opioid-, sedative- and alcohol-induced (schizophrenia spectrum diagnoses) were 30%, 24%, 21%, and 5% respectively.”

For cause and effect (which comes first: psychosis or marijuana use):
Arseneault L, Cannon M, Poulton R, Murray R, Caspi A, Moffitt TE, 2002, Cannabis use in
adolescence and risk for adult psychosis: longitudinal prospective study.BMJ. 2002 Nov 23;325(7374):1212-3.
“Firstly, cannabis use is associated with an increased risk of experiencing schizophrenia symptoms, even after psychotic symptoms preceding the onset of cannabis use are controlled for, indicating that cannabis use is not secondary to a pre-existing psychosis. Secondly, early cannabis use (by age 15) confers greater risk for schizophrenia outcomes than later cannabis use (by age 18). Thirdly, risk was specific to cannabis use, as opposed to use of other drugs….”

Henquet C, Krabbendam L, Spauwen J, et al. Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic symptoms in young people. BMJ. 2005;330:11–15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539839/pdf/bmj33000011.pdf
“Exposure to cannabis during adolescence and young adulthood increases the risk of psychotic symptoms later in life. Cannabis use at baseline increased the cumulative incidence of psychotic symptoms at follow up four years later…but has a much stronger effect in those with evidence of predisposition for psychosis……….Predisposition for psychosis at baseline did not significantly predict cannabis use four years later..”

and also:

Kuepper R, van Os J, Lieb R, Wittchen HU, Höfler M, Henquet C. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study.BMJ. 2011 Mar 1;342: d738 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047001/pdf/bmj.d738.pdf
“In individuals who had no reported lifetime psychotic symptoms and no reported lifetime cannabis use at baseline, incident cannabis use over the period from baseline to T2 increased the risk of later incident psychotic symptoms over the period from T2 to T3 (adjusted odds ratio 1.9, 95% confidence interval 1.1 to 3.1; P=0.021)…………There was no evidence for self medication effects, as psychotic experiences at T2 did not predict incident cannabis use between T2 and T3 (0.8, 0.6 to 1.2; P=0.3).”

For data on those who quit using when psychotic symptoms develop (further evidence against self-medication):

Fergusson DM, Horwood LJ, Ridder EM. Tests of causal linkages between cannabis use and psychotic symptoms. Addiction. 2005;100(3):354-66.

For degree of risk relative to other drugs:

Niemi-Pynttäri JA, Sund R, Putkonen H, Vorma H, Wahlbeck K, Pirkola SP. Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases. J Clin Psychiatry. 2013 74(1):e94-9.
“Eight-year cumulative risk to receive a schizophrenia spectrum diagnosis was 46% for persons with a diagnosis of cannabis-induced psychosis ….. chances for amphetamine-, hallucinogen-, opioid-, sedative- and alcohol-induced (schizophrenia spectrum diagnoses) were 30%, 24%, 21%, and 5% respectively.”

Smith MJ, Thirthalli J, Abdallah AB, Murray RM, Cottler LB. Prevalence of psychotic symptoms in substance users: a comparison across substances. Compr Psychiatry. 2009 May-Jun;50(3):245-50. doi: 10.1016/j.comppsych.2008.07.009. Epub 2008 Sep 23.
“more than half of the respondents who were dependent on cocaine (80%), cannabis (63.5%), amphetamines (56.1%), and opiates (53.1%) reported psychotic symptoms. Among all users of substances without a diagnosis of abuse or dependence, cannabis users reported the highest prevalence of psychotic symptoms (12.4%)……. There was also a marked increase in the risk for psychotic symptoms when dependence became moderate or severe for cannabis (OR=25.1, OR=26.8; respectively).”

Another angle on the potential confound of self-medication: genetic predisposition for schizophrenia does not predict cannabis use:

Veling W, Mackenbach JP, van Os J, Hoek HW. Cannabis use and genetic predisposition for schizophrenia: a case-control study. Psychol Med. 2008 Sep;38(9):1251-6. Epub 2008 May 19.
“BACKGROUND: Cannabis use may be a risk factor for schizophrenia. RESULTS: Cannabis use predicted schizophrenia [adjusted odds ratio (OR) cases compared to general hospital controls 7.8, 95% confidence interval (CI) 2.7-22.6; adjusted OR cases compared to siblings 15.9 (95% CI 1.5-167.1)], but genetic predisposition for schizophrenia did not predict cannabis use [adjusted OR intermediate predisposition
compared to lowest predisposition 1.2 (95% CI 0.4-3.8)].”

For data on potential benefits of cessation:

González-Pinto A, Alberich S, Barbeito S, Gutierrez M, Vega P, Ibáñez B, Haidar MK, Vieta E, Arango C. Cannabis and first-episode psychosis: different long-term outcomes depending on continued or discontinued use. Schizophr Bull. 2011 May;37(3):631-9. Epub 2009 Nov 13. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080669/pdf/sbp126.pdf
“OBJECTIVE: To examine the influence of cannabis use on long-term outcome in patients with a first psychotic episode, comparing patients who have never used cannabis with (a) those who used cannabis before the first episode but stopped using it during follow-up and (b) those who used cannabis both before the first episode and during follow-up….. CONCLUSION: Cannabis has a deleterious effect, but stopping use after the first psychotic episode contributes to a clear improvement in outcome. The positive effects of stopping cannabis use can be seen more clearly in the long term.”

Kuepper R, van Os J, Lieb R, Wittchen HU, Höfler M, Henquet C. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study.BMJ. 2011 Mar 1;342: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047001/pdf/bmj.d738.pdf
“The finding that longer exposure to cannabis was associated with greater risk for persistence of psychotic experiences is in line with an earlier study showing that continued cannabis use over time increases the risk for psychosis in a dose-response fashion. This is also in agreement with the hypothesis that a process of sensitisation might underlie emergence and persistence of psychotic experiences as an indicator of liability to psychotic disorder.”

For data on marijuana use resulting in an earlier age of onset of schizophrenia (suggestive of causality), see Dragt et al. and a meta-analysis (see Large et al.,); also: a very extensive (676 schizophrena patients) and therefore more statistically powered analysis (see DeHert paper); two papers showing that the age-of-onset effect may be specific to those without a family history (see Scherr et al. and Leeson et al., papers); two studies that evaluate the age of onset specific to gender (Veen et al. and Compton et al. ) which is important because comparing across genders can be confounded by the greater tendency of males to engage in risky behavior (the conclusions are not the same in terms of gender; the gender distribution was slightly better in the Veen et al. study) and finally, two papers of relevance to specificity of age of onset effect to cannabis, a meta-analysis of published studies on age of onset that shows another drug of abuse (tobacco) is not associated with
a decreased age of onset (Myles et al.) and a study showing that ecstasy, LSD, stimulants, or sedatives did not have an effect to lower age of onset whereas cannabis use did (Barnes et al.) :

Large M, Sharma S, Compton MT, Slade T, Nielssen O. Cannabis Use and Earlier Onset of Psychosis: A Systematic Meta-analysis. Arch Gen Psychiatry. 2011 68(6):555-61. http://www.ncbi.nlm.nih.gov/pubmed/21300939
“The results of meta-analysis provide evidence for a relationship between cannabis use and earlier onset of psychotic illness, and they support the hypothesis that cannabis use plays a causal role in the development of psychosis in some patients. The results suggest the need for renewed warnings about the potentially harmful effects of cannabis.”

Dragt S, Nieman DH, Schultze-Lutter F, van der Meer F, Becker H, de Haan L, Dingemans PM, Birchwood M, Patterson P, Salokangas RK, Heinimaa M, Heinz A, Juckel G, Graf von Reventlow H, French P, Stevens H, Ruhrmann S, Klosterkötter J, Linszen DH; on behalf of the EPOS group.Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis. Acta Psychiatr Scand. 2011 Aug 29. doi: 10.1111/j.1600-0447.2011.01763.x. [Epub ahead of print]
“Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis. Objective: Numerous studies have found a robust association between cannabis use and the onset of psychosis. Nevertheless, the relationship between cannabis use and the onset of early (or, in retrospect, prodromal) symptoms of psychosis remains unclear. The study focused on investigating the relationship between cannabis
use and early and high-risk symptoms in subjects at clinical high risk for psychosis. Results: Younger age at onset of cannabis use or a cannabis use disorder was significantly related to younger age at onset of six symptoms (0.33 < r(s) < 0.83, 0.004 < P < 0.001). Onset of cannabis use preceded symptoms in most participants. Conclusion: Our results provide support that cannabis use plays an important role in the development of psychosis in vulnerable individuals.”

De Hert M, Wampers M, Jendricko T, Franic T, Vidovic D, De Vriendt N, Sweers K, Peuskens J, van Winkel R.Effects of cannabis use on age at onset in schizophrenia and bipolar disorder. Schizophr Res. 2011 Mar;126(1-3):270-6.

“BACKGROUND: Cannabis use may decrease age at onset in both schizophrenia and bipolar disorder, given the evidence for substantial phenotypic and genetic overlap between both disorders….RESULTS:… Both cannabis use and a schizophrenia diagnosis predicted earlier age at onset. There was a significant interaction between cannabis use and diagnosis, cannabis having a greater effect in bipolar patients….DISCUSSION:…. Our results suggest that cannabis use is associated with a reduction in age at onset in both schizophrenic and bipolar patients. This reduction seems more pronounced in the bipolar group than in the schizophrenia group: the use of cannabis reduced age at onset by on average 8.9 years in the bipolar group, as compared to an average predicted reduction of 1.5 years in the schizophrenia group.”

Scherr M, Hamann M, Schwerthöffer D, Froböse T, Vukovich R, Pit schel-Walz G, Bäuml J.. Environmental risk factors and their impact on the age of onset of schizophrenia: Comparing familial to non-familial schizophrenia. Nord J Psychiatry. 2011 Aug 31. [Epub ahead of print]
“Background and aims: Several risk factors for schizophrenia have yet been identified. The aim of our study was to investigate how certain childhood and adolescent risk factors predict the age of onset of psychosis in patients with and without a familial component (i.e. a relative with schizophrenia or schizoaffective disorder). Results: Birth complications and cannabis abuse are predictors for an earlier onset of schizophrenia in patients with non-familial schizophrenia. No environmental risk factors for an earlier age of onset in familial schizophrenia have been identified.”

Leeson VC, Harrison I, Ron MA, Barnes TR, Joyce EM. The Effect of Cannabis Use and Cognitive Reserve on Age at Onset and Psychosis Outcomes in First-Episode Schizophrenia. Schizophr Bull. 2011 Mar 9. [Epub ahead of print] http://schizophreniabulletin.oxfordjournals.org/content/early/2011/03/09/schbul.sbq153.full.pdf+html
“Objective: Cannabis use is associated with a younger age at onset of psychosis, an indicator of poor prognosis, but better cognitive function, a positive prognostic indicator. We aimed to clarify the role of age at onset and cognition on outcomes in cannabis users with first-episode schizophrenia as well as the effect of cannabis dose and cessation of use……Conclusions: Cannabis use brings forward the onset of psychosis in people who otherwise have good prognostic features indicating that an early age at onset can be due to a toxic action of cannabis rather than an intrinsically more severe illness. Many patients abstain over time, but in those who persist, psychosis is more difficult to treat.”

Veen ND, Selten JP, van der Tweel I, Feller WG, Hoek HW, Kahn RS. Cannabis use and age at onset of schizophrenia. Am J Psychiatry. 2004 Mar;161(3):501-6. http://ajp.psychiatryonline.org/cgi/reprint/161/3/501
“The results indicate a strong association between use of cannabis and earlier age at first psychotic episode in male schizophrenia patients.”

Compton MT, Kelley ME, Ramsay CE, Pringle M, Goulding SM, Esterberg ML, Stewart T, Walker EF. Association of pre-onset cannabis, alcohol, and tobacco use with age at onset of prodrome and age at onset of psychosis in first-episode patients. Am J Psychiatry. 2009 Nov;166(11):1251-7. Epub 2009 Oct 1. http://ajp.psychiatryonlie.org/cgi/reprint/166/11/1251
“Whereas classifying participants according to maximum frequency of use prior to onset (none, ever, weekly, or daily) revealed no significant effects of cannabis or tobacco use on risk of (editor’s note: “timing of”) onset, analysis of change in frequency of use prior to
onset indicated that progression to daily cannabis and tobacco use was associated with an increased risk of onset of psychotic symptoms. Similar or even stronger effects were observed when onset of illness or prodromal symptoms was the outcome. A gender-by-daily-cannabis use interaction was observed; progression to daily use resulted in a much larger increased relative risk of onset of psychosis in females than in males.”

Myles N, Newall H, Compton MT, Curtis J, Nielssen O, Large M. The age at onset of psychosis and tobacco use: a systematic meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2011 Sep 8. [Epub ahead of print]
“Unlike cannabis use, tobacco use is not associated with an earlier onset of psychosis.”

Barnes TR, Mutsatsa SH, Hutton SB, Watt HC, Joyce EM. Comorbid substance use and age at onset of schizophrenia. Br J Psychiatry. 2006 Mar;188:237-42. http://bjp.rcpsych.org/content/188/3/237.full.pdf+html
“Alcohol misuse and any substance use (other than cannabis use) were not significant in relation to age at onset….. those patients in the sample who reported that they had used cannabis had an earlier age at onset of psychosis than other patients who did not report cannabis use but who shared the same profile with regard to the other variables (e.g. comparing men who reported alcohol misuse and use of both cannabis and other drugs with men who had the same characteristics apart from the fact that they had not used cannabis).”

Data from other cultures

Sarkar J, Murthy P, Singh SP. Psychiatric morbidity of cannabis abuse. Indian J Psychiatry. 2003 Jul;45(3):182-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952166/pdf/IJPsy-45-182.pdf
“The paper evaluates the hypothesis that cannabis abuse is associated with a broad range of psychiatric disorders in India, an area with relatively high prevalence of cannabis use. Retrospective case-note review of all cases with cannabis related diagnosis over a 11 -year period, for subjects presenting to a tertiary psychiatric hospital in southern India was carried out. Information pertaining to sociodemographic, personal, social, substance-use related, psychiatric and treatment histories, was gathered. Standardized diagnoses were made according to Diagnostic Criteria for Research of the World Health Organization, on the basis of information available.Cannabis abuse is associated with
widespread psychiatric morbidity that spans the major categories of mental disorders under the ICD-10 system, although proportion of patients with psychotic disorders far outweighed those with non-psychotic disorders. Whilst paranoid psychoses were more prevalent, a significant number of patients with affective psychoses, particularly mania, was also noted.”

Rodrigo C, Welgama S, Gunawardana A, Maithripala C, Jayananda G, Rajapakse S. A retrospective analysis of cannabis use in a cohort of mentally ill patients in Sri Lanka and its implications on policy development. Subst Abuse Treat Prev Policy. 2010 Jul 8;5:16. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910013/pdf/1747-597X-5-16.pdf
”BACKGROUND: Several epidemiological studies have shown that cannabis; the most widely used illegal drug in the world, is associated with schizophrenia spectrum disorders (SSD)……. CONCLUSIONS: Self reported LTC (editor’s note: life time cannabis) use was strongly associated with being diagnosed with SSD (editor’s note: schizophrenia spectrum disorders”.

Population study showing change in incidence rate in young when drug laws are eased

Ajdacic-Gross V, Lauber C, Warnke I, Haker H, Murray RM, Rössler W. Changing incidence of psychotic disorders among the young in Zurich. Schizophr Res. 2007 Sep;95(1-3):9-18. Epub 2007 Jul 16.
“There is controversy over whether the incidence rates of schizophrenia and psychotic disorders have changed in recent decades. To detect deviations from trends in incidence, we analysed admission data of patients with an ICD-8/9/10 diagnosis of psychotic disorders in the Canton Zurich / Switzerland, for the period 1977-2005. The data was derived from the central psychiatric register of the Canton Zurich. Ex-post forecasting with ARIMA (Autoregressive Integrated Moving Average) models was used to assess departures from existing trends. In addition, age-period-cohort analysis was applied to determine hidden birth cohort effects. First admission rates of patients with psychotic
disorders were constant in men and showed a downward trend in women. However, the rates in the youngest age groups showed a strong increase in the second half of the 1990’s. The trend reversal among the youngest age groups coincides with the increased
use of cannabis among young Swiss in the 1990’s.”

Estimates of how many men aged 20-40 would have to avoid regular marijuana use for one year in order to prevent one case of schizophrenia in that same year (but for number relevant to a 20 year avoidance of schizophrenia by avoiding regular marijuana use during
20 years, divide by 20):

Hickman M, Vickerman P, Macleod J, Lewis G, Zammit S, Kirkbride J, Jones P. If cannabis caused schizophrenia–how many cannabis users may need to be prevented in order to prevent one case of schizophrenia? England and Wales calculations. Addiction. 2009;104(11):1856-61.

“In men the annual mean NNP (number needed to prevent) for heavy cannabis and schizophrenia ranged from 2800 [90% confidence interval (CI) 2018–4530] in those aged 20–24 years to 4700 (90% CI 3114–8416) in those aged 35–39”.

Key studies interpreted to diminish the connection between marijuana and schizophrenia:

Proal AC, Fleming J, Galvez-Buccollini JA, Delisi LE. A controlled family study of cannabis users with and without psychosis. Schizophr Res. 2014 Jan;152(1):283-8.
“The results of the current study, both when analyzed using morbid risk and family frequency calculations, suggest that having an increased familial risk for schizophrenia is the underlying basis for schizophrenia in these samples and not the cannabis use. While cannabismay have an effect on theage of onset of schizophrenia it is unlikely to be the cause of illness.”

Rebuttal: Miller CL. Caution urged in interpreting a negative study of cannabis use and schizophrenia. Schizophr Res. 2014 Apr;154(1-3):119-20.
“The morbid risk reported for the relatives of the non-cannabis-using patients (Sample 3) was actually 1.4-fold higher than the cannabis using patients (Sample 4), but the study did not have enough power to statistically confirm or refute a less than 2-fold difference. An increase in sample size would be required to do so, and if the observed difference were to be confirmed, it would explain not only why the Sample 4 data fits poorly with a multigene/small environmental impact model but also would give weight to the premise that cannabis use significantly contributes to the development of this disease.”

Power RA, Verweij KJ, Zuhair M, Montgomery GW, Henders AK, Heath AC, Madden PA, Medland SE, Wray NR, Martin NG. Genetic predisposition to schizophrenia associated with increased use of cannabis. Mol Psychiatry. 2014 Jun 24. doi: 10.1038/mp.2014.51. [Epub ahead of print] http://emilkirkegaard.dk/en/wp-content/uploads/Genetic%20predisposition%20to%20schizophrenia%20associated%20with%20increased%20use%20of%20cannabis.pdf
“Our results show that to some extent the association between cannabis and schizophrenia is due to a shared genetic aetiology across common variants. They suggest that individuals with an increased genetic predisposition to schizophrenia are
both more likely to use cannabis and to use it in greater quantities.”

Rebuttal: Had this paper been titled “The causal genes for schizophrenia have been discovered” it would never have been published. In the absence of a consistent finding of genes of major effect size for schizophrenia, this study of inconsistently associated genes of low effect size is meaningless.

Buchy L, Perkins D, Woods SW, Liu L, Addington J. Impact of substance use on conversion to psychosis in youth at clinical high risk of psychosis. Schizophrenia Res 156 (2-3): 277–280.
“Results revealed that low use of alcohol, but neither cannabis use nor tobacco use at baseline, contributed to the prediction of psychosis in the CHR sample”.
Rebuttal: The study was small in size and the age range of their subjects at study onset was large (12 to 31) which included both subjects that had not reached the peak age of risk for schizophrenia even by the end of the study as well as subjects who were well past the peak age of onset of schizophrenia. The fact that the study screened out psychotic individuals was problematic for the latter group, in that those who were most vulnerable to the psychosis inducing effects of cannabis would already have converted to psychosis by that age.

Overview of Key Public Health Issues Regarding the Mental Health Effects of Marijuana

For the monetary cost of schizophrenia to the U.S. annually ($63 billion in 2002 dollars):

Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M, Aggarwal J. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatry. 2005 Sep;66(9):1122-9.

For the trends in adolescent drug, alcohol and cigarette use, showing an upward tick in marijuana use as medical marijuana has become more prevalent, and that the mind-altering drug legal for adults (alcohol) is still more commonly used by teens than is marijuana:

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor, MI: Institute for Social Research, The University of Michigan.

For a summary of Sweden’s drug law experience:
Hallam C., 2010, Briefing paper 20, The Beckley Foundation: What Can We Learn from Sweden’s Drug Policy Experience? www.beckleyfoundation.org/pdf/BriefingPaper_20.pdf
“in the case of Sweden, the clear association between a restrictive drug policy and low levels of drug use is striking. In his foreword to the article on Sweden’s Successful Drug Policy, Antonio Maria Costa is frank enough to confess that, “It is my firm belief that the generally positive situation of Sweden is a result of the policy that has been applied to address the problem”.

For data showing the relationship between drug enforcement policies in Europe and drug use, such that Sweden has a zero tolerance policy on drugs and has one of the lowest rates of “last month use” in Europe (1%), 4-fold lower than the Netherlands and 7-fold lower than Spain and Italy, two countries that have liberalized their enforcement policies so that marijuana possession carries no substantive penalty.

European Monitoring Centre for Drugs and Addiction, 2012 Annual report
http://www.emcdda.europa.eu/attachements.cfm/att_190854_EN_TDAC12001ENC_.pdf

Source: Microsoft Word – 2015- Summary of literature on marijuana and psychosis.doc (momsstrong.org) January 2016

(-)-Trans-Δ9-tetrahydrocannabinol (Δ9-THC) is the main compound responsible for the intoxicant activity of Cannabis sativa L. The length of the side alkyl chain influences the biological activity of this cannabinoid. In particular, synthetic analogues of Δ9-THC with a longer side chain have shown cannabimimetic properties far higher than Δ9-THC itself. In the attempt to define the phytocannabinoids profile that characterizes a medicinal cannabis variety, a new phytocannabinoid with the same structure of Δ9-THC but with a seven-term alkyl side chain was identified.

The natural compound was isolated and fully characterized and its stereochemical configuration was assigned by match with the same compound obtained by a stereoselective synthesis. This new phytocannabinoid has been called (-)-trans-Δ9-tetrahydrocannabiphorol (Δ9-THCP). Along with Δ9-THCP, the corresponding cannabidiol (CBD) homolog with seven-term side alkyl chain (CBDP) was also isolated and unambiguously identified by match with its synthetic counterpart. The binding activity of Δ9-THCP against human CB1 receptor in vitro (Ki=1.2nM) resulted similar to that of CP55940 (Ki=0.9nM), a potent full CB1 agonist. In the cannabinoid tetrad pharmacological test, Δ9-THCP induced hypomotility, analgesia, catalepsy and decreased rectal temperature indicating a THC-like cannabimimetic activity.
The presence of this new phytocannabinoid could account for the pharmacological properties of some cannabis varieties difficult to explain by the presence of the sole Δ9-THC.

Cannabis sativa has always been a controversial plant as it can be considered as a lifesaver for several pathologies including glaucoma and epilepsy, an invaluable source of nutrients, an environmentally friendly raw material for manufacturing and textiles, but it is also the most widely spread illicit drug in the world, especially among young adults
.
Its peculiarity is its ability to produce a class of organic molecules called phytocannabinoids, which derive from an enzymatic reaction between a resorcinol and an isoprenoid group. The modularity of these two parts is the key for the extreme variability of the resulting product that has led to almost 150 different known phytocannabinoids. The precursors for the most commonly naturally occurring phytocannabinoids are olivetolic acid and geranyl pyrophosphate, which take part to a condensation reaction leading to the formation of cannabigerolic acid (CBGA). CBGA can be then converted into either tetrahydrocannabinolic acid (THCA) or cannabidiolic acid (CBDA) or cannabichromenic acid (CBCA) by the action of a specific cyclase enzyme. All phytocannabinoids are biosynthesized in the carboxylated form, which can be converted into the corresponding decarboxylated (or neutral) form by heat.

The best known neutral cannabinoids are undoubtedly Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD), the former being responsible for the intoxicant properties of the cannabis plant, and the latter being active as antioxidant, anti-inflammatory, anti-convulsant, but also as antagonist of THC negative effects.
All these cannabinoids are characterized by the presence of an alkyl side chain on the resorcinol moiety made of five carbon atoms. However, other phytocannabinoids with a different number of carbon atoms on the side chain are known and they have been called varinoids (with three carbon atoms), such as cannabidivarin (CBDV) and Δ9-tetrahydrocannabivarin (Δ9 -THCV), and orcinoids (with one carbon atom), such as cannabidiorcol (CBD-C1) and tetrahydrocannabiorcol (THC-C1)7. Both series are biosynthesized in the plant as the specific ketide synthases have been identified.
Our research group has recently reported the presence of a butyl phytocannabinoid series with a four-term alkyl chain, in particular cannabidibutol (CBDB) and Δ9-tetrahydrocannabutol (Δ9-THCB), in CBD samples derived from hemp and in a medicinal cannabis variety. Since no evidence has been provided for the presence of plant enzymes responsible for the biosynthesis of these butyl phytocannabinoids, it has been suggested that they might derive from microbial ω-oxidation and decarboxylation of their corresponding five-term homolog.
The length of the alkyl side chain has indeed proved to be the key parameter, the pharmacophore, for the biological activity exerted by Δ9-THC on the human cannabinoid receptor CB1 as evidenced by structure-activity relationship (SAR) studies collected by Bow and Rimondi. In particular, a minimum of three carbons is necessary to bind the receptor, then the highest activity has been registered with an eight-carbon side chain to finally decrease with a higher number of carbon atoms. Δ8-THC homologs with more than five carbon atoms on the side chain have been synthetically produced and tested in order to have molecules several times more potent than Δ9-THC.
To the best of our knowledge, a phytocannabinoid with a linear alkyl side chain containing more than five carbon atoms has never been reported as naturally occurring. However, our research group disclosed for the first time the presence of seven-term homologs of CBD and Δ9-THC in a medicinal cannabis variety, the Italian FM2, provided by the Military Chemical Pharmaceutical Institute in Florence.

The two new phytocannabinoids were isolated and fully characterized and their absolute configuration was confirmed by a stereoselective synthesis. According to the International Non-proprietary Name (INN), we suggested for these CBD and THC analogues the name “cannabidiphorol” (CBDP) and “tetrahydrocannabiphorol” (THCP), respectively. The suffix “-phorol” comes from “sphaerophorol”, common name for 5-heptyl-benzen-1,3-diol, which constitutes the resorcinol moiety of these two new phytocannabinoids.
A number of clinical trials and a growing body of literature provide real evidence of the pharmacological potential of cannabis and cannabinoids on a wide range of disorders from sleep to anxiety, multiple sclerosis, autism and neuropathic pain20–23. In particular, being the most potent psychotropic cannabinoid, Δ9-THC is the main focus of such studies.

In light of the above and of the results of the SAR studies, we expected that THCP is endowed of an even higher binding affinity for CB1 receptor and a greater cannabimimetic activity than THC itself. In order to investigate these pharmacological aspects of THCP, its binding affinity for CB1 receptor was tested by a radioligand in vitro assay and its cannabimimetic activity was assessed by the tetrad behavioral tests
in mice.
Results
Identifcation of cannabidiphorol (CBDP) and Δ9-tetrahydrocannabiphorol (Δ9-THCP) by liquid chromatography coupled to high-resolution mass spectrometry (LC-HRMS).

The FM2 ethanolic extract was analyzed by an analytical method recently developed for the cannabinoid profiling of this medicinal cannabis variety. As the native extract contains mainly the carboxylated forms of phytocannabinoids as a consequence of a cold extraction25, part of the plant material was heated to achieve decarboxylation where the predominant forms are neutral phytocannabinoids.

The advanced analytical platform of ultra-high performance liquid chromatography coupled to high resolution Orbitrap mass spectrometry was employed to analyze the FM2 extracts and study the fragmentation spectra of the analytes under investigation. The precursor ions of the neutral derivatives cannabidiphorol (CBDP) and Δ9-tetrahydrocannabiphorol (Δ9-THCP), 341.2486 for the [M-H]− and 343.2632 for the [M+H]+, showed an elution time of 19.4 min for CBDP and 21.3 min for Δ9-THCP (Fig. 1a).
Their identification was confirmed by the injection of a mixture (5 ng/mL) of the two chemically synthesized CBDP and Δ9-THCP (Fig. 1b) as it will be described later. As for their carboxylated counterpart, the precursor ions of the neutral forms CBDP and Δ9-THCP break in the same way in ESI+mode, but they show a different fragmentation pattern in ESI− mode. Whilst Δ9-THCP shows only the precursor ion [M-H]− (Fig. 1d), CBDP molecule generates the fragments at m/z 273.1858 corresponding to a retro Diels-Alder reaction, and 207.1381
corresponding to the resorcinol moiety after the break of the bond with the terpenoid group (Fig. 1c). It is noteworthy that for both molecules, CBDP and Δ9-THCP, each fragment in both ionization modes differ exactly by an ethylene unit (CH2)2 from the corresponding five-termed homologs CBD and THC.

Moreover, the longer elution time corroborates the hypothesis of the seven-termed phytocannabinoids considering the higher lipophilicity of the latter.

Source: https://www.nature.com/articles/s41598-019-56785-1 December 2019

Alex Azar
Secretary of Health and Human Services
US Department of Health and Human Services
200 Independence Avenue SW
Washington D.C, 20201
November 5, 2019

Dear Secretary Azar:
This letter is to bring to your attention a study underway at the University of Washington referred to as the “Moms and Marijuana Study” and granted under the title: “Olfactory Activation and Brain Development in Infants with Prenatal Cannabis Exposure.” The Office of Human Research Protections issued a decision against opening a case on this research, and we are asking you, as the Secretary of Health and Human Services, to overturn that decision based on the scientific concerns we outline in this letter.

Women who are in their first trimester of a pregnancy, who are frequent users of marijuana for morning sickness, are being recruited. The study seeks to assess the damage marijuana prenatal exposure may have on the babies by means of various testing, including an MRI scan of the infants at six months of age. The recruited women will receive $300.00 + for their participation. The study is solely funded by NIDA. This study calls into question serious issues over human rights and raises ethical questions, including mandatory reporting pertaining to substance abuse in pregnancy. This open letter seeks to gather support from you in seeing that this study is re-evaluated at the federal level. The study’s website is at the following link: https://depts.washington.edu/klab/infoMM.html

We are of the view that the Kleinhans study does not meet the requirements set forth by the Office of Human Research Protections (https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr46/ ): “Subpart B presumption that pregnant women may be included in research, provided certain conditions are met. According to Subpart B, the permissibility of research with pregnant women hinges on a judgment of the potential benefits and risks of the research. Approval of proposed research carrying no “prospect of direct benefit” to the woman or fetus requires that the risk to the fetus be judged “not greater than minimal”. Fetal risk that exceeds that standard is permissible only when the proposed research offers a prospect of direct benefit to the pregnant woman, the fetus, or both.

Notably, if the proposed research does not fit within either of those two parameters, Subpart B offers an additional mechanism at the national level for approval by the Secretary of Health and Human Services.”

The federal definition of minimum risk reads: “That the magnitude and probability of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.” Although the primary harm at issue is exposure to marijuana, the use of MRI or fMRI has not yet been proven safe for otherwise healthy infants, where an unknown risk would come with no benefit, as there is no diagnosis being sought. The UW study consent form reads on page 3:“There are no known side effects associated with MRI or fMRI when earphones are used to protect your hearing.” …. “There may be risks associated with the use of magnetic resonance which are not known at this time.” It is precisely questions about the potential for MRI risks that should be investigated in an animal model first. In principle, any study that recruits subjects and then tracks the consequences of drug transfer to a developing fetus should be carried out in animal models first, and not in humans until the animal results point towards safety. The evidence of decades of research on marijuana in pregnancy does not point to safety but rather to risk and harm.

Two basic principles in bioethics are relied upon to determine the merit of research that involves human subjects: Is the study necessary and can the research be done without the use of human subjects? There now exists a significant body of scientific evidence that warrants and justifies warning women not to use marijuana products at pre-conception, while pregnant, or breast-feeding. The University of Washington study is not necessary to conclude that marijuana use is associated with risk to the child (and also the mother). The National Academies, a lead authority, concluded in a scientific literature review in 2017: There is substantial evidence of a statistical association between maternal cannabis smoking and lower birth weight of the offspring. Studies have already shown that prenatal use is associated with a 50 percent increased likelihood of low birth weight. The Surgeon General’s advisory of August 29, 2019 is also relied upon here. What is the “necessity” that this study addresses? The conclusion has already been made by the findings of science – pregnant women should refrain from marijuana use in order to protect the life and health of their child.

Yet, in spite of existing scientific literature of concern, a highly misleading recruitment statement appears on the University of Washington study’s website introductory page: “We do not expect to find anything of medical concern during the infant MRI scans…If you’re interested in helping us learn more about whether cannabis is safe to use for morning sickness, click the Sign Up button and let us know!” Their lack of concern about the potential for adverse medical outcomes directly contradicts the findings of Grewen et al. (2015) which similarly evaluated postnatal outcomes using MRI scans on infants that had been exposed to marijuana in utero. As compared to controls, the exposed infants showed hypoconnectivity between brain regions: ” Marijuana-specific differences were observed in insula and three striatal connections: anterior insula–cerebellum, right caudate–cerebellum, right caudate–right fusiform gyrus/inferior occipital, left caudate–cerebellum. +MJ neonates had hypo-connectivity in all clusters compared with −MJ and CTR groups.” While an imperfect study because the cases included a proportion of women in the case group who used not only marijuana but also alcohol, tobacco, opiates and SSRIs, one of the two control groups was matched to the cases for use of those drugs, while the other was completely drug free. Notably, work in an animal model by Tortoriello et al. (2014) presents a plausible mechanism for the observed effect of marijuana seen between cases and controls. The combined evidence points towards harm, and confirmation could easily be sought in an animal model that parallels the intent of the University of Washington study.

Furthermore, the ethics are clearly different between the Kleinhans et al. and Grewen et al. studies, because unlike the protocol for the former, the study of Grewen et al. did not recruit women while the fetus was developing but recruited shortly before or after the time of birth. Being unaware of marijuana use until the time of birth, the researchers could not intervene to encourage abstinence for the sake of the fetus, whereas the University of Washington team could intervene, but their protocols do not allow them to. As a further point of distinction, the University of Washington protocol states that infants enrolled in the study will be screened and excluded if they have been in an NICU for 24 hours. This will, for obvious reasons, result in a biased outcome in reporting overall harm from marijuana use during pregnancy.

Typical morning sickness affects up to 91% of pregnancies (Castillo and Phillippi, 2015), and is regarded by many medical practitioners as being a reflex protecting against consumption of dangerous foods or beverages, as well as a sign of a healthy pregnancy because the absence of morning sickness is associated with a higher rate of miscarriage (reviewed by Sherman and Flaxman, 2002). The rare condition when morning sickness becomes pathologic, hyperemesis gravidarum, affects on average 1.1% of pregnancies, and is defined as a loss of 5% or more of the pre-pregnancy weight (Castillo and Phillippi, 2015). Maintenance of fluid and electrolyte balance may become problematic in this situation and pharmacologic intervention may become necessary, both for the health of the mother and the baby. To date, the serious documented outcomes include an increased risk for preterm births and low birth weight (Dodds et al., 2006).

Thus, if the Kleinhans study were to be proposing to recruit only those with hyperemesis gravidarum, the ethics might be more favorable. They would, however, have to exclude women whose marijuana use may have triggered the hyperemesis, which may occur in a subset of pregnant users (Alaniz et al., 2015). The study recruitment website is definitely remiss in not making that possibility clear to those interested in enrolling, and the research protocol describes no effort to ascertain if marijuana might be triggering hyperemesis in their study subjects.

In summary, there is already sufficient scientific evidence to answer the question as to whether or not marijuana is safe to use for typical morning sickness. That answer is no. Please see additional references for numerous research publications showing harm at the end of this letter.
Complaints have been filed with NIDA, The University of Washington, The World Medical Association regarding the Helsinki Declaration, The Office of Human Research Protections, and two doctors have filed a human rights complaint on behalf of the children involved. Complaint documents will be forwarded on request.

Thank you for your time in reviewing this serious situation.

Best regards,
Pamela McColl
Child Rights Activist
pjmccoll@shaw.ca

and

Christine L. Miller, Ph.D.
Neuroscientist
MillerBio
6508 Beverly Rd
Baltimore, Maryland 21239
cmiller@millerbio.com

et al.

Correspondence with the OHRP in regards to the University of Washington study began in September
of 2019. On October an email was received from the OHRP to Pamela McColl:
October 25, 2019

Hello,
OHRP has reviewed the study and will not be opening a case.
Sincerely,
Division of Compliance Oversight OHRP

September 25, 2019
“OHRP is now reviewing your complaint and this study. We are currently gathering the information about the research being conducted before a full review is started. Once OHRP completes a full review of the study, the research conducted and the study’s approval process, we will contact you with our findings. Please remember, this does not mean you can’t contact OHRP again before we finish the full review. You can contact us using this email address to update your complaint at any time.
Thank-you,
Division of Compliance Oversight (OHRP)

September 17, 2019
Thank you for contacting the Office for Human Research Protections (OHRP). OHRP has responsibility for oversight of compliance with the U.S. Department of Health and Human Services (HHS) regulations for the protection of human research subjects (see 45 CFR Part 46 at
www.hhs.gov/ohrp/regulations-and-policy/guidance/index.html

In carrying out this responsibility, OHRP reviews allegations of noncompliance involving human subject research projects conducted or supported by HHS or that are otherwise subject to the regulations, and determines whether to conduct a for-cause compliance evaluation. For further details see OHRP’s guidance, “Compliance Oversight Procedures for Evaluating Institutions,” at www.hhs.gov/ohrp/compliance-and-reporting/evaluating-institutions/index.html.

OHRP has jurisdiction only if the allegations involve human subject research (a) conducted or supported by HHS, or (b) conducted at an institution that voluntarily applies its Assurance of Compliance to all research regardless of source of support. Since this requirement appears to be met by the circumstances described in your email, OHRP appears to have jurisdiction.
Sincerely,
Division of Compliance Oversight
cc. Surgeon General Jerome Adams
cc. Director NIDA Dr. Nora Volkow

In-text citations:
Alaniz VI, Liss J, Metz TD, Stickrath E. Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy. Obstet Gynecol. 2015 Jun;125(6):1484-6.
Castillo MJ, Phillippi JC. Hyperemesis gravidarum: a holistic overview and approach to clinical assessment and management. J Perinat Neonatal Nurs. 2015;29(1):12-22.
Dodds L, Fell DB, Joseph KS, Allen VM, Butler B. Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstet Gynecol. 2006;107(2, pt 1):285–292.
Grewen K, Salzwedel AP, Gao W. Functional Connectivity Disruption in Neonates with Prenatal Marijuana Exposure. Front Hum Neurosci. 2015;9:601.
Sherman PW, Flaxman SM. Nausea and vomiting of pregnancy in an evolutionary perspective. Am J Obstet Gynecol. 2002;186(5 Suppl Understanding):S190-7.
The National Academies of Sciences, Engineering, and Medicine, 2017, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. National Academies Press, Washington, D.C. 20001
Tortoriello G, et al. Miswiring the brain: Δ9-tetrahydrocannabinol disrupts cortical development by inducing an SCG10/stathmin-2 degradation pathway. EMBO J. 2014;33(7):668-85.

Additional references on specific neonatal outcomes:
Lower birth weight, animal studies
Benevenuto SG et al., Recreational use of marijuana during pregnancy and negative gestational and fetal outcomes: An experimental study in mice. Toxicology. 2017;376:94-101.
“Five minutes of daily (low dose) exposure during pregnancy resulted in reduced birthweight…..females from the Cannabis group presented reduced maternal net body weight gain, despite a slight increase in their daily food intake compared to the control group”

Lower birth weight, human studies
Gunn,JKL, Rosales CB, Center KE, Nunez A, Gibson SJ, Christ C, and Ehiri EJ. Prenatal exposure to cannabis and maternal and child health outcomes: A systematic review and meta-analysis. BMJ Open 2016; 6(4):e009986.
“Infants exposed to cannabis in utero had a decrease in birth weight (low birth weight pOR=1.77: 95% CI 1.04 to 3.01; pooled mean difference (pMD) for birth weight=109.42 g: 38.72 to 180.12) compared with infants whose mothers did not use cannabis during pregnancy. Infants exposed to cannabis in utero were also more likely to need placement in the neonatal intensive care unit compared with infants whose mothers did not use cannabis during pregnancy (pOR=2.02: 1.27 to 3.21).”
Brown SJ, Mensah FK, Ah Kit J, Stuart-Butler D, Glover K, Leane C, Weetra D, Gartland D, Newbury J, Yelland J. Use of cannabis during pregnancy and birth outcomes in an Aboriginal birth cohort: a crosssectional, population-based study. BMJ Open. 2016;6(2):e010286.
“Controlling for education and other social characteristics, including stressful events/social health issues did not alter the conclusion that mothers using cannabis experience a higher risk of negative birth outcomes (adjusted OR for odds of low birth weight 3.9, 95% CI 1.4 to 11.2).”
Fergusson, D. M., L. J. Horwood, and K. Northstone. 2002. Maternal use of cannabis and pregnancy outcome. British Journal of Obstetrics and Gynaecology 109(1):21–27.
“Over 12,000 women expecting singletons at 18 to 20 weeks of gestation who were enrolled in the Avon Longitudinal Study of Pregnancy and Childhood……the babies of women who used cannabis at least once per week before and throughout pregnancy were 216g lighter than those of non-users.”

Preterm birth, animal studies
Wang H, Xie H, Dey SK. Loss of cannabinoid receptor CB1 induces preterm birth. PLoS One. 2008;3(10):e3320.
“CB1 deficiency altering normal progesterone and estrogen levels induces preterm birth in mice…. CB1 regulates labor by interacting with the corticotrophin-releasing hormone-driven endocrine axis.”

Preterm birth, human studies
Luke S, Hutcheon J, Kendall T. Cannabis Use in Pregnancy in British Columbia and Selected Birth Outcomes. J Obstet Gynaecol Can. 2019;41(9):1311-1317.
“Using cannabis in pregnancy was associated with a 47% increased risk of SGA (adjusted OR 1.47; 95% CI 1.33–1.61), a 27% increased risk of spontaneous preterm birth (adjusted OR 1.27; 95% CI 1.14–1.42), and a 184% increased risk of intrapartum stillbirth (adjusted HR [aHR] 2.84; 95% CI 1.18–6.82).”
Corsi DJ, Walsh L, Weiss D, Hsu H, El-Chaar D, Hawken S, Fell DB, Walker M. Association Between Selfreported Prenatal Cannabis Use and Maternal, Perinatal, and Neonatal Outcomes. JAMA. 2019;322(2):145-152.
“In a cohort of 661 617 women…. The crude rate of preterm birth less than 37 weeks’ gestation was 6.1%among women who did not report cannabis use and 12.0% among those reporting use in the unmatched cohort (RD, 5.88% [95%CI, 5.22%-6.54%]). In the matched cohort, reported cannabis exposure was significantly associated with an RD of 2.98%(95%CI, 2.63%-3.34%) and an RR of 1.41 (95% CI, 1.36-1.47) for preterm birth. Compared with no reported use, cannabis exposure was significantly associated with greater frequency of small for gestational age (third percentile, 6.1% vs 4.0%; RR, 1.53 [95%CI, 1.45-1.61]), placental abruption (1.6%vs 0.9%; RR, 1.72 [95% CI, 1.54-1.92]), transfer to neonatal intensive care (19.3%vs 13.8%; RR, 1.40 [95%CI, 1.36-1.44]), and 5-minute Apgar score less than 4 (1.1% vs 0.9%; RR, 1.28 [95%CI, 1.13-1.45]).”
Saurel-Cubizolles MJ, Prunet C, Blondel B. Cannabis use during pregnancy in France in 2010. BJOG. 2014;121(8):971-7.
“Cannabis users had higher rates of spontaneous preterm births: 6.4 versus 2.8%, for an adjusted odds ratio (aOR) of 2.15 (95% CI 1.10–4.18).”
Leemaqz SY, Dekker GA, McCowan LM, Kenny LC, Myers JE, Simpson NA, Poston L, Roberts CT;

SCOPE Consortium. Maternal marijuana use has independent effects on risk for spontaneous preterm birth but not other common late pregnancy complications. Reprod Toxicol. 2016;62:77-86. “continued maternal marijuana use at 20 weeks’ gestation was associated with” spontaneous preterm birth “independent of cigarette smoking status [adj OR2.28 (95% CI:1.45–3.59)] and socioeconomic index (SEI) [adj OR 2.17 (95% CI:1.41–3.34)]. When adjusted for maternal age, cigarette smoking, alcohol and SEI, continued maternal marijuana use at 20 weeks’ gestation had a greater effect size [adj OR 5.44 (95% CI 2.44–12.11)].”

Impacts on the neonatal immune system, animal study
Zumbrun EE et al. Epigenetic Regulation of Immunological Alterations Following Prenatal Exposure to Marijuana Cannabinoids and its Long Term Consequences in Offspring. J Neuroimmune Pharmacol. 2015; 10(2):245-54.
“Data from various animal models suggests that in utero exposure to cannabinoids results in profound T cell dysfunction and a greatly reduced immune response to viral antigens

Impacts on cortical wiring and development, animal studies
Tortoriello G, et al. Miswiring the brain: Δ9-tetrahydrocannabinol disrupts cortical development by inducing an SCG10/stathmin-2 degradation pathway. EMBO J. 2014;33(7):668-85.
“Here, we show that repeated THC exposure disrupts endocannabinoid signaling, particularly the temporal dynamics of CB1 cannabinoid receptor, to rewire the fetal cortical circuitry….these data highlight the maintenance of cytoskeletal dynamics as a molecular target for cannabis”
DiNieri JA, Wang X, Szutorisz H, Spano SM, Kaur J, Casaccia P, Dow-Edwards D, Hurd YL. Maternal cannabis use alters ventral striatal dopamine D2 gene regulation in the offspring. Biol Psychiatry. 2011 Oct 15;70(8):763-9.
“we exposed pregnant rats to THC and examined the epigenetic regulation of the NAc Drd2 gene in their offspring at postnatal day 2, comparable to the human fetal period studied, and in adulthood…. Decreased Drd2 expression was accompanied by reduced D2R binding sites and increased sensitivity to opiate reward in adulthood”
Rodríguez de Fonseca F, Cebeira M, Fernández-Ruiz JJ, Navarro M, Ramos JA. Effects of pre- and perinatal exposure to hashish extracts on the ontogeny of brain dopaminergic neurons. Neuroscience. 1991;43(2-3):713-23.
“Perinatal exposure to cannabinoids altered the normal development of nigrostriatal, mesolimbic and tuberoinfundibular dopaminergic neurons, as reflected by changes in several indices of their activity”.

Impacts on cortical wiring and development, human studies
Grewen K, Salzwedel AP, Gao W. Functional Connectivity Disruption in Neonates with Prenatal Marijuana Exposure. Front Hum Neurosci. 2015;9:601.

“+MJ (marijuana-exposed) neonates had hypo-connectivity in all clusters compared with –MJ (marijuana unexposed) and CTR (control) groups. Altered striatal connectivity to areas involved in visual spatial and motor learning, attention, and in fine-tuning of motor outputs
involved in movement and language production may contribute to neurobehavioral deficits reported in this at-risk group. Disrupted anterior insula connectivity may contribute to altered integration of interoceptive signals with salience estimates, motivation, decision-making, and later drug use.”
El Marroun H, Tiemeier H, Franken IH, Jaddoe VW, van der Lugt A, Verhulst FC, Lahey BB, White T. Prenatal Cannabis and Tobacco Exposure in Relation to Brain Morphology: A Prospective Neuroimaging Study in Young Children. Biol Psychiatry. 2016;79(12):971-9.
“prenatal cannabis exposure was associated with differences in cortical thickness….. it may be possible that the frontal cortex in cannabis-exposed children undergoes altered neurodevelopmental maturation (i.e., having differences in cortical trajectories) as compared with
nonexposed control subjects”
Wang X, Dow-Edwards D, Anderson V, Minkoff H, Hurd YL. In utero marijuana exposure associated with abnormal amygdala dopamine D2 gene expression in the human fetus. Biol Psychiatry. 2004; 56:909–915.
“Adjusting for various covariates, we found a specific reduction, particularly in male fetuses, of the D(2) mRNA expression levels in the amygdala basal nucleus in association with maternal marijuana use. The reduction was positively correlated with the amount of maternal marijuana intake during pregnancy.”

Received by email

I, Surgeon General VADM Jerome Adams, am emphasizing the importance of protecting our Nation from the health risks of marijuana use in adolescence and during pregnancy. Recent increases in access to marijuana and in its potency, along with misperceptions of safety of marijuana endanger our most precious resource, our nation’s youth.

BE PREPARED. GET NALOXONE. SAVE A LIFE.

Background

Marijuana, or cannabis, is the most commonly used illicit drug in the United States. It acts by binding to cannabinoid receptors in the brain to produce a variety of effects, including euphoria, intoxication, and memory and motor impairments. These same cannabinoid receptors are also critical for brain development. They are part of the endocannabinoid system, which impacts the formation of brain circuits important for decision making, mood and responding to stress.

Marijuana and its related products are widely available in multiple forms. These products can be eaten, drunk, smoked, and vaped. Marijuana contains varying levels of delta-9-tetrahydrocannabinol (THC), the component responsible for euphoria and intoxication, and cannabidiol (CBD). While CBD is not intoxicating and does not lead to addiction, its long-term effects are largely unknown, and most CBD products are untested and of uncertain purity.

Marijuana has changed over time. The marijuana available today is much stronger than previous versions. The THC concentration in commonly cultivated marijuana plants has increased three-fold between 1995 and 2014 (4% and 12% respectively). Marijuana available in dispensaries in some states has average concentrations of THC between 17.7% and 23.2%. Concentrated products, commonly known as dabs or waxes, are far more widely available to recreational users today and may contain between 23.7% and 75.9% THC.

The risks of physical dependence, addiction, and other negative consequences increase with exposure to high concentrations of THC and the younger the age of initiation. Higher doses of THC are more likely to produce anxiety, agitation, paranoia, and psychosis. Edible marijuana takes time to absorb and to produce its effects, increasing the risk of unintentional overdose, as well as accidental ingestion by children and adolescents. In addition, chronic users of marijuana with a high THC content are at risk for developing a condition known as cannabinoid hyperemesis syndrome, which is marked by severe cycles of nausea and vomiting.

This advisory is intended to raise awareness of the known and potential harms to developing brains, posed by the increasing availability of highly potent marijuana in multiple, concentrated forms. These harms are costly to individuals and to our society, impacting mental health and educational achievement and raising the risks of addiction and misuse of other substances.  Additionally, marijuana use remains illegal for youth under state law in all states; normalization of its use raises the potential for criminal consequences in this population. In addition to the health risks posed by marijuana use, sale or possession of marijuana remains illegal under federal law notwithstanding some state laws to the contrary.

Watch the Surgeon General Answer FAQs on Marijuana

Marijuana Use during Pregnancy

Pregnant women use marijuana more than any other illicit drug. In a national survey, marijuana use in the past month among pregnant women doubled (3.4% to 7%) between 2002 and 2017. In a study conducted in a large health system, marijuana use rose by 69% (4.2% to 7.1%) between 2009 and 2016 among pregnant women. Alarmingly, many retail dispensaries recommend marijuana to pregnant women for morning sickness.

Marijuana use during pregnancy can affect the developing fetus.

  • THC can enter the fetal brain from the mother’s bloodstream.
  • It may disrupt the endocannabinoid system, which is important for a healthy pregnancy and fetal brain development
  • Studies have shown that marijuana use in pregnancy is associated with adverse outcomes, including lower birth weight.
  • The Colorado Pregnancy Risk Assessment Monitoring System reported that maternal marijuana use was associated with a 50% increased risk of low birth weight regardless of maternal age, race, ethnicity, education, and tobacco use.

The American College of Obstetricians and Gynecologists holds that “[w]omen who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. Women reporting marijuana use should be counseled about concerns regarding potential adverse health consequences of continued use during pregnancy”. In 2018, the American Academy of Pediatrics recommended that “…it is important to advise all adolescents and young women that if they become pregnant, marijuana should not be used during pregnancy”.

Maternal marijuana use may still be dangerous to the baby after birth. THC has been found in breast milk for up to six days after the last recorded use. It may affect the newborn’s brain development and result in hyperactivity, poor cognitive function, and other long-term consequences. Additionally, marijuana smoke contains many of the same harmful components as tobacco smoke. No one should smoke marijuana or tobacco around a baby.

Marijuana Use during Adolescence

Marijuana is also commonly used by adolescents, second only to alcohol. In 2017, approximately 9.2 million youth aged 12 to 25 reported marijuana use in the past month and 29% more young adults aged 18-25 started using marijuana. In addition, high school students’ perception of the harm from regular marijuana use has been steadily declining over the last decade. During this same period, a number of states have legalized adult use of marijuana for medicinal or recreational purposes, while it remains illegal under federal law. The legalization movement may be impacting youth perception of harm from marijuana. 

The human brain continues to develop from before birth into the mid-20s and is vulnerable to the effects of addictive substances. Frequent marijuana use during adolescence is associated with:

  • Changes in the areas of the brain involved in attention, memory, decision-making, and motivation. Deficits in attention and memory have been detected in marijuana-using teens even after a month of abstinence.
  • Impaired learning in adolescents. Chronic use is linked to declines in IQ, school performance that jeopardizes professional and social achievements, and life satisfaction.
  • Increased rates of school absence and drop-out, as well as suicide attempts.

Risk for and early onset of psychotic disorders, such as schizophrenia. The risk for psychotic disorders increases with frequency of use, potency of the marijuana product, and as the age at first use decreases. 

  • Other substance use. In 2017, teens 12-17 reporting frequent use of marijuana showed a 130% greater likelihood of misusing opioids23.

Marijuana’s increasingly widespread availability in multiple and highly potent forms, coupled with a false and dangerous perception of safety among youth, merits a nationwide call to action. 

You Can Take Action

No amount of marijuana use during pregnancy or adolescence is known to be safe. Until and unless more is known about the long-term impact, the safest choice for pregnant women and adolescents is not to use marijuana.  Pregnant women and youth–and those who love them–need the facts and resources to support healthy decisions. It is critical to educate women and youth, as well as family members, school officials, state and local leaders, and health professionals, about the risks of marijuana, particularly as more states contemplate legalization.

Science-based messaging campaigns and targeted prevention programming are urgently needed to ensure that risks are clearly communicated and amplified by local, state, and national organizations. Clinicians can help by asking about marijuana use, informing mothers-to-be, new mothers, young people, and those vulnerable to psychotic disorders, of the risks. Clinicians can also prescribe safe, effective, and FDA-approved treatments for nausea, depression, and pain during pregnancy. Further research is needed to understand all the impacts of THC on the developing brain, but we know enough now to warrant concern and action. Everyone has a role in protecting our young people from the risks of marijuana.

Information for Parents and Parents-to-be

You have an important role to play for a healthy next generation.

Information for Youth:

You have an important role to play for a healthy next generation.

Information for States, Communities, Tribes, and Territories:

You have an important role to play for a healthy next generation.

Information for Health Professionals:

You have an important role to play for a healthy next generation.

Source: Surgeon General’s Advisory: Marijuana Use & the Developing Brain | HHS.gov August 2019

Nearly 10% of cannabis users in the United States report using it for medicinal purposes.
As of August 2019, 33 states and the District of Columbia have initiated policies allowing the use of cannabis or cannabinoids for the management of specific medical conditions.
Yet, the federal government still classifies cannabis as illegal, complicating its medical use and research into its effectiveness as a treatment for the various conditions purported to benefit from cannabis pharmacotherapy. Because of this conflict and restrictions on cannabis research, evidence of the efficacy of cannabis to manage various diseases is often lacking.

This article updates a review published in the June 23, 2015, issue of JAMA2 and describes newer evidence regarding what is known and not known about the efficacy of cannabis and cannabinoids for managing various conditions.

Indications for Therapeutic Use Approved by the US Food and Drug Administration
Cannabis has numerous cannabinoids, the most notable being tetrahydrocannabinol, which accounts for its psychoactive effects. Individual cannabinoids have unique pharmacologic profiles enabling drug development to manage various conditions without having the cognitive effects typically associated with cannabis.

Only a few cannabinoids have high-quality evidence to support their use and are approved for medicinal use by the US Food and Drug Administration (FDA). The cannabinoids dronabinol and nabilone were approved by the FDA for chemotherapy-induced nausea and vomiting in 1985, with dronabinol gaining an additional indication for appetite stimulation in conditions that cause weight loss, such as AIDS, in 1992. Recently, a third cannabinoid, cannabidiol (CBD), was approved by the FDA for the management of 2 forms of pediatric epilepsy, Dravet syndrome and Lennox-Gastaut syndrome, based on the strength of positive randomized clinical trials (RCTs).

Other Medical Indications
Cannabinoids are often cited as being effective for managing chronic pain. The National Academies of Science, Engineering, and Medicine examined this issue and found that there was conclusive or substantial evidence that cannabis or cannabinoids effectively managed chronic pain, based on their expert committee’s assessment that the literature on this topic had many supportive findings from good-quality studies with no credible opposing findings.

The panel relied on a single meta-analysis of 28 studies, few of which were from the United States, that assessed a variety of diseases and compounds. Although they concluded that cannabinoids effectively managed pain, the CIs associated with these findings were large, suggesting unreliability in the meta-analysis results.
A more recent meta-analysis of 91 publications found cannabinoids to reduce pain 30% more than placebo (odds ratio, 1.46 [95% CI, 1.16 1.84]), but had a number needed to treat for chronic pain of 24 (95% CI, 15-61) and a number needed to harm of 6 (95% CI, 5-8).While a moderate level of evidence supports these recommendations, most studies of the efficacy of cannabinoids on pain are for neuropathic pain, with relatively few high-quality studies examining other types of pain. Taken together, at best, there is only inconclusive evidence that cannabinoids effectively manage chronic pain, and large numbers of patients must receive treatment with cannabinoids for a few to benefit, while not many need to receive treatment to result in harm.
There is strong evidence to support relief of symptoms of muscle spasticity resulting from multiple sclerosis from cannabinoids as reported by patients, but the association is much weaker when outcomes are measured by physicians. There is insufficient evidence to support or refute claims that cannabinoids provide relief for spinal cord injury–related muscle spasms.

Recent Clinical Trials
Two multicenter, international trials with substantial numbers of patients (n = 120 and n = 171) demonstrated the efficacy of CBD as an add-on drug to manage some seizure disorders. Over 14 weeks, 20mg/kg of CBD significantly reduced the median frequency of convulsive seizures in children and young adults with Dravet syndrome as well as the estimated median difference in monthly drop seizures between CBD and placebo in patients with Lennox-Gastaut syndrome. Although promising, these results were found in relatively uncommon disorders and the studies were limited by the use of subjective end points and incomplete blinding that is typical of cannabinoid studies because these drugs have readily identifiable side effects.
Numerous other medical conditions, including Parkinson disease, posttraumatic stress disorder, and Tourette syndrome, have a hypothetical rationale for the use of cannabis or cannabinoids as pharmacotherapy based on cannabinoid effects on spasticity, anxiety, and density of cannabinoid receptors in areas implicated in development of tics, such as the basal ganglia and cerebellum. The strength of the evidence supporting the use of cannabinoids for these diseases is weak because most studies of patients with these diseases have been small, often uncontrolled, or crossover studies.

Few pharmaceutical companies are conducting cannabinoid trials. Thus, it is not likely that additional cannabinoids will be approved by the FDA in the near future. Public interest in cannabis and cannabinoids as pharmacotherapy continues to increase, as does the number of medical conditions for which patients are utilizing cannabis and CBD, despite insufficient evidence to support this trend.

Neurologic Adverse Effects Are Better Defined Than Physical Adverse Effects
Acute cannabis use is associated with impaired learning, memory, attention, and motor coordination, areas that can affect important activities of daily living, such as driving. Acute cannabis use can also affect judgment, potentially resulting in users making risky decisions that they would not otherwise make. While there is consensus that acute cannabis use results in cognitive deficits, residual cognitive effects persisting after acute intoxication are still debated, especially for individuals who used cannabis regularly as adolescents.

Chronic cannabis use is associated with an increased risk of psychiatric illness and addiction. There is a significant association— possibly a causal relationship—between cannabis use and the development of psychotic disorders, such as schizophrenia, particularly among heavy users. Chronic cannabis use can lead to cannabis use disorder (CUD) and contributes to impairment in work, school, and relationships in up to 31% of adult users.  Regular cannabis use at levels associated with CUD (near-daily use of more than one eighth ounce of cannabis per week) is associated with worsening functional status, including lower income, greater need for socio-economic assistance, criminal behavior, unemployment, and decreased life satisfaction.

Cannabis use is associated with adverse perinatal outcomes as well; a 2019 study showed the crude rate of preterm birth was 12.0% among cannabis users and 6.1% among nonusers (risk difference, 5.88% [95% CI, 5.22%-6.54%]).

Inadequate Evidence Supporting the Use of Cannabinoids for Many Medical Conditions
The quality of the evidence supporting the use of cannabinoids is suboptimal. First, studies assessing pain and spasticity are difficult to conduct, in part because of heterogeneity of the outcome measures used in these studies. Second, most RCTs that have evaluated cannabinoid clinical outcomes were small, with fewer than 100 participants in each, and small trials may overestimate treatment effects. Third, the timeframe for most studies is too short to assess the long-term effects of these medications. Fourth, tolerance, withdrawal, and potential for drug-drug interactions may affect the usefulness of cannabis, and these phenomena are not well understood for cannabinoids.

The lack of high-quality evidence results in outsized claims of the efficacy of cannabinoids for numerous medical conditions. There is a need for well-designed, large, multisite RCTs of cannabis or cannabinoids to resolve claims of efficacy for conditions for which there are claims of efficacy not supported by high quality evidence, such as pain and spasticity.

Conclusions
Insufficient evidence exists for the use of medical cannabis for most conditions for which its use is advocated. Despite the lack of evidence, various US state governments have recommended cannabis for the management of more than 50 medical conditions. Physicians may be appropriately reticent to recommend medical cannabis for their patients because of the limited scientific evidence supporting its use or because cannabis remains illegal in federal law. Cannabis is useful for some conditions, but patients who might benefit may not get appropriate treatment because of insufficient awareness regarding the evidence supporting its use or confusion from federal law deeming cannabis illegal.

Source: Medical Use of Cannabis in 2019 | Clinical Pharmacy and Pharmacology | JAMA | JAMA Network August 2019

Cannabis hyperemesis syndrome (CHS) is nothing new, but nonetheless lacks a diagnosis code. This means that nobody—including the Centers for Disease Control and Prevention, which is meant to track such things—knows the prevalence of the condition. It is, however, relatively rare. Medical sources say that it’s likely, as you’d expect, to become more common as nationwide cannabis use increases.

No one claims that CHS is lethal, but it is uncomfortable—and in an emergency room situation requires such medications as haloperidol, an antipsychotic, to relieve vomiting and pain. Business Insider recently reported the story of 29-year-old Alice Moon, who began using cannabis regularly to treat pain and nausea. She did so without problems for five years, but then began experiencing CHS symptoms monthly, and eventually weekly.

People who use any substance deserve access to relevant health information, without exaggeration in either direction. “Marijuana is somehow making millions violently sick” and “Mysterious Syndrome Related To Marijuana Use Begins To Worry Doctors” are two CHS-related news headlines from the past month alone. But CHS likely doesn’t affect millions, and it is less mysterious than some imply.

So this isn’t a Reefer Madness story, designed to scare people, nor a head-in-the-sand story, designed to appeal to those who see cannabis as a risk-free panacea.

Even pro-cannabis advocates agree that CHS exists. “It’s a diagnosis of exclusion,” Peter Grinspoon, MD, a primary care physician at an inner-city clinic in Boston, told Filter. Grinspoon is also on staff at Massachusetts General Hospital, teaches at Harvard Medical School, and authored the memoir Free Refills: A Doctor Confronts His Addiction (2016). “I’m not sure how you can really differentiate it from cyclic vomiting syndrome (CVS), idiopathic [unknown cause] vomiting, or just something else causing the vomiting—except for a cannabis history.”

Experts believe that the action of the cannabinoid THC on our CB1 receptors, which are found all over the body but mainly in the brain, produces the symptoms of CHS—though the amounts of THC required, the duration of use in months or years, and why some people experience CHS and not others, are still unexplained.

One thing everyone seems to agree on: CHS is caused by heavy long-term use of cannabis—i.e., it’s not a result of overdose or acute toxicity. And it has one unusual manifestation: People afflicted like to take many hot baths or showers for relief.

study published last month, based on emergency room visits in a Colorado hospital, also found that CHS is more likely to be associated with smoked than edible cannabis. Of 2,567 ER visits that were at least partly attributed to cannabis use, 18 percent of patients who inhaled it were said to have CHS, versus 8.4 percent of those who ate it.

Emergency Physicians’ Experiences

 “It’s very dramatic—patients are sometimes writhing on the floor, and they’re vomiting so much. It’s a horrible syndrome,” said Andrew C. Meltzer, MD, associate professor in the Department of Emergency Medicine and Clinical Research Director of GWU School of Medicine and Health Sciences. “It’s very different from any other kind of vomiting thing, and very disruptive to the ED.”

And in the worst cases, “repeated aggressive vomiting can cause tears in the esophagus.”  

 Unlike gastroenteritis, with CHS there is no diarrhea, no fever and more of a hypersensitivity to pain in the abdomen, Meltzer told Filter. There is an “overlap” with cyclical vomiting syndrome (CVS), in that many symptoms are the same. Blood work might be needed to rule out pancreatitis and hepatitis, and some patients get radiology.

Toxicology testing, on the other hand, is not very useful, because so many people use marijuana without showing these symptoms. Rather, it’s important to get a history of the extent and duration of marijuana use from the patient, said Meltzer. “Confusion exists in the medical literature,” he noted. In addition, he believes there is a pervasive failure to recognize chronic cannabis use as a possible cause of vomiting.

“We’re still trying to figure out how to make them feel better,” said Meltzer of CHS patients. “Typical anti-emetics like Phenergan and Zofran don’t work. Instead, we use antipsychotics, like haloperidol.” In fact, if the haloperidol works, Meltzer views that as diagnostic of CHS in some ways. The heat from capsaicin rubbed on the abdomen also provides some relief from pain.

In the patients Meltzer has seen with CHS, all “would qualify as addicted” to cannabis, he said. He doesn’t recommend using morphine for CHS pain because of what he sees as the addiction risk in this population.

Some CHS patients can’t be treated with emergency room management alone. Meltzer said he had to admit one patient for dehydration, fluids replacement, renal insufficiency, and other problems. “But now we’re getting more used to how to manage this with haloperidol and even Ativan. They are sedated, they sleep, and they go home.”

“I don’t care what people do in their free time, but in the medical history I try to include things that are pertinent.”

Ryan Marino, MD, an emergency medicine physician and medical toxicologist at the University of Pittsburgh, sees CHS about two-to-three times a month—but acknowledges it could be more, because sometimes it’s hard to be sure.

“The big issue is [CHS] is under-recognized,” said Marino, agreeing with Meltzer. “So a lot of patients get unnecessary testing.” For someone who comes in with a lot of nausea and vomiting, and is young and otherwise healthy, he says it’s important to ask about their marijuana use.

“I try to be as non-judgemental as possible” in asking those questions, he said. “I don’t care what people do in their free time, but in the medical history I try to include things that are pertinent.”

With emergency patients, the differential diagnosis is crucial and must be done quickly. “When there’s belly pain, you worry about things that need surgery, like appendicitis and the gallbladder,” said Marino. “CVS is kind of similar [to CHS], but people aren’t using cannabis.” So asking about marijuana use history can clearly help.

“The main thing seems to be people who use heavily and regularly: daily use or near-daily use,” said Marino. “With the rise of medical cannabis, more people have access to it, so maybe there are more presentations now than there used to be. But with no ICD [International Classification of Diseases] code, I don’t think you’d be able to say whether you can find prevalence.”

Marino acknowledges that there’s a fine line to tread in questioning patients, especially in situations where they are worried about law enforcement, and some healthcare providers are better than others at getting honest histories. “There are going to be people on the provide side who don’t get the truth out of patients, and there are patients who won’t disclose. This is why the way we treat patients is important.”

Gastroenterologists’ Perspectives

 Whether they’re called in to consult in the emergency department or see a person in their office, gastroenterologists have a big role to play for CHS patients. CHS has been known about since 2004, but a seminal 2011 Current Drug Abuse Reviews article put gastroenterologists on the alert.

A year ago, Healio interviewed gastroenterologist Joseph Habboushe, MD for an article titled “Cannabinoid hyperemesis syndrome: What GIs should know.” Habboushe had surveyed 155 patients in an emergency department who reported smoking marijuana frequently and found that 32.9 percent of them met criteria for CHS. He concluded that the syndrome is vastly underreported.

“I would definitely ask” about marijuana use in the case of an otherwise-healthy, vomiting patient, said Lisa Gangarosa MD, AGAF, FACP, professor of Medicine at the UNC Division of Gastroenterology and Hepatology, speaking for the American Gastroenterological Association. “The diagnosis is largely made on the history.”

There is no clear test. “Basically, if the history fits, and if the patient stops smoking and gets better, that’s what it was.”

Some testing would be done to exclude other problems, such as stomach cancer, a large ulcer or gallstones, Gangarosa told Filter. It’s also important to conduct basic lab testing, such as for pregnancy, and then, if all of that testing comes back negative, to think about endoscopy and ultrasound of the gallbladder.

Gangarosa has only seen CHS in patients who have been “smoking pot,” not in anyone who has been prescribed dronabinol, which is synthetic THC.

There is no clear test for the syndrome. “In some cases you can say your impression is suspected marijuana-induced hyperemesis,” she said. “Basically, if the history fits, and if the patient stops smoking and gets better, that’s what it was.”

Surprisingly, many patients who use cannabis haven’t heard of CHS, said Gangarosa. For others, they don’t want to stop smoking, “and they don’t want to believe that this is the cause of their problems. It’s the same thing with pancreatitis—just because of the health harms, doesn’t mean people want to give up drinking.”

The Hot Bath Phenomenon

Andrew Meltzer, the ED physician, said that some of his patients have taken six-to-eight warm baths a day to relieve symptoms.

This reminds me of a personal experience. A member of my family had acute gastritis at the age of six, with a lot of vomiting, and was hospitalized for a week. All she wanted to do was lie in the hospital bathtub with the water as hot as possible. There was no marijuana involved, but bells went off in my head when I heard about the hot shower “cure.” Could this be a common way of responding to extreme vomiting and pain in general?

Experts stress that the hot shower treatment is anecdotal, and can’t be used as a sure sign of CHS. “But it’s something I ask people,” said Ryan Marino. “It seems as if most people have figured out” that it works. “It might be that they’re so symptomatic they try anything, and find the one thing that works.”

Like the capsaicin, which provides heat, and heating pads, heat from the hot shower on the belly might relieve the pain, said Marino. However, “I don’t think anyone has a good reason for the link” between CHS and hot showers.

A Researcher’s View

The National Institute on Drug Abuse (NIDA) referred Filter to Kiran Vemuri, PhD, a research assistant professor at Northeastern University in Boston, who has a grant from the agency to find an antidote for synthetic cannabinoid intoxication.

That, of course, is a very different issue from CHS. But as an organic chemist, Vemuri has studied emesis from a CB1 antagonist perspective. He is aware of the paradox with THC: The synthetic version, dronabinol, is approved by the FDA to treat the nausea and vomiting associated with chemotherapy, as well as to increase appetite in wasting associated with AIDS, and for many other conditions.

How would the same substance that treats nausea induce it?

“This only happens in people who have been consuming cannabis for a long time,” Vemuri said. But he noted that most information in the literature is anecdotal and based on case histories. “People try to come up with a number”— how much cannabis, for how long—“but you can never really tell as to what causes the hyperemesis. Is it the dose, is it the strain?”

“If you know the CB1 receptor is implicated … the best treatment option would be an antagonist.” Except there isn’t one.

Vemuri has studied antagonists which induce nausea, with the CB1 receptor the biological target. CB1 receptors are all over the body, but most are in the brain, he said.

If you want to know everything the top researcher in emesis (vomiting) knows about the topic, look up the work of Linda Parker. It’s hard to study in animals, because not all of them even vomit.

There is no antidote for emesis itself, said Vemuri. “But if you know that the CB1 receptor is implicated, and the patient is presenting with an overdose of THC or synthetic cannabinoids, the best treatment option would be an antagonist.” Except there isn’t one.

As for the hot showers, CB1 receptors could indeed be involved, but there is no “concrete connection” to CHS or its treatment, said Vemuri.

And he cautions that “‘overdose’ is a big word when it comes to THC.” The dose, the strain, the route of administration all matter, he said. And because THC can reside in fat, and build up, it makes sense that some of the side effects could be worse in people who have consumed THC over a long period of time. “At the end of the day, anything in excess is not good.”  

No Easy Cure

There was one medication which briefly showed promise for CHS—ribonabant—but it was removed from the market due to psychiatric side effects (suicidal ideation). “The target is so new,” Vemuri said. “But NIDA is definitely interested, and no one ever gave up on the target, and no one ever gave up on cannabis, and no one ever gave up on the antagonists. Recently I was at a conference where I got to know companies that are pursuing both CB1 and CB2.”

While hot showers may provide temporary relief, and anti-emetics and intravenous hydration can help “someone in the throes of repetitive vomiting,” for now, the best way for CHS patients to avoid further symptoms for good is to stop using cannabis, said Lisa Gangarosa, the gastroenterologist.

“That is always the recommendation,” agreed Marino. “It seems to be the only thing that makes it better or makes it go away. But it’s not always the easiest thing. It’s easy for me to say.”

The implications of quitting for people who use cannabis for medical reasons—and the difficulties for people who are addicted—are clear. But for now, the unknown minority of cannabis users unfortunate enough to experience cannabis hyperemesis syndrome have no other reliable recourse.

Source:  https://www.dbrecoveryresources.com/2019/04/what-is-cannabis-hyperemesis-syndrome/ April 2019

The doctors told Regina Denney and her son Brian Smith Jr. what was causing his severe vomiting and abdominal pain.

Neither the teenager nor his mother believed what they said: smoking weed.

Smoking marijuana, the two knew, was recommended to cancer patients to spur the appetite. How could it lead to Brian’s condition?

As the months went by and the pounds slipped off Brian’s once healthy frame, it was clear that whatever was causing his stomach troubles had just the opposite effect.

Brian kept smoking. The symptoms continued on and off.

Last October, after another severe bout of vomiting, the teenager died. He was 17 years old.

Five months later, as Denney pored over a coroner’s report for answers, she finally accepted that marijuana played a pivotal role in her son’s death. The autopsy report, which Denney received in March, attributed her son’s death to dehydration due to cannabinoid hyperemesis syndrome.

“We had never heard about this, had never heard about marijuana causing any vomiting. He and I were like, ‘Yeah, I think it’s something else,’ ” Denney said. “Brian did not believe that was what it was because of everything we had ever been told about marijuana. … It didn’t make any sense.”

Cannabinoid hyperemesis syndrome, also known as CHS, can arise in response to long-term cannabis use. The syndrome consists of vomiting, nausea and abdominal pain, which can often be alleviated by taking hot showers.

Doctors say CHS is on the rise, but they are not certain why. Marijuana is more available than in years past, and it is more potent.

Rarely does CHS result in death.

‘Basically, they smoked weed’

Denney didn’t like the fact that her teen son started smoking at 13, but she figured the situation could be worse. Brian and she had a strong relationship, and he always had been honest with her about his use of marijuana.

For the most part, Brian was a good kid who had a tightknit group of friends who called themselves the GBS, Gimber Block Savages, after the south side street where many of them lived. Although they called themselves a gang, Denney said, they never caused any trouble.

“Basically, they smoked weed,” she said.

About two years after Brian started smoking, he began using a lot more, perhaps to help deal with depression, Denney said. He dropped out of school after ninth grade and started working full-time with an uncle who had a tree-trimming business. Brian helped clear brush.

The job provided enough money to support his marijuana habit, another reason Denney felt there was no reason for her to intervene. After all, many of Brian’s peers were using heroin or methamphetamine.

“I thought, ‘OK, if that’s all he’s doing, smoking marijuana, pick and choose your battles,’ ” she said. “If this is the worst thing he’s doing, I’m OK. He’s not in any trouble legally. He’s not playing with guns, robbing people and stealing things. He’s supporting his own habit. I thought, ‘OK, this is what it is.’ ”

Denney had no reason to be concerned about cannabinoid hyperemesis syndrome. She, like many others, had never heard of it.

‘A totally underdiagnosed entity’

A few years ago, many doctors had no idea this condition existed. First described 15 years ago, CHS symptoms follow heavy cannabis use and include intense stomach pain, bouts of vomiting and debilitating nausea.

A study published last year in the journal Basic & Clinical Pharmacology & Toxicology surveyed urban emergency room patients who smoked marijuana 20 or more days a month. Of the 155 who said yes, almost a third experienced CHS symptoms.

“A lot of papers prior to mine would say it’s very rare,” said Joseph Habboushe, one of the study’s authors and a clinical associate professor of emergency medicine at NYU Langone Health in New York City, who saw his first case five or six years ago. “Emergency room doctors on the front-line lines, we know that it’s a totally underdiagnosed entity.”

On the other side of the country, Dr. Jeff Lapoint and his colleagues saw an influx of patients with CHS symptoms about six years ago. Lapoint is the director of the division of medical toxicology at Kaiser Permanente Southern California and practices in San Diego, which he said is home to both craft beer and craft marijuana.

Many of Lapoint’s patients returned time after time when the next bout hit, seeking relief from their stomach woes.

“We would see lots of it. We would see an alarming amount of it,” Lapoint said. “People were coming in all the time, and physicians didn’t know what to do with them.”

Op-ed: Vaping deaths and booming black market: Pot experiment will fail without better oversight

Lapoint said he and his colleagues have seen fewer such cases lately.

Habboushe concluded in his study that as many as 2.75 million regular cannabis users may suffer from symptoms of CHS, though many of them may be mild. Mild symptoms can serve as a warning to discontinue cannabis use to avoid more severe distress down the line, Habboushe said.

A study this year in the Journal of Forensic Science described two people in Canada who died from CHS and a third for whom the condition contributed to death.

‘It makes no sense’

Brian was Denney’s baby, her boy after two girls. From the time he was a child, he suffered from acid reflux and often took medicine to ease the symptoms.

Brian, who loved sports and the movie “Twilight,” was close to his family and called himself his mother’s “snuggle bunny.” He was beloved uncle BubBub to his toddler nephew, Zayden. He was a loyal friend, once giving up his bed so a buddy who was homeless had a place to sleep. As a teen, he split time between Denney’s home and that of his father.

In April 2018, Brian felt ill. At first everyone, including his pediatrician, thought his acid reflux was acting up. He lost 40 pounds and frequently complained of nausea that led him to avoid food.

A few days into the illness, he called his mother and told her he couldn’t stop vomiting. Denney drove to his father’s house to take him to the hospital. On the way to Franciscan St. Francis Health, Denney had to stop multiple times for Brian to vomit.

The 1st tied to a weed shop: Another death is linked to vaping. This time, it’s in Oregon

Brian complained of tingling in his face. When they got to the hospital, half his face was numb, the muscles in his hands and legs constricted and froze, and he projectile vomited.

Denney assumed he was having a stroke.

Within a few minutes, he was hooked up to oxygen and a heart monitor. Medical staff placed IVs in each arm. Tests revealed his kidneys were failing, and many of his other lab values were abnormal. No one could tell what was behind the attack, though they knew the frequent vomiting left him dehydrated.

Another emergency room doctor poked her head in the door and asked two questions: Do you smoke marijuana often? Do you take frequent hot showers?

Yes, Brian said. Yes.

You have CHS, the doctor said.

The following day, Brian was discharged with an appointment to follow up with a gastroenterologist in July.

Although neither Denney nor Brian accepted the diagnosis completely, she urged him to consider not smoking as a process of elimination. He agreed, but he struggled with nausea and was too sick to work.

The GI doctor took a tube of blood, did no further testing and confirmed the earlier diagnosis: CHS.

Denney remained unconvinced, thinking the specialist was too quick to accept the emergency room doctor’s diagnosis without doing any confirmatory testing.

“Going to the GI doctor, I thought we’re going to finally get an answer. We’re going to finally know what we need to do to make him better,” she said. “Then when they didn’t run any other tests, it was like, ‘OK, so why are we not doing them?’ It makes no sense.”

After that visit, Brian returned to his dad – and started smoking again.

He told Denney he had symptoms the whole time he wasn’t smoking, so what was the point of quitting?

‘The dose makes the poison’

Experts aren’t 100% sure what’s behind the relatively sudden advent of this condition. They suspect that more potent cannabis may be to blame, along with several states’ decision to legalize the drug for medicinal purposes or altogether.

In the 1970s, THC concentration in most marijuana would be about 7%, Lapoint said. The mean concentration has risen to 15% to 30%, and it’s possible to make extracts with 99% THC.

“Marijuana was the joke of the toxicology world when it was 7%,” Lapoint said. “People never got sick. … But now if you make the concentration 99%, it’s just like if a 17-year-old kid goes to a frat party and has a beer. That’s a lot different than drinking shots of Everclear 151. Just like anything, the dose makes the poison.”

Vaping lung illness:: What we know about the recent spate of cases and deaths

The best treatment for CHS is to stop using cannabis entirely, Habboushe said.

Once a person develops the condition, he or she has probably done something permanent. Further exposure to cannabis highly increases risk of recurrence. Persuading patients to accept this can be difficult, Habboushe said.

“There’s a lot of denial,” he said. “A lot of patients are really heavy marijuana smokers, and they really don’t want to believe that it’s related to cannabis and hard for them to believe because they have been using cannabis forever.”

‘Don’t give up’

In July Brian moved back in with Denney. She knew he was not going to give up smoking, but she thought being around his nephew would encourage him to smoke less.

A few months passed. Brian did not put back the weight, but he seemed to be a bit better.

Then came Oct. 7. Brian started feeling ill again. Denney and her daughters had concert tickets, so she went to buy him Gatorade and popsicles to stem the nausea and asked his father to come and stay with him.

When they returned from the concert, he started vomiting nonstop. They rushed to the St. Francis emergency room, where doctors transferred him to Riley Hospital for Children. Once more, Brian was rehydrated.

Denney said her son cut back on smoking, but a few weeks later, he went to visit his cousins. “I know they smoked,” Denney said. “That’s just what he did.”

When she picked him up Oct. 21, he felt a little nauseated but had not been vomiting.

Three days later, Denney woke up around 5 a.m. to find her son sitting in the living room and clutching his stomach.

He told her it was his acid reflux but he was fine. Then he started vomiting again.

“He was throwing up so much,” Denney said. “I was taking the bucket in there and holding it for him because he didn’t have the energy to hold it.”

For the first time, Brian told her he was going to quit smoking.

He grabbed his lower back, saying it hurt bad.

Remembering his kidneys had suffered in his previous attacks, Denney called 911.

Before the paramedics arrived, she found her son lying on his side.

She rolled him over. He was not breathing.

Denney screamed. She started doing chest compressions. Her daughter’s boyfriend ran across the street to get their neighbor, a Navy veteran.

“I kept telling him, ‘Fight, B, fight. I need you. Don’t give up.’ I begged God to take me instead,” Denney said.

The paramedics arrived and worked on Brian for about 45 minutes to no avail. On Oct. 24, Brian died.

Because he died at home, detectives had to investigate, and the coroner prepared a report. It took five months for Denney to receive a copy. It arrived on her birthday in early March.

Soon after Brian’s death, Denney found edibles in his backpack.

She asked herself again and again what she should have done. Should she have forced him to go to rehab?

Denney devoted herself to helping raise awareness about CHS. She started a Facebook group in Brian’s name. She talks about Brian and CHS every chance she gets. She keeps Brian close to her, wherever she is.

Photos of her son hang on the walls in her bedroom. On her dresser sits a dark urn emblazoned with a gold marijuana leaf that contains Brian’s ashes. His sister chose it. She knew her brother would have liked it.

Source: Indiana boy, 17, died from smoking weed. CHS is to blame. What is CHS? (usatoday.com) September 2019

The rise in prescription opioid and heroin abuse creates countless problems for healthcare professionals, law enforcement, the drug abusers themselves and society as a whole. It’s a complex issue that continues to claim lives. Unfortunately, Fentanyl, a painkiller 100 times more powerful than morphine, is showing up on the streets disguised as other drugs, such as Norco and Xanax. The results are an increase in fatal overdoses.

Problems with fentanyl are not new. As recently as last year, we wrote about the dangers of fentanyl when it is mixed with heroin, and Dr. A.R. Mohammad, the founder of Inspire Malibu, did a recent interview with FOX 11 News in Los Angeles regarding the rise in fentanyl on the streets. What is new, however, are reports of synthetic fentanyl, likely manufactured in illegal labs in the states, China and Mexico, sold under different drug names to unsuspecting users.

In March of this year, Sacramento County, California, saw six deaths and 22 overdoses as a result of fentanyl peddled as Norco, which is supposed to be a mix of acetaminophen and hydrocodone. “In reality, they’re taking fentanyl, which is much, much, much more potent,” Laura McCasland, a spokeswoman for the Department of Health and Human Services, told The New York Times.

Legally manufactured fentanyl is an injectable opioid often administered before surgeries. It also comes in a time release lozenge or patch for patients coping with severe chronic pain from conditions like pancreatic, metastatic and colon cancer.

Fentanyl is so strong, fast-acting and creates such a high tolerance, many patients find that other opiates no longer work for them. This is also one of the reasons that fentanyl is so addictive.

With abuse and addiction to fentanyl, quitting “cold turkey” can cause severe withdrawal.

What are the Withdrawal Symptoms of Fentanyl?

  • Fast heart rate and rapid breathing
  • Muscle, joint and back pain
  • Insomnia, yawning and restlessness
  • Sweating and chills
  • Runny nose and eyes
  • Anxiety, depression and irritability
  • Lethargy and weakness
  • Vomiting, nausea, diarrhea, loss of appetite and stomach cramps

Even a tiny amount of fentanyl can be deadly. The president of the American Society of Anesthesiologists, J.P. Abenstein, told National Public Radio, “What happens is people stop breathing on it. The more narcotic you take, the less your body has an urge to breath.”

Abenstein added that people who don’t know how much to take will easily overdose. This no doubt also applies to users who aren’t even aware they’re taking the dangerous opiate when it’s sold under another name or mixed with heroin.

The Centers for Disease Control and Prevention (CDC) reported that of the estimated 28,000 people who died from opioid overdoses in 2014, almost 6,000 of those deaths were fentanyl related.

The agency also suggests that states make Naloxone (Narcan), an overdose-reversal drug, more widely available in hospitals and ambulances to prevent deaths.

Abstinence from illicit drug use is the only guaranteed way to avoid an accidental overdose on fentanyl. Addiction, however, changes the brain’s chemistry and drives those affected to make decisions and behave in a manner that continues to put them at risk.

Source:  https://www.inspiremalibu.com/blog/drug-addiction/fentanyl-hits-the-streets-disguised-as-xanax-and-norco/  19th June 2019

ANDRI TAMBUNAN FOR THE WALL STREET JOURNAL

Last year, members of Congress introduced a bill that would add the veterinary tranquilizer xylazine to a list of controlled substances. The drug has worsened the fentanyl crisis as it has been showing up in drug users’ fentanyl supply at an alarming pace.

What is fentanyl?

Fentanyl is a heavily regulated legal medication, prescribed largely for pain relief in cancer patients, postsurgery and for people with chronic pain who have developed tolerance for other opioids.

When prescribed by a doctor, fentanyl can be given as a shot, a patch that is placed on a person’s skin, as lozenges that are sucked like cough drops or film that sits between the cheek and gum, according to the American Society of Health-System Pharmacists Inc. It also can be sprayed in the nose or under the tongue.

The illicit form of fentanyl, a powder that is often mixed into other drugs, has overtaken the drug market in the U.S. Fentanyl is made in clandestine labs in Mexico from easily sourced chemicals.

Drug overdose deaths reached a record high in 2022, with more than 100,000 people lost to the continuing epidemic. PHOTO: ALYSSA SCHUKAR FOR THE WALL STREET JOURNAL

What is “tranq” drug xylazine?

Xylazine is a veterinary tranquilizer that has increasingly been showing up in illicit drugs, including in fentanyl. The drug, which is authorized only for animals, has been complicating overdoses and producing severe wounds for users that can lead to serious infection and amputation.

Dealers may mix xylazine into fentanyl to save money, federal law-enforcement authorities have said. The drug—known as “tranq” among some users—can be purchased at low prices from Chinese suppliers and offset some of the opioid in the mix.

Drug users often don’t know that xylazine is being mixed into their fentanyl batch and unknowingly become hooked on both substances. Drug users say xylazine can prolong a high from fentanyl but that also often means being unconscious, sometimes for hours at a time.

In February, the FDA said it would restrict imports of xylazine and more carefully scrutinize shipments of the drug into the U.S. to check that they are bound for legitimate use in animals.

The Drug Enforcement Administration said in March that about 23% of seized fentanyl powder and 7% of fentanyl pills contained xylazine last year. The Senate and House bills introduced in March would make xylazine a Schedule III drug, a category that includes ketamine. The bill would require producers and distributors to report order volumes to the DEA.

Drug test results also show xylazine is spreading throughout the U.S. About 43% of fentanyl-positive urine samples in Pennsylvania from April to July contained xylazine, according to Millennium Health, a drug-testing laboratory. The rate in North Carolina was second-highest at 40%. Rates in Ohio and Maryland were close behind.

Which drugs are typically laced with fentanyl?

Drug manufacturers mix illicit fentanyl with other materials to create a powder that can be dissolved into liquid and injected. PHOTO: MORIAH RATNER FOR THE WALL STREET JOURNAL

Fentanyl is often found mixed into heroin, cocaine and methamphetamine, according to the CDC. The drug is also made into fabricated pills that are often indiscernible from commonly prescribed medications such as Percocet (the narcotic oxycodone), Xanax (the sedative alprazolam) or even Adderall (an amphetamine).

Chinese chemical companies are making more ingredients for illegal fentanyl than ever, including N-Phenyl-4-piperidinamine, which Mexican cartels purchase to make into fentanyl.

Drug manufacturers in Mexico also mix illicit fentanyl with other materials, such as baking soda, starch and sugar, to create a powder that can be smoked or dissolved into liquid and injected, a process called “cooking,” or fabricated pills purchased on the illicit market.

Fentanyl is so powerful that in pure form the amount in roughly two sugar packets can provide a year’s supply for a user. When drug suppliers mix fentanyl into drugs or press it into illicit pills, a few grains too many can be enough to trigger a fatal overdose. It is unclear why fentanyl is showing up in such a large array of drugs. Evidence that fentanyl is showing up in more places comes from laboratory tests of drug seizures, toxicology testing and death certifications that take months to complete, according to the National Institute on Drug Abuse. Law-enforcement officials believe that in some cases, the drug is mixed in accidentally by drug manufacturers working with multiple white powders in the same lab, while at other times, drug manufacturers are experimenting in the attempt to create new psychoactive substances.

Fentanyl can be made into fabricated pills that are often indiscernible from commonly prescribed medications. PHOTO: ANDRI TAMBUNAN FOR THE WALL STREET JOURNAL

How often are illicit drugs laced with fentanyl?

Fentanyl has infiltrated virtually every channel of the illicit drug supply, according to U.S. law officials. The proportion of seized counterfeit pills in the U.S. containing a potentially lethal dose of fentanyl increased to 60% in 2022 from 10% in 2017, according to samples analyzed by the DEA.

WHAT’S NEWS

Tainted drugs are so common in cities across the country, including Columbus, Ohio, that the city offers a program for distribution of fentanyl testing strips to users so they can determine whether substances are contaminated with the drug.

In New York City, authorities have been warning of the risks of unknowingly taking fentanyl in cocaine and of its increased presence in cocaine seized by police. Of 980 cocaine deaths in 2020, 81% involved fentanyl, according to recent New York City health department data.

People who use methamphetamine are also sometimes accidentally exposed to fentanyl. But many users are intentionally using meth and opioids simultaneously or in sequence in search of balancing or offsetting effects, researchers say. The drug combination is becoming an emerging driver of U.S. overdoses.

What is fentanyl’s effect on the human body?

Fentanyl works by binding to the body’s opioid receptors—found in the areas of the brain that control pain and emotions, according to the National Institute on Drug Abuse. Some of the effects of fentanyl include euphoria, relaxation, pain relief, drowsiness and sedation, among others, according to the DEA. With repeated use, the brain adapts to the drug, making it hard to feel pleasure without it. Stopping the use of fentanyl leads to withdrawal, or “dope sickness,” which can include extreme anxiety, vomiting, muscle pain, chills, racing heartbeat and profuse sweating. Many chronic users have long since stopped feeling the euphoric effects of fentanyl and use it to avoid feeling sick.

Drug users who are accustomed to using heroin or prescription pain pills say illicit fentanyl’s effect can be more dramatic and shorter lasting than other opioids, making it more difficult to hold down a job as they seek out drugs every few hours.

Naloxone is an antidote to opioids that can reverse the effects of an overdose within two to three minutes. PHOTO: ASH PONDERS FOR THE WALL STREET JOURNAL

What are some of the signs and symptoms of someone overdosing on fentanyl?

Fentanyl slows the body down and reduces respiration but becomes deadly when it suppresses breathing to such slow shallow breaths that a person can’t sustain life and their heart stops. If someone is unconscious, awake but unable to talk, or their breathing slows sharply, that could be an early sign of an overdose. According to the New York State Department of Health, that person’s skin may soon turn bluish purple or ashen. In some cases, a person overdosing will have a faint heartbeat. An overdose can also lead to hypoxia, the decrease in oxygen to the brain, according to neuropsychopharmacologists.

Still, it can be difficult to tell if a person is just very high or experiencing an overdose, according to the National Harm Reduction Coalition. People who are high may display slurred speech or seem dazed, but still be able to respond to a loud noise or someone lightly shaking them, the group says.

How do you treat an overdose?

Naloxone is an antidote to opioids that can reverse the effects of an overdose within two to three minutes, according to the Mayo Clinic. Naloxone has virtually no effect in people who haven’t taken opioids, according to the World Health Organization.

Recently, the U.S. Food and Drug Administration encouraged pharmaceutical companies to apply for approval for over-the-counter versions of overdose-reversal medications such as Narcan to help address a swelling overdose crisis from bootleg versions of the powerful opioid fentanyl.

The FDA on March 29 approved Emergent BioSolutions Inc.’s Narcan brand of naloxone nasal spray for over-the-counter sale. The company said its nasal spray-version of the medication will likely become available on store shelves by late summer.

The pharmaceutical nonprofit Harm Reduction Therapeutics Inc. has already received priority review from the agency to make an inexpensive naloxone nasal spray for use without a prescription. The company said the FDA gave it a target approval date of April 28.

Supplies for drug users at an overdose prevention center in New York. PHOTO: SARAH BLESENER FOR THE WALL STREET JOURNAL

What is harm reduction?

Harm reduction is a public-health strategy aimed at reducing as much harm as possible to people while they are using drugs, rather than stopping them from taking substances altogether.

Groups that practice harm reduction for drug users teach about using clean needles to prevent infection and the spread of disease. Some groups provide fentanyl test strips so that users can test drugs for fentanyl and hand out naloxone to prevent deaths from overdose. An increasing number of groups supervise drug consumption. The Biden administration is the first to name harm reduction as a priority for drug policy.

Who is affected by overdose rates?

Disparities in access to treatment are driving up overdose rates among Black and Native American people, the CDC has said. Overdose deaths per 100,000 people increased 44% for Black people and 39% for Native Americans in 2020 from a year earlier, compared with a 22% increase among white people, according to a study in which the CDC analyzed 25 states and Washington, D.C.

Deaths from fentanyl have affected every age group, but particularly the 25-to 34-year-old and 35-to 44-year-old populations. These two groups combined made up more than half of all synthetic opioid overdose deaths in 2021, according to preliminary CDC data.

Young children have also been directly affected by fentanyl. There were 133 opioid-related deaths among children younger than 3 last year, according to federal mortality data.

Overdose rates were higher in areas with more opioid-treatment programs than average, a finding that the study’s authors said demonstrated other barriers to access for some people. Overdose rates were also higher in counties with higher income inequality, according to the study. The findings show how the escalating overdose crisis is exacting a mounting toll on minority groups that are in some cases marginalized by the healthcare system, CDC researchers said.

Some prisons and jails have programs that dispense antiaddiction medications to help put inmates who are addicted to opioids on a path to sobriety and curb overdose rates. The Biden administration has said it wants medication available for drug users in federal custody and at half of state prisons and jails by 2025.

This explanatory article may be periodically updated.

Brian Spegele, Margot Patrick, Arian Campo-Flores and Jon Kamp contributed to this article.

SOURCE: https://www.wsj.com/health/healthcare/what-is-fentanyl-drug-opioid-health-safety-explained-11658341650

 

The title of “Cannabis in Medicine: An Evidence-Based Approach” contains an irony. In chapter after chapter in this multi-authored book written predominately by providers associated with mainstream medical facilities in Colorado, the authors point out the inadequacy of the evidence we have and the absence of the evidence we need to determine how – or even if – cannabis has medical legitimacy. The foreword’s title, “Losing Ground: The Rise of Cannabis Culture,” sets the tone. David Murray, a senior fellow at the Hudson Institute, argues convincingly that “the current experiment with cannabis, underway nationwide [is] leading us towards a future of unanticipated consequences, a future already established in the patterns of use ‘seeded’ in the population but as yet unmanifested.” In other words, the cannabis horse has not only fled the barn but has been breeding prolifically to the point that we couldn’t get rid of it and its progeny if we wanted to!

The 20 chapters following the foreword are divided into basic science (three chapters) and clinical evidence (17 chapters) sections. Over and over in the clinical evidence chapters, individual authors remind the reader of the lack of quality control in production, the dearth of strong evidence from adequately designed research trials, and the intensifying potency of cannabis with attendant dangers, particularly for youth. The organization of this section lacks consistency in that some chapters focus on specialty (e.g. pulmonary medicine), others on patient groups (e.g. the pediatric and adolescent population), others on physiological implications (e.g. clinical cardiovascular effects; neuropsychiatric effects), others on specific diseases (e.g. gastrointestinal disorders; ocular conditions), and still others on public health topics (e.g. cannabis-impaired driving). While all are relevant, a specialty or organ system focus, with a separate public health section might lend the book more coherence. It would also be worth exploring how “cannabis culture” has become in essence a parallel medical system, with many of cannabis’s most ardent proponents as dropouts from establishment medicine after its nostrums for diagnoses like chronic pain, anxiety, and depression have failed to bring them relief.

I would have liked a chapter specifically grappling with the porous boundary between federal and state jurisdictions over cannabis as medicine and marijuana as recreational substance. Lawyer David G. Evans’ admirable chapter on “The Legal Aspects of Marijuana as Medicine” moves in that direction when he writes that, “‘medical marijuana’ is not a ‘states’ rights’ issue.” To wit, for no other drug than cannabis has the federal government ceded regulatory responsibility to states that are variably (but mostly not) equipped to handle it. The truth, complex in its contradictions and inconsistencies, is that in the United States, marijuana remains a Schedule I drug without recognized medical value; the Federal Drug Administration overseeing American pharmaceuticals throws roadblocks in the way of studying it, thereby interfering with the development of a robust evidence base; the federal government has looked the other way and even colluded with the states as one after another has legalized cannabis medically, recreationally, or both; and physicians risk their federal licenses to prescribe if they do more than recommend this drug. In a nutshell, any effort to impose logic is doomed because the American scene vis-à-vis cannabis is seemingly irretrievably illogical.

The editor of this volume, Kenneth Finn, MD, a PMR and pain management specialist in Colorado Springs, Colorado, is to be commended for encouraging individual chapter authors to develop encyclopedic bibliographies. The book can thus serve as a resource for practitioners wishing to delve into a vast and growing literature that continues to offer little that is conclusive. The book can also serve as a primer on what is known about cannabis as medicine, keeping in mind a slant throughout – not necessarily unjustified, at least from an allopathic or osteopathic perspective – that cannabis is neither legitimate as medicine nor safe, even for recreational use.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723137/ Sept-Oct 2020

‘Hot topics’ offer background and analysis on important issues which sometimes generate heated debate. Drug consumption rooms are a particularly contentious form of harm reduction, viewed on one hand as a practical, humane, life-saving approach to dangerous drug use, and on the other, as an endorsement of drugtaking and a dereliction of the duty to treat people dependent on drugs.

STEP-BY-STEP THROUGH SOME OF THE KEY ISSUES

Drug consumption rooms provide hygienic and supervised spaces for people to inject or otherwise consume illicit drugs. When counted at the end of 2018, there were 117 sanctioned drug consumption rooms in 11 countries around the world, generating an evidence base of ‘real world’ trials for scrutinising their biggest appeals and detractors’ greatest fears. Evidence of their effectiveness is one motivation for introducing drug consumption rooms; another is that they provide a common sense solution to the suffering and risks associated with public injecting.

The Scottish Government has recognised mounting harms to the health, wellbeing, and dignity of people who use drugs, and supports trialling drug consumption rooms as part of an approach to substance use based on public health objectives and human rights principles. However, the UK Government based in Westminster (London) has repeatedly blocked any such action. This stalemate provides the backdrop for a hot topic exploring the following questions:
• In communities dealing with the consequences of public injecting, could drug consumption rooms be part of the solution?
• Knowing the human cost of unsafe public injecting practices, would it be negligent for governments not to consider them at this point?

The mounting harms of public injecting

People who inject in public typically have nowhere else to go, and for complex reasons are unable or unwilling to engage with treatment for their drug dependence, or are in treatment but still using illicit drugs. They are very often homeless, and have reached a ‘boiling point’ of risk where they live with the daily prospect of bacterial infections, contracting blood-borne viruses, overdosing, and in the absence of someone witnessing the overdose and stepping in with life-saving support at the right time, dying on our streets.

Injecting in public places is a high-risk practice associated with an inability to inject in a sterile way, both due to unhygienic environments and difficulty maintaining personal hygiene, and hasty, unsafe injecting practices due to the threat of being seen by the public or police.

2006 study involving 100 people from Glasgow, Edinburgh, Bristol and London, whose day-to-day life at home or at work was likely to expose them to public drug use or its aftereffects, identified three types of locations used for public injecting:
• open areas including alleyways, car parks, cars, derelict or rubble/rubbish strewn open spaces, and train stations;
• neglected property including disused and seldom used parts of buildings, building sites, drug houses, and squats;
• publicly accessible places held as residential or commercial property including houses, cafés, pubs, toilets, gardens, bushes, backyards, doorsteps, stairwells, bin shelters, and garages.

However, participants’ sympathy for people who used drugs was often offset with blame and resentment for the impact public injecting had on them personally. Drawing a line in the sand, participants talked of people who used drugs as a group distinct from residents, tourists, workers, and patrons. This ranged from expressing their appreciation for people who used drugs “keep[ing] away from residential areas”, to condemning them for “blighting an area’s reputation and their own quality of life”.

Public injecting can indeed have an impact on other people, but as these participant responses illustrated, there is a danger of people who inject in public being represented as public order problems to communities to the exclusion or minimisation of the personal and individual harms they experience. Furthermore, the ‘public impact’ narrative can overlook the fact that people who inject in public are also members of communities, and rather than being held responsible for ‘blighting’ those communities, there could be recognition that they are carrying the burden of some of the worst health and social inequalities in society.

Scenes of public injecting in Birmingham documented by harm reduction advocate Nigel BrunsdonScenes of public injecting in Birmingham documented by Nigel Brunsdon

“Time for safer spaces”: Scenes of public injecting in Birmingham documented by Nigel Brunsdon

 

In August 2016, harm reduction advocate and photographer Nigel Brunsdon spent a day walking around Birmingham, documenting evidence of public injecting. He visited three known injecting areas – two on waste grounds next to car parks, and one in a main walkway in the centre of town – and found the ground covered in injecting equipment and general waste; needles alongside garbage and human excrement. “No one ‘chooses’ to inject in these spaces”, he said, “this is where the most desperate people in our society have been driven”.

A few years earlier in 2012, Philippe Bonnet explored these key issues in a documentary produced by Social Impact Films. He toured known injecting sites in Birmingham, and interviewed outreach workers, healthcare professionals, and people who were currently injecting (or had injected) drugs in public places. Injecting equipment was already available to the city’s population, and services were providing this equipment knowing that it would be used by people to inject illicit drugs. Many vulnerable people would go on to inject those illicit drugs in unsafe spaces – places that were cold, unhygienic, with poor lighting and no washing facilities. Describing the conditions as “completely appalling’, he said:

“The aim of this video is to highlight the problem we have in this city. Can we let people inject in these situations? Can we let the harm carry on?”

A core demographic of drug consumption rooms is homeless people who use drugs, due to links between homelessness and high-risk behaviours such as public injecting, sharing injecting equipment, and poor injecting hygiene.

The term homelessness covers a spectrum of living situations. Though traditionally associated with ‘rough sleeping’, someone who has a roof over their head can still be homeless. The broad categories of homelessness described by Crisis, the UK national charity for homeless people, are:
• ‘rough sleeping’;
• in temporary accommodation (night/winter shelters, hostels, B&Bs, women’s refuges, and private/social housing);
• hidden homeless (people dealing with their situation informally, ie, people who stay with family and friends, ‘couch-surf’, and ‘squat’);
• statutory homeless (people deemed ‘priority need’ who their local authority have a duty to house).

By its very nature, homelessness exposes people to materially poor living conditions – increasing their exposure to risky situations and decreasing their capacity to protect themselves from harm. This supplementary text details some of the life-limiting diseases and disorders experienced by homeless people, some of which are complications of risky drinking and drug use, and many of which are preventable and treatable. The Guardian drew attention to this in 2019 (for original data source, see NHS Digital website), writing:

“Thousands of homeless people in England are arriving at hospital with Victorian-era illnesses such as tuberculosis, as well as serious respiratory conditions, liver disease and cancer.”

In 2011, when UK homelessness charity Crisis reviewed deaths among homeless people, the situation was very bleak. They found that homeless people die on average 30 years before the general population (48 for men and 43 for women, compared to 74 and 80 respectively), and a third of these deaths are related to drink and drugs. According to recent assessments, the situation may be getting worse rather than better. Figures from the Office for National Statistics revealed that 597 homeless people died in England and Wales in 2017, an increase of 24% from the 482 deaths recorded in 2013. Most of these were men (84%), with an average age of 44 years old (44 years for men, 42 years for women), and more than half died from causes related to drugs (32%), alcohol (10%) or suicide (13%) – much higher than the 3% of deaths attributable to drugs, alcohol, or suicide in the general population the same year.

A 2018 study analysed the social distribution of homelessness and found that in the UK homelessness is not randomly distributed across the population – the odds of experiencing it are systematically structured around a set of identifiable individual, social and structural factors, most of which are outside the control of those directly affected. Poverty (especially childhood poverty) is central to understanding people’s pathways to homelessness, and on the flipside, the ‘protective effect’ of social support networks is key to understanding how people can avoid homelessness.

Where harm is concentrated in the general population and what that harm looks like are of critical relevance to the question of whether to introduce drug consumption rooms. The heightened level of risk among homeless people suggests that at the very least the debate needs to be able to navigate the different environments and contexts in which people take illicit drugs. Just as not all drugs were created equal, not all people who use drugs were created equal. As Nigel Brunsdon said: “No one ‘chooses’ to inject in these spaces, this is where the most desperate people in our society have been driven”.

What happens inside a drug consumption room?

Cubicles for hygienic, supervised injecting inside a drug consumption room

Cubicles for hygienic, supervised injecting inside a drug consumption room

 

Drug consumption rooms are legally sanctioned spaces where people can bring their own pre-obtained illegal or illicit drugs, and either inject or inhale them using sterile equipment under the supervision of nurses or other medical professionals. This differentiates them from:
• illegal ‘shooting galleries’ run for profit by drug dealers – though colloquial references to drug consumption rooms in the media can blur this line (1 2);
• hostel or housing services that tolerate drug use among residents but provide no medical supervision;
• programmes which prescribe pharmaceutical heroin (diamorphine) for consumption by their patients under medical supervision (1 2).

Until the 1970s there were informal, ad hoc facilities including the ‘fixing rooms’ of London’s Hungerford and Community Drug Projects, and Blenheim in west London, which had a toilet where people routinely injected. These stopped running primarily due to the knock-on effects of people using barbiturates, a sedative which can result in ‘drunken’ behaviour. Staff felt unable to support users safely and were disillusioned at facilities becoming ‘crash pads’ for people turning up already stoned.

The first officially approved supervised consumption room opened in Bern (Switzerland) in 1986. Rooms were then introduced in Germany and the Netherlands in the 1990s, and in Spain, Australia and Canada in the early 2000s. As of April 2018, when the European Monitoring Centre for Drugs and Drug Addiction updated their overview of provision and evidence (for earlier version, click here), there were 31 facilities in 25 cities in the Netherlands, 24 in 15 cities in Germany, five in four cities in Denmark, 13 in seven cities in Spain, two in two cities in Norway, two in two cities in France, one in Luxembourg, and 12 in eight cities in Switzerland. Outside Europe, at the time of the 2018 Global State of Harm Reduction report there were two facilities in Australia and 26 in Canada.

Most rooms are integrated into existing, easy-access (or ‘low threshold’) services for people who use drugs and/or homeless people, giving them access to ‘survival-orientated’ services including food, clothing and showers, needle exchange, counselling, and activity programmes. Less common are facilities exclusively for people who use drug consumption rooms that offer a narrow range of services directly related to supervised consumption (1 2). Spain, Germany and Denmark also have mobile facilities offering a more flexible service (ie, going where people who use drugs are) but with limited capacity.

The most recent drug consumption room census, facilitated by the International Network of Drug Consumption Rooms in 2017, included 51 responses collected from 92 drug consumption rooms operating in Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland. This found that almost all drug consumption rooms (94%) provided referrals to treatment and distributed sterile injecting equipment for taking away. Many also provided condoms (89%) and HIV-related counselling (70%), personal care (76%), including shower and laundry facilities, and support with financial and administrative affairs (74%). Frequently provided were HIV testing (54%), outpatient counselling (46%), mental health care (44%), hepatitis B vaccinations (41%), legal counselling (39%), take-home naloxone (37%), and opioid substitution treatment (24%), as well as meals (61%), recreational activities (57%), work and reintegration projects (41%) and use of a postal address (39%). Almost half of services also reported offering tours or open days to the public (49%).

Demystifying what happens within the four walls of a drug consumption room, Marianne Jauncey from the University of New South Wales described the operating practices of a facility in North Richmond, Victoria (Australia):
• Stage one: First-time visitors register with the service. This involves them talking to a member of trained nursing or counselling staff, and providing a brief medical history. If they wish, people attending can use an alias; they are not required to leave either their full names or their real names. Once registered, attendees are asked what drug they are seeking to use, as well as what other drugs they have used recently, which gives staff a sense of what to expect.
• Stage two: Staff provide clean injecting equipment, typically including small 1 ml syringes, swabs to clean the skin, a tourniquet, water, filters, and a spoon. Clients sit at one of eight stainless steel booths, and inject themselves. Staff are not legally able to inject a client, but their role as clinicians trained in harm reduction is to reduce the risks associated with that injection. This may involve talking to someone about where and how they inject, encouraging them to wash their hands and use swabs, ensuring they don’t share any equipment, and other techniques aimed at ensuring they understand the risks of blood-borne virus transmission.
• Stage three: After the injection, clients safely dispose of their used equipment, and move to a more relaxed space in the next room. Drawing on the therapeutic relationship they build, staff and clients have discussions about health and wellbeing, what to do in the event of an overdose (eg, the recovery position and rescue breathing), and how to access other services, including mental health treatment, dental services, hepatitis C treatment, wound care, relapse prevention, counselling and referral to specialised treatment.

For now the closest contemporary Britain comes to having safer injecting centres are the few clinics where patients inject legally prescribed pharmaceutical heroin (diamorphine) under clinical supervision. These clinics are unlikely to engage the target group of drug consumption rooms, but nonetheless provide a service to people who have not benefitted from more conventional treatment. Furthermore, it could be argued, they provide an experience- and skills-base for drug consumption rooms in the UK as they have to exercise the same monitoring of patients and have the same capacity to respond to overdose incidents as drug consumption rooms.

Determining whether they produce sufficient benefits (with no countervailing problems)

Evidence of the need for and impact of drug consumption rooms tends to be divided into “public harms which affect communities, such as discarded syringes in public parks and toilets”, and “private harms which affect individuals, such as overdose death and blood-borne viruses”. The extent to which each is used to justify the introduction of drug consumption rooms differs from country to country. For example, overdose deaths were a key driving force in Norway, Spain, Canada and Switzerland, while public disorder and local concerns about drugtaking in public places were important in Canada, pivotal in the Netherlands, and have been raised in towns and cities around the UK, such as Neath Port TalbotBrighton and Hove, and Manchester, though Britain is yet to see a single drug consumption room.

Outcomes from the first drug consumption rooms were “relatively inaccessible to the international research community” until 2003/2004, at which time Professor John Strang, a leading figure in British substance use practice and policy, cautioned that “claims” of harm reduction from drug consumption rooms would need to be more robustly tested. Although the evidence base has grown considerably since then, it remains difficult to evaluate the rooms’ impacts in ways that meets the scientific ‘gold standard’.

Randomised controlled trials feature at the top of “traditional evidence hierarchies”. They involve researchers randomly allocating participants to two or more groups – an intervention versus an alternative intervention, a ‘dummy’ intervention, or no intervention at all. The following extract explains the logic behind randomised controlled trials, and hence why they prove to be so desirable:

“When a new treatment is administered to a patient and an improvement in her condition is observed, the possibility of drawing a conclusion from the fact is hindered by the absence of a counterfactual: possibly the patient would have recovered anyways if left untreated, or maybe a different treatment would have been more effective. In [a randomised controlled trial], participants are divided into two groups, one that receives the experimental treatment and another that acts like a control, providing the answer to the ‘what if’ counterfactual question. For the concept to work as intended, though, the administration of the experimental treatment should be the sole difference between the experimental and the control group.”

As drug consumption rooms tend to emerge from local initiatives aimed at reducing the harms of public drug consumption, they are not designed or implemented with the random allocation of people in mind. Instead, researchers undertake evaluations in ‘real world’ circumstances, for example comparing changes in outcomes in a neighbourhood that opened a drug consumption rooms versus a comparison area that did not. The limitation of this approach is that the effects of drug consumption rooms are obscured by complex sets of factors not under a researcher’s control. In Sydney, for instance, calculating lives saved by harm reduction measures has been complicated by “dramatic changes in the availability of heroin”. What was colloquially referred to as the ‘Australian heroin drought’ affected the amount of heroin being used, and probably resulted in a reduction in associated problems such as heroin-related overdose.

Expecting evidence for drug consumption to rooms come from randomised controlled trials also raises ethical issues. Drug consumption rooms provide a range of services, some of which are unique to this intervention. If one group of people who inject drugs were randomly allocated to drug consumption rooms, that would mean another group of people who inject drugs would be denied access. If the study was recruiting participants from the target group of drug consumption rooms – a particularly vulnerable and marginalised cohort of people who typically have nowhere else to go, and for complex reasons are unable or unwilling to engage with treatment for their drug dependence, or are in treatment but still using illicit drugs – participants without access to a drug consumption room would likely continue to inject in public places with the extremely high levels of risk this carries.

ASSESSING IMPACT

Europe’s monitoring centre on drugs described (1) improving survival and (2) increasing social integration as the overarching aims of drug consumption rooms. Indicators that these aims are being achieved include:
✔ establishing contact with hard-to-reach populations;
✔ identifying and referring clients needing medical care;
✔ reducing immediate risks related to drug consumption;
✔ reducing morbidity and mortality;
✔ stabilising and promoting clients’ health;
✔ reducing public disorder;
✔ increasing client awareness of treatment options and promoting clients’ service access;
✔ increasing chances that client will accept a referral to treatment.

Even without a randomised trial, it is possible to at least estimate the likelihood that an intervention (in this case, a drug consumption room) is having a positive or negative impact. For example, it may not be possible to determine impact on the transmission of infectious diseases, but it is possible to observe impacts on self-reported needle and syringe sharing, the key cause of transmission among people who use drugs. Furthermore, there are other high-quality research methods that instill confidence in the results, including ‘natural experiments’ that compare changes in outcomes in neighbourhoods where a drug consumption room had opened to control areas where they had not, and simulation studies that estimate the costs and benefits of existing drug consumption rooms at reducing disease transmission and overdose.

As the Joseph Rowntree Foundation’s Independent Working Group on Drug Consumption Rooms put it, “the methodological problems involved here should not detract from [drug consumption rooms’] considerable success” and their mechanisms for improving the health and wellbeing of their clients – ensuring hygienic and (relatively) safe injecting in the facility, providing personalised advice and information on safe injecting practices, recognising and responding to emergencies, and providing access to a range of other on-site and off-site interventions and support. Below we look at some of the outcomes and mechanisms for achieving those outcomes referred to by the Joseph Rowntree group.

Forging therapeutic relationships

Drug consumption rooms are aimed at “limited and well-defined groups of problem drug users” – typically, people who inject on the streets, who are not in treatment, and who are characterised by extreme vulnerability to harm, for example due to social exclusion, poor health and homelessness. The temperament and attitude of staff, as well as the ‘house style’, are critical to whether drug consumption rooms can engage with their target client groups – for example, the extent to which they encourage rather than deter potential clients, and are sympathetic and non-judgemental towards people with multiple problems who may be ostracised in other spaces.

In Danish drug consumption rooms, staff strive to be welcoming, and have prioritised forging relations with people who use drugs. The effect is that both clients and staff see the facilities as providing a ‘safe haven’ – one in which acceptance can clear the path for prevention, treatment and support. This view of drug consumption rooms as ‘sanctuaries’ and ‘spaces of healing’ was shared by a colleague in Victoria (Australia):

“An injecting centre provides the setting and the possibility for a new type of connection with our clients. The power of suspending judgement for those who are the most judged and vilified in our society can be transformative.”

For highly marginalised people who use drugs in particular, drug consumption rooms can be the first step into the health and social care system. Though they do not guarantee that clients access treatment – making use of the drug consumption room conditional on accepting treatment would undermine the ethos of harm reduction – they do remove some of the traditional barriers to treatment, which can ultimately make treatment a more realistic prospect. To support this suggestion, reviews have consistently found that drug consumption rooms are associated with an increase in the uptake of treatment including opioid substitution therapy and supervised withdrawal (1 2).

Though little is known about the potential of co-locating drug consumption rooms with services for supervised withdrawal, findings from the Insite facility in Vancouver (Canada) suggest that drug consumption rooms may be a useful point of access to “detoxification services” for high-risk people who inject drugs. Between 2010 and 2012, 11% of people injecting drugs who used the safer injecting facility (147 of 1316 total) reported enrolling in withdrawal programmes at least once. This was more likely among people residing near the consumption room, frequently attending the consumption room, and among people who reported enrolling in methadone maintenance therapy, injecting in public, injecting frequently, and recently overdosing.

Reducing public injecting

How much drug consumption rooms can significantly reduce public drug use depends on their accessibility, opening hours, and capacity. Understanding the characteristics of drugtaking among local people is essential for providing sufficient capacity to meet demand, remain accessible, encourage regular use, and achieve adequate coverage of the injecting population. For example, facilities focusing on or seeking to explicitly include sex workers may need to remain open in the evening and at night.

A 2014 survey by the International Network of Drug Consumption Rooms found that (among participating organisations) drug consumption rooms across Europe were open for an average of eight hours a day. Despite 20 of the 34 also opening on weekends, this left large periods of time when clients who would otherwise use the facilities had to inject elsewhere. In Hamburg, over a third of people surveyed who attended drug consumption rooms had also used drugs in public during the past 24 hours, citing among their main reasons waiting times at injecting rooms, distance from place of drug purchase, and limited opening hours.

Germany has the strictest admission criteria in Europe, which includes excluding people in opioid substitution treatment. In an unnamed consumption room, potential clients were denied access on 544 occasions because they were:
• not residing in the vicinity of the drug consumption room (250);
• drunk or intoxicated (150 times);
• in opioid substitution treatment (109);
• first-time or occasional users (four);
• under 18 years of age without permission from their parents (two).

Even when admission criteria are strongly justified – for example, on the basis that they protect clients and staff, and enable staff to run a safe facility – they do leave a proportion of people who, without access to a drug consumption room, may continue to inject in public. For reasons outside of admission criteria, studies of existing facilities suggest that drug consumption rooms may not yet be accessible to all groups at risk from public injecting, especially pregnant women and those who cannot self-inject, or people whose patterns of drug use mean that they need 24-hour access, for instance people primarily using cocaine who might “go without sleep for days on end”.

Litter and public disorder

The chief political defence for drug consumption rooms is to mitigate the public nuisance, disorder and crime associated with public injecting. Consequently they are usually sited where concentrated public drug use and discarded paraphernalia ‘spoil’ the environment, and hamper or undermine regeneration. Service user Nick Goldstein, whose article “The Right Fix?” was published in the November 2018 edition of Drink and Drugs News, and who was admittedly not enamoured of drug consumption rooms as an approach, stressed the imbalance inherent in this:

“I must admit that one of my pet peeves is that drug treatment is rarely designed for the primary purpose of helping drug users. Instead it tends to be designed to protect wider society from drug users by reducing crime, reducing the spread of [blood-borne viruses] in society and even by attempting to make drug users more economically productive.”

“At my most cynical I feel there’s something disturbing about an approach that can easily be seen as saying ‘come in for half an hour, have a shot so you don’t scare the public and then fuck off back to your cardboard box’.”

This is an understandable criticism considering that the more vulnerable and desperate people become, the more ostracised and stigmatised they tend to be in our communities. However, it could be argued that ‘moving injecting drug use off the streets’ directly serves vulnerable people who use drugs in two key ways: (1) it recognises the dignity of homeless people by considering the impact of discarded paraphernalia and public injecting drug use on them too, including homeless people who might be forced to inject drugs where they live; and (2) gives an opportunity to build the political profile of this considerably underrepresented population by bringing people together under one roof.

Compelling evidence about the impact of drug consumption rooms on litter and public disorder comes from Vancouver (Canada), where acceptance of the facility among residents and workers had been generated by the distressing sight of public injecting and injecting-related litter, and despite a large local needle exchange, risky injecting, disease and overdose deaths had remained high. After the facility opened there was a significant reduction in people seen injecting in public places from a daily average of 4.3 to 2.4. Also roughly halved were discarded syringes and injecting-related litter in the surrounding area. In Barcelona a fourfold reduction was reported in the number of unsafely disposed syringes being collected in the vicinity of safer injecting facilities from a monthly average of over 13,000 in 2004 before they opened to around 3,000 in 2012 after they opened (source paper in Spanish).

Injecting- and drug-related harm

In Vancouver alone, 88% of drug consumption room clients were found to have hepatitis C, and up to a third had HIV. This baseline level of harm exemplified the need for drug consumption rooms to function not only as a means of preventing harm among clients themselves – and facilitating access to treatment for blood-borne viruses and infections – but preventing harm being transmitted to others (eg, by sharing contaminated needles and syringes).

Regular use of drug consumption rooms has been linked to the use of sterile injecting equipment, and in particular a self-reported decrease in syringe sharing and re-use of syringes. Furthermore, although studies generally focus on harm reduction outcomes inside facilities, reductions have been seen outside drug consumption rooms in clients’ risk-taking behaviour, and it seems likely that ‘safer use’ messages could be transmitted to a wider population of people who use drugs via consumption room attendees.

While reducing risky behaviours such as syringe sharing could be expected to reduce risk of HIV and hepatitis C, the impact of drug consumption rooms on this is not directly observable. Drug consumption rooms have limited coverage and tend to go hand-in-hand with other services, and therefore it would be difficult to isolate their effect.

A point that is becoming increasingly salient as governments pay attention to new psychoactive substances is the potential for frontline staff in drug consumption rooms to “play [a role] in the early identification of new and emerging trends among the high-risk populations using their services”. In the UK, the national response to new psychoactive substances has been focused on legislation (the Psychoactive Substances Act 2016) and its effectiveness, while relatively little consideration has been given to developing a treatment response. Research undertaken in Manchester (England) between January and June 2016 uncovered two changes – the first of which may have consequences for traditional drug consumption room clients, and both of which represent new challenges for harm reduction services: (1) a shift away from heroin and crack cocaine among homeless people to spice; and (2) a change in the ingestion route of drugs within the emergent chemsex scene among men who have sex with men from the conventional recreational use of substances such as ecstasy and cocaine (1 2) to intravenous injection of crystal methamphetamine or mephedrone.

Mortality

While drug consumption rooms do provide safer spaces for injecting, “dangerous situations that require intervention arise frequently … (as they do in any drug-injecting context)”; the difference is the capacity to respond to these emergencies and prevent them progressing to serious harm or death:

“The aim of an injecting centre is to physically accommodate the injection of drugs that would normally occur somewhere inherently more dangerous, and often public.”

Because there is no quality control for illicitly sourced drugs, part of the harm comes from simply not knowing what may or may not be in the mixture, so staff are always on the look-out for unexpected reactions.

Recommended reading

Essay on overdose deaths in the UK

The main cause of opioid-related deaths is respiratory failure, caused by opiate-type drugs switching off the part of the brain that reminds you to breathe. If no one intervenes in the event of this type of overdose, oxygen will be depleted and eventually the heart will stop, causing death. Staff can prevent overdoses becoming fatal by: protecting a person’s airway; providing supplemental oxygen; providing resuscitation (artificially breathing for the person using a bag/valve/mask); and administering the opiate overdose antidote naloxone.

Staff in two facilities in Hamburg (Germany) estimated that nearly three quarters of emergencies were related to heroin use. More difficult to manage, they suggested, were cocaine-related emergencies characterised by increased anxiety, psychotic states, or epileptic seizures. Whereas the response to opioids was driven by the need to aid breathing, interventions after problematic cocaine use generally involved calming and protecting the person who had used drugs.

Only one death has been documented in a drug consumption room since the first opened in 1986, and this was not linked to the drug consumption room itself; in 2002, a person who used drugs died from anaphylaxis (an acute allergic reaction) in a German facility (1 2). While ‘nobody has died from an overdose inside a drug consumption room’ serves as a strong argument for them having a positive effect, this in itself is not a principal and necessary measure of success, but rather a comment or observation on the history of drug consumption rooms to date.

Conservative estimates of lives saved by drug consumption rooms include the prevention of four fatal overdoses per year in Sydney (Australia), and ten deaths per year in Germany. In Vancouver (Canada), there was a 35% decrease in fatal overdoses, and an estimated two to 12 fatal overdoses were prevented each year.

Costs and benefits

Costs for supervising drug use (the most distinctive function of drug consumption rooms) have been estimated at roughly the same in Vancouver and Sydney – the equivalent in Canadian currency of C$7.50–C$10 per injection. This would bring the cost of supervising all injections for someone who injects twice a day to about C$5,500–C$7,300 per year, which is in the same ballpark as the cost of providing methadone for a year to a patient in the United States.

Focusing almost exclusively on Vancouver, simulation studies have found that the value of averting a fatal overdose or HIV infection is so high that drug consumption rooms can pass the cost–benefit test even if the number of people affected is small (1 2). However, many other interventions also pass that test, including medication-assisted treatment, needle and syringe exchanges and naloxone, raising the question of how best to distribute scarce financial resources across such interventions.

It is unclear whether greater benefit would be achieved by investing the same amount of resources in interventions other than drug consumption rooms due to a lack of evidence about the magnitude of population-level benefits – firstly, because the literature can blur the lines between the impact of a drug consumption room’s entire suite of interventions and its supervision of consumption, and secondly, because supervised consumption can have spillover effects on behaviour outside drug consumption rooms as well as within the four walls.

Though other interventions may serve some of the functions of drug consumption rooms, they may not all be equally accessible to the target group of drug consumption rooms. For example, some would seem to be appointment-based rather than, as with drug consumption rooms, attended on a drop-in basis. Therefore, while it is understandable to question whether greater benefit would be achieved by investing the same amount of resources in interventions other than drug consumption rooms, this excludes the more fundamental argument about why drug consumption rooms should be considered in addition to existing interventions.

Adverse effects

Honeypot

‘Honeypot effect’ applies to bees, not consumption rooms

The published literature is large and almost unanimous in its support for drug consumption rooms, and there is little to no basis for concern about drug consumption rooms producing adverse effects. However, fears of adverse effects persist.

One of the concerns about drug consumption rooms is that they will aggravate public disorder and crime in surrounding local areas by attracting people who use drugs and dealers from elsewhere – termed the ‘honeypot effect’. While if this did happen it would also presumably extend the benefits of drug consumption rooms to non-local people who use drugs, neither the adverse nor the beneficial results of the honeypot effect have materialised in practice; where used, the term is alluding to a ‘phenomenon’ based in fear (or fear-mongering) rather than fact.

The European Union’s drug misuse monitoring centre found no evidence that drug consumption rooms result in higher rates of drug-related crimes in the vicinity (eg, trafficking, assaults, robbery). Most consumption room users live locally, and typically reflect the profiles of people buying drugs in local markets, and for this reason, facilities located any distance from drug markets tend to attract very few users. Explaining why, people who use drugs and gave evidence to the Joseph Rowntree Foundation’s Independent Working Group pointed out that:

“…An addicted injecting heroin user is likely to be primarily driven by the need to obtain their drugs. If they have the money, their first port of call will be a dealer. If there is somewhere nearby where they can safely use their drug (and obtain a clean syringe), then this is likely to be their next step. If they need to go any distance to reach such a place, their need to inject their drug is likely to lead to them using somewhere else (often a public area nearby).”

Although, on balance, research suggests that drug consumption rooms make drug use safer (eg, increasing access to health and social services, identifying and responding to emergencies, and reducing public drug use), and that fears (eg, encouraging drug use, delaying treatment entry, or aggravating problems arising from local drug markets) are not grounded in evidence (1 2 3), policy is not informed by evidence alone.

Evidence ‘just one ingredient in the policymaking process’

Drug consumption rooms have been seriously considered in the UK on several occasions since the turn of the millennium, but have arguably never been a realistic prospect because of government opposition. Though each time there has been genuine concern about harms associated with injecting drug use, followed with a review to understand the effectiveness of drug consumption rooms in mitigating these harms, ultimately the evidence base did little to convince decision-makers.

In 2002, a Home Affairs Select Committee on drugs policy recommended that drug consumption rooms be piloted in the UK:

“We recommend that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if, as we expect, this is successful, the programme is extended across the country.”

However, the ‘New Labour’ government rejected this recommendation, arguing that the evidence appraised by the committee was insufficient to justify implementation, despite the pilot programme being proposed at least in part to generate evidence specific to the UK.

Looking at the wider context, it seems the political conditions were “not ripe for drug consumption rooms”. Concerns which likely had a prohibitive effect on the policy included (1 2):
• the potential for public confusion between drug consumption rooms and existing supervised heroin prescribing pilots;
• the potential for drug consumption rooms to be perceived as inconsistent with the government’s commitment to being “tough on crime, tough on the causes of crime”;
• the potential for the government to be accused by the media and others of opening ‘drug dens’;
• being open to legal challenges.

For this government, their future electoral success largely depended on being (and appearing to voters as) “tough on crime”, and drug consumption rooms risked appearing to condone the use of illegally bought drugs. ‘Heroin prescribing’, on the other hand, was a policy that New Labour was amenable to; the UK Government agreed to expanding diamorphine prescribing, approving a trial of three heroin prescription maintenance clinics in London, Brighton, and Darlington between 2005 and 2007. Unlike drug consumption rooms, this could be framed as ‘tough on crime’ – obviating the need for patients to commit acquisitive crimes to fund dependent heroin use.

Two years later, the British Medical Journal published a paper arguing that “the case for piloting supervised injecting centres in the United Kingdom [was] strong”, and that its rejection should be overturned. Diamorphine prescribing was an important tool in the box, the authors acknowledged, but would appeal to, and benefit, different groups to drug consumption rooms – the former, long-term heroin addicts who have not responded to traditional treatment, and the latter, people who are socially excluded and homeless:

“…Neither is a panacea…holistic provision should include both”.

The next time drug consumption rooms came under review in the UK was in 2006 by the Independent Working Group on Drug Consumption Rooms, made up of senior police officers, senior academics, a GP consultant, and a barrister specialising in drug offences. The group found that while there were “high levels of injecting drug use in particular areas of the UK, these did not appear to be associated with the sort of extensive public injecting that had been instrumental in the setting up of some of the European [drug consumption rooms]”. Although this did not deter them from making a strong recommendation in favour of piloting drug consumption rooms, their comment revealed that without these large open drug scenes associated with serious health and public order problems, the case for drug consumption rooms might appear weaker to politicians and the wider public. Nevertheless, their conclusion was:

“The [Independent Working Group] considers [drug consumption rooms] to be a rational and overdue extension to the harm reduction policy that has produced substantial individual and public benefits in the UK. They offer a unique and promising way to work with the most problematic users, in order to reduce the risk of overdose, improve their health and lessen the damage and costs to society.”

The political response to the Independent Working Group report was warm. However, the proposition was once again rejected.

Moving away from the national stage, cities have often taken the lead in continental Europe, and in Britain too they have not simply accepted the central government’s position. An important case study in this respect is Brighton, which had an unenviable reputation for one of the nation’s highest rates of drug-related mortality. Prompted by a call from Brighton’s Green Party MP, an Independent Drugs Commission was set up in Brighton in 2012. The following year the commission agreed that “where it is not possible to stop users from taking risks, it is better that they have access to safe, clean premises, rather than administer drugs on the streets or in residential settings”. Brighton’s Safe in the City Partnership should, they recommended, consider the feasibility of incorporating “consumption rooms into the existing range of drug treatment services in the city,” focusing on ‘hard-to-reach’ groups and those not engaged in treatment. These points were key: drug consumption rooms were to be deliberated as part of a larger framework of services; and drug consumption rooms were to be focused on a particularly vulnerable and marginalised cohort, as opposed to all injecting people who use drugs.

The feasibility study was undertaken, but in 2014 the commission’s final report concluded “that a consumption room was not a priority for Brighton and Hove at this time – the working group was convinced by the international evidence on the potential benefit from these facilities, but thought that they would have little impact on the types of factors that were contributing to deaths in the city”. Perhaps more importantly, “members of the working group were…concerned at the cost implications, in a time of budget pressure, and also advice from the Home Office that opening such facilities would contravene UK law”.

Drink and Drugs News article on what would persuade a city to accept a drug consumption room

Drink and Drugs News article on what would persuade a city to accept a drug consumption room

 

A month later in June 2014, the feasibility working group explained that there was insufficient support at the time to consider drug consumption rooms; both the Association of Chief Police Officers and Sussex Police were opposed, as were other organisations. Resistance was partially attributed to a “shift in focus for substance misuse services from harm reduction to recovery [which placed…] a greater emphasis on abstinence”. It was unclear whether as a group stakeholders were aligned with the values of abstinence-based recovery, or whether the policy and funding climate was forcing their hand. However, Brighton’s local paper The Argus reported that weeks after the feasibility study was launched, several stakeholders spoke out against drug consumption rooms, revealing a less than open mind in advance of the enquiry being concluded. This included Andy Winter, chief executive of Brighton Housing Trust, who said he wanted to see “something far more positive [done] with addiction and recovery”. Frustrated at what he considered a ‘distraction’ from recovery, treatment and abstinence, he resolved to “oppose any further waste of public funds, time and effort on exploring [their] feasibility”. With members like this on the group, whose minds were made up from the beginning, it would have been a surprise if drug consumption rooms were deemed feasible in Brighton.

In 2016, the Advisory Council for the Misuse of Drugs recommended that “consideration be given – by the governments of each UK country and by local commissioners of drug treatment services – to the potential to reduce [drug-related deaths] and other harms through the provision of medically-supervised drug consumption clinics in localities with a high concentration of injecting drug use”. However, a 2017 letter from the Home Office to the advisory council clarified that the government would not change its position on drug consumption rooms. The following year the government restated its position in public (1 2):

“We have no intention of introducing drug consumption rooms, nor do we have any intention of devolving the United Kingdom policy on drug classification and the way in which we deal with prohibited drugs to Scotland” (Home Office Minister Victoria Atkins, January 2018, House of Commons debate on drug consumption rooms).

“There is no legal framework for the provision of drug consumption facilities in the UK and we have no plans to introduce them” (Prime Minister Theresa May, July 2018, Prime Minister’s Questions).

In 2017, an advisory panel on substance misuse in Wales pledged to address the feasibility of establishing “enhanced harm reduction centres” – the term preferred by service providers to “reflect a desire to consider much more than simply providing a safe, clean place for individuals to inject but to expand the services on offer to include other harm reduction interventions (such as advice, wound care, blood borne virus testing, sexual health provision and links with wraparound services such as housing)”. Reminiscent of other ‘serious considerations’, the panel concluded just under a year later that, “based on the current available evidence”, it could not recommend the implementation of drug consumption rooms:

“In summary, there is evidence to suggest that [drug consumption rooms] are effective in decreasing drug-related mortality and morbidity […and, drug consumption rooms] should therefore be considered a successful tool as part of broader harm reduction interventions and strategies.”

“However…uncertainty about the generalisability of available research to the Welsh context must be taken into account in any consideration.”

Leaving the door ajar, the panel suggested a feasibility study “to inform decisions about possible implementation”, including what outcomes such facilities would seek to achieve, how these could be measured, operating procedures, and the inward and outward referral pathways.

‘Lack of evidence’ has repeatedly been cited as a barrier to implementing drug consumption rooms, despite reviews of the international evidence indicating that drug consumption rooms more likely than not remove harm (and do not cause harm), and despite the fact that pilot drug consumption rooms have been recommended in Britain at least in part to generate evidence of their viability and effectiveness in the domestic context. For cities like Glasgow in the midst of a crisis, calls for more rigorous research with no clearly defined end in sight is difficult to comprehend – “no reasonable person would wait for a randomized control trial evaluating parachutes before donning one when leaping from a plane”. The satirical paper published in the British Medical Journal that inspired this quote highlighted the absurdity of claiming that only randomised controlled trials will suffice in every scenario. As for resolving “whether parachutes are effective in preventing major trauma related to gravitational challenge”, the authors suggested two options for moving forward:

“The first is that we accept that, under exceptional circumstances, common sense might be applied when considering the potential risks and benefits of interventions. The second is that we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial.”

Growing acceptance of safer injecting facilities and increasing concern about overdoses in Canada prompted a rapid escalation in efforts to establish consumption rooms in various cities. However, for a long time only one facility existed, and this remained in “perpetual pilot status for over a decade”. For Canada, political opposition to drug consumption rooms was the most significant barrier to expansion. The shift came in October 2015 with the election of a new government, which had expressed support for safer injecting facilities. Between 2016 and 2018 the country went from having two facilities to 26.

Through successive political parties, the UK Government has remained opposed to drug consumption rooms. Recent statements ( view above) exemplify unwavering commitment to the prohibition of drugs, which drug consumption rooms are perceived to contradict or undermine.

The ‘legal hurdles’

The message that has filtered down from government is that drug consumption rooms are incompatible with UK law. In Brighton, one of the reasons that stakeholders were collectively unwilling to recommend trialling drug consumption rooms was “advice from the Home Office that opening such facilities would contravene UK law”. However, that is not the end to the story. Though there may be some legal barriers, they could be easily overcome if the political will were there.

In 2016, plans to open a consumption room in Scotland were reported to be ‘pressing forward’, with advocates awaiting approval from James Wolffe QC, Scotland’s chief legal officer, in order to ensure compliance with the law. However, his legal opinion put the brakes on their perceived momentum (1 2). While the Lord Advocate had the power to instruct police not to refer people caught with illegal drugs for criminal proceedings, he said he could not remove the designation of those acts as illegal. In 2017, the Lord Advocate ruled that a change to the Misuse of Drugs Act 1971 would be necessary before drug consumption rooms could be introduced. Speaking to the Scottish Affairs Committee in 2019, he said:

“The introduction of such a facility would require a legislative framework that would allow for a democratically accountable consideration of the policy issues that arise and would establish an appropriate legal regime for its operation.”

To this end, the Supervised Drug Consumption Facilities Bill 2017–19 was introduced to the House of Commons in March 2018, containing provisions to make it lawful to take controlled substances within supervised consumption facilities. This included amendments to the Misuse of Drugs Act 1971, which would protect anyone employed within or using the drug consumption facilities.

The following year, a cross-party group of ConservativeLabourLiberal DemocratScottish National PartyGreen, and Crossbench politicians wrote a letter to The Telegraph urging the government to reconsider its “failing” approach to illicit drug use:

“These rooms have proved successful in many countries, including Germany, Canada and Australia. As it stands, they sit in a legal grey zone. It’s time for Britain to catch up with the rest of the world by providing a clear legal framework to trial drug consumption rooms in areas with high levels of drug-related harm.”

Clarifying the law, Release, the national centre of expertise on drugs law, has said that the Misuse of Drugs Act 1971 does not in fact make it illegal to allow someone to possess or inject controlled drugs on your premises, but does make it illegal to allow their production or supply or the smoking of cannabis and opium, which would suggest that a carefully managed facility could operate within the law despite its clients breaking laws prohibiting possession of controlled drugs – though this may not relieve concerns among professionals such as nurses and doctors about their liability in the event of a serious issue and the coverage of their medical insurance.

Asking the police to turn a ‘blind eye’ to illicit drugs may seem like it is asking them not to fulfil one of their key obligations – enforcing the law. However, this is not their only role; the police also have a responsibility for maintaining public order and public safety. Indeed, there are already examples of criminal justice objectives being compromised or reconsidered at the discretion of police forces for the ‘greater good’ – including to facilitate treatment and harm reduction, and better utilise limited resources – which could translate to drug consumption rooms if the political, institutional, and social will was there. Recent comparable examples include the following:
• Thames Valley Police are trialling an approach whereby police will urge people found with small quantities of controlled drugs to engage with support services, rather than arresting them. Dismissing allegations of being ‘soft on crime’, Assistant Chief Constable Jason Hogg said there is “nothing soft about trying to save lives”.
• Drug safety testing services have been piloted at a UK festival with the support of local police, who agreed to ‘tolerance zones’ where they would not search or prosecute for possession in order for members of the public to be able to bring drugs for testing and receive results as part of an individually tailored brief intervention.

Police and Crime Commissioners, who would be essential to build the local support for drug consumption rooms, have been prominent among those lobbying for the facilities. Several key figures have used their unique positions to advocate for a compassionate and pragmatic harm reduction-based approach to drugs, which they say should include drug consumption rooms. At least four have publicly come forward – Ron Hogg (Durham), Arfon Jones (North Wales), David Jamieson (West Midlands), and Martyn Underhill (Dorset) – and seven in total signed a letter to the Home Secretary, Sajid Javid MP, which called on him to end the government’s ‘policy’ of blocking the implementation of drug consumption rooms.

As part of its remit, the Independent Working Group on Drug Consumption Rooms commissioned an analysis by a leading expert on UK drugs law, Rudi Fortson. While he concluded that some adjustments of the law might further shield rooms from legal challenge, the group was “not persuaded that this would be a necessary and unavoidable first step. Pilot [drug consumption rooms] could be set up with clear and stringent rules and procedures that were shared with – and agreed by – the local police (and crime and disorder partnerships), the Crown Prosecution Service (CPS), the Strategic Health Authority and the local authority.” Despite this information being added to the public discourse, ambiguity over the legal footing of drug consumption rooms has prevailed.

Rudi Fortson has also investigated how facilities in Canada (see Effectiveness Bank analysis of the Insite project) and Australia operate, providing a glimpse into the workings of drug consumption rooms in countries with legal systems similar to that of the UK. For more click here.

In terms of international law, signatories to the United Nations’ international drug control conventions (including the UK, Australia and Canada) have another issue to consider: whether drug consumption rooms violate their obligations under those conventions. Charged with policing adherence to the conventions is the International Narcotics Control Board. From in 1999 an extreme condemnation claiming the rooms breach the conventions because they “facilitate illicit drug trafficking”, by 2015 the board seemed to admit that if a facility “provides for the active referral of [persons suffering from drug dependence] to treatment services”, they might be admitted within the spirit and letter of the conventions. For more click here.

For Rudi Fortson the thousands of words on whether drug consumption rooms contravene UN conventions had missed the wood for the trees. He observed that there has been a tendency to focus on the parts that impose restrictions and prohibitions, yet “conventions often embody statements of political will, intent, or hope”, and in this case prohibition was intended to be at the service of promoting public health and wellbeing, not its opposite. Moreover, none of the three main UN conventions have direct application in the UK; they are interpreted into UK law by parliament, and it is those interpretations on which the courts rely in their judgements.

When countries view drinking and illicit drug use through the lens of public health, laws often follow that prioritise the safety and wellbeing of people who use drugs and those around them, instead of prioritising the inviolability of prohibition. For instance, so-called ‘Good Samaritan laws’ have been enacted in the context of overdose-related deaths in Canada and various states in the US. In Canada, the Good Samaritan Drug Overdose Act was introduced in 2017, providing legal protections (eg, from charges for possession of a controlled substance or breach of parole) for people who experience or witness an overdose and call the emergency services.

Acceptance is at the root of benefits and criticisms

Recommended reading

Essay on harm reduction

Drug consumption rooms seek to minimise the harms of drugtaking for a cohort of people who, for complex reasons, are unable or unwilling to engage with treatment for their drug dependence, or are in treatment but still using illicit drugs.

What makes drug consumption rooms distinct from and more disruptive than other harm reduction approaches such as needle exchanges, is that they employ staff who bear witness to illicit drug use, as opposed to staff who advise and provide resources but are ultimately absent for the act of drugtaking. This enables the dissemination of specific (rather than generic) harm reduction advice based on direct observation of “consumption patterns, risky dosages and improper handling of equipment”:

“In order to successfully promote harm reduction topics, staff expressed that safer-use messages must be related to drug use practice, connected to daily life experiences and be given in one-on-one conversations.”

It also enables people who inject drugs to be fully seen and accepted – even and especially while engaging in behaviour that is typically shrouded with so much stigma and shame.

“…There’s no doubt that for the drug users this is a really, really good step in the right direction. Before they used to shoot up outside in the cold, in staircases, or in playgrounds using water from puddles. They shared syringes and they lived miserable lives. For many years they have been crying out: ‘…Maybe I cannot help using drugs but give me a decent life and some dignity’…It has been horrible for them. So I think that it means a lot to get off the streets, and to not be looked down on by other people.” (Nurse, Danish drug consumption room)

What drug consumption rooms set out to achieve is to “fundamentally reconfigure…each event of drug use”, producing “pleasurable and positive modes of engagement” that can improve survival and increase social integration.

However, the features above are not universally viewed as strengths; critics have persistently positioned drug consumption rooms as legitimising drug use, and therefore doing rather than alleviating harm. Speaking out against proposed consumption room pilots in Brighton in 2013, Kathy Gyngell from the right-wing Centre for Policy Studies questioned the premise of a ‘safe space’ for injecting altogether, saying that drug consumption rooms are “described as safe despite the very unsafe street drugs used in them, and despite the intrinsic risk of addicts continuing to inject drugs at all”. In 2016 a pilot drug consumption room opened in Paris near a busy central station where drug crime is common. For France’s health minister it was “a very important moment in the battle against the blight of addiction”, but for a politician from the centre-right opposition, the country was “moving from a policy of risk reduction to a policy of making drugs an everyday, legitimate thing. The state is saying ‘You can’t take drugs, but we’ll help you to do so anyway’” – wildly differing perspectives on the same facility.

Though the loudest voices may be people totally in favour of, or totally against, harm reduction services, many people sit somewhere in the middle – perhaps accepting the need for needle exchanges, but instinctively opposed to drug consumption rooms, believing that they cross an ideological red line from reducing harm to facilitating drug use. It is in this space that misunderstandings and misrepresentations of drug consumption rooms can flourish.

Claims that drug consumption rooms ‘enable’ drug use are hard to shake, but fail at face value. The target group of drug consumption rooms do not need help or encouragement to take drugs; they need support to take drugs without preventable risks. If harm reduction measures aren’t in place, they will likely continue to take drugs, just in a riskier way. Introducing a Bill to the House of Commons which would make the necessary legal provisions for drug consumption rooms, Alison Thewliss MP said in March 2018:

“On Monday, one of my constituents mentioned to me that Glasgow already has drug consumption facilities: they are behind the bushes near his flat and in his close when it rains. Right now, they are also in bin shelters, on filthy waste ground and in lonely back lanes. They are in public toilets and in stolen spaces where intravenous drug users can grasp the tiniest modicum of dignity and privacy for as long as it takes to prepare and inject their fix. Often they are alone, and, far too regularly, drug users will die as a result. As a society, we can and must do much better than that.”

Drug consumption rooms recognise these realities and ‘meet people where they’re at’ – creating a bubble of acceptance of drugtaking within a broader context of criminalisation. With stigma and shame alleviated, and relationships forged with harm reduction professionals, this may open a door to treatment further down the line. However, it may also ‘just’ lead to safer injecting practices; it may ‘just’ lead to overdoses being prevented, lives being saved, health and wellbeing improved, and dignity and social connections restored.

If there is an ideological ‘green line’ over which people must cross to support drug consumption rooms, that line is agreement with the idea that where harms can be minimised or prevented, they should be – even if that means a degree of toleration of illegal drug use. One can still hold that position while believing that people’s lives would be improved if they stopped taking drugs, or even that illicit drugs have a deleterious impact on society overall. This perspective prioritises the current health, wellbeing and dignity of people, over judgements about their behaviour or wishes for their future selves.

Reframing drug consumption rooms and the people who use them

Drug consumption rooms go by many names, including overdose prevention centres, safer injecting facilities, enhanced harm reduction centres, medically supervised injecting centres, safe injecting sites, drug injection rooms, and drug fixing rooms. Each have different connotations. For example, ‘safer injecting facility’ refers narrowly to venues where people can more safely inject illicit drugs, though there are also consumption rooms where people can inhale or inject, depending on the landscape of harms in the locality. The term ‘enhanced harm reduction centres’ takes an expanded view of the harm reduction services and routes into treatment on offer, but could have the (unintended) consequence of minimising the importance of the supervised drug consumption element.

In academia and the news media, drug consumption rooms are often framed as a controversial prospect, highlighting how far they lean away from the status quo of prohibition and law enforcement. Sometimes articles use the word ‘controversial’, sometimes they imply it by listing concerns (even if unfounded or so far disproved by the evidence base) about drug consumption rooms, and sometimes articles achieve it through innuendo, for example referring to them as ‘shooting galleries’, which are illegal venues run for profit by drug dealers.

In the UK, this can have the effect of cementing (rather than merely reflecting) their political reality as ‘extreme’ and ‘unrealistic’ – perpetuating the thinking that current drug policy is the neutral position to take, and ignoring the fact that drug consumption rooms have become a “normalised harm reduction approach across Europe and other countries”. It also embeds a debate defined around the problem of implementing drug consumption rooms, rather than drug consumption rooms being a potential solution to the problem of public injecting.

“Words matter,” stressed commentators in North America in an article about the role of language in advancing or inhibiting evidence-based responses to the worldwide opioid crisis. Our choice of words can have an impact on how people who inject drugs are perceived, and the extent to which we advance solutions to drug-related harm based on a person’s “individual responsibility” versus wider situational, environmental, political and social factors such as inadequate distribution of naloxone, contaminated drug supply, social isolation, and lack of social support.

An analysis of how the UK news media represented proposals to introduce drug consumption rooms in Glasgow identified the use of derogatory language (such as ‘junkies’) to describe people who inject, and this was not confined to articles that opposed drug consumption rooms, but also present in articles that supported drug consumption rooms. Articles also tended to define individuals primarily by their drug use, reducing their humanity to a stigmatised behaviour, and doing nothing to contest the “morally charged” perception of individuals causing harm to themselves and wider society through their continued drug use.

The UK Government’s approach to illicit drugs is built on the pillars of prohibition and abstinence, which themselves rest on the belief that drugs are inherently harmful to people who use them, and to wider society. Therefore, any messages which contradict or soften the prioritisation of drug criminalisation and abstinence-based approaches are seen as undermining the ability of criminal justice and treatment systems to ‘protect’ people from harm.

While proponents of drug consumption rooms may be able to see drug consumption rooms as compatible with services based on both harm reduction and abstinence, opponents tend to position them as mutually exclusive – arguably because of what they represent, as well as what they do. Drug consumption rooms challenge the dominant interpretation of where harm (and subsequently blame) lies, showing how the environment in which drugs are consumed can decrease or increase, mitigate or compound, the harms people experience; in other words, drugs may produce harms (as well as benefits), but a fatal overdose or blood-borne virus need not be the price a person pays for taking drugs. Drug consumption rooms were specifically established to address the disproportionate level of harm that disadvantaged people who use drugs experience. They radically change the conditions in which people take drugs, and serve as a brick and mortar reminder of the structural inequalities that make it necessary to offer this alternative to public injecting.

“Current discussions about drug consumption rooms risk excluding, minimising, or erasing the current, specific, and urgent problem of public injecting”Philosophical differences between “those calling for a change in UK drug policy to incorporate harm reduction, and those who attempt[…] to maintain status quo responses based on abstinence[,…] recovery” and prohibition account for a large part of the disagreement about drug consumption rooms. Though understandable, discussion framed around these higher-level philosophical differences may risk excluding, minimising, or erasing the current, specific, and urgent problem of public injecting.

One thing proposed which could help interested parties navigate their differences in “harmony” is a better appreciation for how and why someone’s professional and intellectual background informs their view of drug consumption rooms, and specifically their appraisal of the evidence base. Published in the Addiction journal (and analysed in the Effectiveness Bank), a paper by Caulkins and colleagues distinguishes between three types of decision-makers (the politician, the planner, and the pioneer), and three types of thinkers (the academic, the advocate, and the allocator of scarce resources), arguing that there is plenty of nuance between the commonly-heard extreme positions.

This nuance is helpful, particularly introducing concerns that may hold people back in a practical sense from endorsing drug consumption rooms. For instance, commissioners – people allocating already stretched resources – may support drug consumption rooms personally or politically, but also need to know on paper how drug consumption rooms fare against interventions already in place (or themselves needing expansion) such as naloxone and opioid substitute medications:

‘Would drug consumption rooms save more lives per dollar than other available alternatives?’

‘Would we need to disinvest in other services to pay for drug consumption rooms?’

What the paper did not do, was acknowledge the power dynamics between stakeholders, for example the way that politicians may act as or be perceived as gatekeepers or roadblocks to lifesaving interventions. It didn’t recognise that the status quo in countries like the UK, maintained by stakeholders including politicians, represents unwavering opposition to drug consumption rooms. Stakeholders may have different perspectives about these facilities, informed by their decision-making responsibilities and intellectual backgrounds, but how is the power to make decisions and influence public opinion distributed, and how close are the people in positions of power and influence to the day-to-day realities of the target groups of drug consumption rooms?

Time for safer injecting spaces in Britain?

In Scotland, record-breaking levels of drug-related deaths and an outbreak of HIV among people who inject drugs have been at the forefront of discussions about the need to expand services for people with drug and alcohol problems – without which it is feared that substance use in the context of deprivation and homelessness will remain a threat to the life and quality of life of vulnerable people.

“…A public health and humanitarian crisis which must be addressed urgently”Figures released by National Records of Scotland in July 2019 showed that drug-related deaths in Scotland had increased by 27% from 2017 to 2018. At 1,187 in 2018, Scotland was looking at the highest rate of drug-related deaths since records began in 1996 – three times that of the UK as a whole, and indeed higher than reported for any other EU country. In a press release for the National AIDS Trust, Director of Strategy Yusef Azad said: “The high rate of drug-related deaths constitutes a public health and humanitarian crisis which must be addressed urgently.”

In Glasgow city centre there were 47 new diagnoses of HIV among people who inject drugs in 2015, compared to an annual average of 10. This problem caught the attention of the European Monitoring Centre for Drugs and Drug Addiction, which reported 119 new cases of HIV in Glasgow between November 2014 and January 2018, specifically among homeless people who inject drugs. The agency described this as “the largest cluster of people who inject drugs infected with HIV…in the United Kingdom since the 1980s”. An important feature of this outbreak was its strong link to cocaine use, which surveillance data from needle and syringe programmes using dried blood testing and data from syringe residues in 2017 indicates is increasingly being injected (with or without heroin). Critically, harm reduction services (including the provision of injecting equipment and opioid substitution treatment) were available before and during the outbreak – needle and syringe programmes in Glasgow distribute over one million syringes per year – suggesting that circumstances had changed or were changing and required a different or intensified response.

The_Times_Scotland_HIVDaily_Record_Scotland_deaths
In Taking away the chaos, the local health service and Glasgow’s drug service coordinating partnership reviewed the health and service needs of people who inject drugs in public places in the city centre. Resulting recommendations were to develop existing services, including extending assertive outreach services and developing a peer network for harm reduction, and to introduce new services, such as a pilot safer injecting facility in the city centre to “address the unacceptable burden of health and social harms caused by public injecting”. However, to date the Scottish Government has been constrained by legal judgements that drug consumption rooms would fall under the purview of the UK Government (and UK-wide Misuse of Drugs Act 1971).

The Scottish Government’s approach to drugs and alcohol reflects the belief that substance use problems are predominantly public health and human rights issues, which enables it to pursue policies that save and improve lives. This puts it at odds with the UK Government, which has been unwilling to depart from treating substance use as a criminal justice issue. As with minimum unit pricing, Scotland has been nudging the UK position on drug consumption rooms, referring in a 2018 strategy to the Scottish Government’s efforts to “press the UK Government to make the necessary changes in the law, or if they are not willing to do so, to devolve the powers in this area so that the Scottish Parliament has an opportunity to implement this life-saving strategy in full.” Not letting this be a footnote in the strategy, the Minister for Public Health, Sport and Wellbeing Joe FitzPatrick used drug consumption rooms in his opening remarks (see page 3) as an example of “supporting responses which may initially seem controversial or unpopular”:

“Adopting a public health approach also requires us all to think about how best to prevent harm, which takes us beyond just health services. This, requires links into other policy areas including housing, education and justice. It also means supporting responses which may initially seem controversial or unpopular, such as the introduction of supervised drug consumption facilities, but which are driven by a clear evidence base.”

If there was an evidentiary threshold for trialling drug consumption rooms in the UK, the Home Affairs Select Committee on drugs policy, Independent Working Group on Drug Consumption Rooms, and Advisory Council on the Misuse of Drugs were confident in 20022006, and 2016 (respectively) that this had been passed. That successive governments have not accepted recommendations for a pilot study indicates that factors outside of the evidence base are fundamental to determining the acceptability and feasibility of drug consumption rooms in Britain.

2004 briefing explained that in order for drug consumption rooms to be accepted and allowed to supplement the UK’s repertoire of substance use interventions, three broad areas inhibiting policymakers would need resolving:
• Principle: “How do policy makers justify providing a service that enables people to engage legitimately in activities that are both harmful and illegal?”
• Messages: “Do [drug consumption rooms] legitimise drug use, encourage more people to use hard drugs or – at the local level – increase drug-related problems in the areas where they are situated?”
• Effectiveness: “Do [drug consumption rooms] reduce drug related harms and, even if they do, are they the most appropriate and cost effective way of reducing these harms?”

The last two points are arguably the easiest to address. On messages, the answer is clear: there is an evidence base of ‘real world’ trials determining that drug consumption rooms produce sufficient benefits, with no countervailing problems; specifically, there is no evidence that they encourage more people to use ‘hard drugs’ or increase drug-related problems in the vicinity of drug consumption rooms. On effectiveness, there is sufficient evidence that drug consumption rooms reduce drug-related harms among the target population, however: (1) this evidence does not rise to the ‘gold standard’ of randomised controlled trials, though the ethics of holding harm reduction interventions to this bar before implementation should be rigorously challenged; and (2) there is a need to pilot them in the UK context to understand how they could respond to local drug-using populations and fit within wider communities. The principle on which drug consumption rooms rest is where most of the conflict lies.

Despite similar levels of drug-related harm in Germany and the UK, only Germany has responded to the problem with drug consumption rooms (accruing 24 at the time of publication). Researchers from both countries identified differences that could account for this, pointing in particular to:
• limited local powers in the UK compared to Germany, enabling German cities to introduce drug consumption rooms, which could eventually lead to federal support;
• large open drug scenes in Germany (not found to the same degree in the UK), which are associated with serious health and public order problems and played a pivotal role in persuading communities and local politicians that something had to be done;
• historical tendency of the British press to stoke up fears around drug use and people who use drugs; whenever the issue has been discussed, much of the reporting has been negative, with frequent derogatory references to ‘shooting galleries’.

Should the outrage and solutions proposed in Scotland start to shift mindsets, Britain already has a good-practice blueprint to guide implementation. In 2008, the Joseph Rowntree Foundation published guidance for local multi-agency partnerships looking into opening a drug consumption room. It addressed minimum operational standards, domestic and international legal issues, as well as the commissioning process, operational policies and procedures, monitoring and evaluation. It also stressed that local agreement is absolutely essential – something not generated previously in Brighton ( above), though with “accumulating evidence of poor health and social outcomes for [people who inject drugs]” in Scotland and the political will, the story may end differently.

Concluding thoughts

When we first published this hot topic on drug consumption rooms in 2016 we suggested “there seem two scenarios in which support for drug consumption rooms could be generated in the future”:

“…firstly, if there were to be a policy shift towards harm reduction, not just as a mechanism to engage drug users with treatment, but as a legitimate goal in itself; and secondly, if the UK were to reach a ‘tipping point’ in the degree of distress and nuisance perceived to be caused by public injecting, or the degree of concern over the concentration of overdose fatalities and infectious diseases in certain locations.”

Three years on, central government’s position on drug consumption rooms in the face of mounting harms to vulnerable and socially-excluded people injecting in public casts doubt of the notion of reaching such a ‘tipping point’.

Drug consumption rooms are not a replacement for abstinence, treatment, or law and order; they provide respite from public injecting, restore a vital connection to healthcare and social support services for a highly-marginalised and highly-stigmatised group of people, and put the interest and wellbeing of people who use drugs at the heart of drug policy. Consistent evidence of their effectiveness suggests that it would be prudent and overdue to trial drug consumption rooms in UK cities. Whether Westminster will reconsider remains to be seen. Meanwhile, as more and more countries integrate this pragmatic harm reduction approach into their drugs policy, any claim to the moral high ground in Westminster seems easily refuted.

Thanks for their comments on this entry in draft to Blaine Stothard (Co-Editor, Drugs and Alcohol Today), Dr Will Haydock (Visiting Fellow, Bournemouth University), Claire Brown (Editor, Drink and Drugs News), Philippe Bonnet (Chair, National Needle Exchange Forum), and Naomi Burke-Shyne (Executive Director, Harm Reduction International). Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 30 July 2020. First uploaded 27 October 2016

Source: Time for safer injecting spaces in Britain? (findings.org.uk)

A NEW cannabis compound has been discovered and it may be 30 times more potent than THC.

Scientists aren’t yet sure whether the compound causes a high or has medical benefits so they’ve been conducting tests to try and figure this out.

Little is known about the potential effects of the new strong compound Credit: Getty – Contributor

The compound is one of two newfound cannabinoids that have been discovered in the Cannabis plant glands of the sativa L species.

Cannabinoids is the collective term for the group of diverse chemical compounds that act on the cannabinoid receptors of the brain.

THC is just one of these cannabinoids and it’s currently considered to be the principal psychoactive component of cannabis.

THC, or tetrahydrocannabinol, plugs into brain receptors and can alter our ability to co-ordinate movements, reason, record memories and perceive things like time and pleasure.

THC in cannabis is what can give smokers a high feeling Credit: Getty – Contributor

It’s thought that cannabis contains over 140 similar chemicals that can interact with receptors all over the body.

However, THC is currently the only one we know can result in a high spaced out feeling.

Of the two new cannabinoids discovered, one looks similar to the compound CBD, which isn’t psychoactive.

The other appears similar to THC but may even produce stronger mind-bending effects.

This THC lookalike is called tetrahydrocannabiphorol (THCP).

Recent research suggests that it interacts with the same brain receptor as THC but has slight differences in its chain of atoms.

The slight difference in shape of THCP means it can technically fit more snugly into its preferred brain receptor than THC.

A test showed that the compound can actually bind 30 times more reliably than THC.

When given to lab mice, the THCP made them behave as if they were on THC with slower movements and decreased reactions to pain.

The mice reached this state with a much lower dose than would have been required with THC meaning the new compound is stronger.

However, this lab experiment still doesn’t mean that the same effect would happen in humans.

THCP doesn’t appear to be present in large amounts in cannabis plants but even if it was, increased psychoactive properties would still not be guaranteed.

Being caught with cannabis comes with a maximum of five years in prison, an unlimited fine, or both.

  • While being convicted of producing and supplying the Class B drug carries up to 14 years behind bars, an unlimited fine, or both.
  • Police can issue a warning or on-the-spot fine if you’re caught with a small amount – generally less than one ounce – if it is deemed for personal use.

Source:  The Sun  14th Jan. 2020

Limited information exists on marijuana use and male reproductive health. A recent study from Duke University evaluated differences in sperm quality resulting from tetrahydrocannabinol (THC) exposure in both rats and humans. Findings suggest that paternal marijuana use, prior to conception, may present epigenetic risks to potential offspring.

Public perceptions pertaining to marijuana have evolved radically over the past 2 decades. While marijuana remains criminalized at the federal level, 33 states and the District of Columbia have legalized marijuana, in some capacity, for either medical or recreational use. According to the most recent National Survey on Drug Use and Health, nearly 26 million Americans, over the age of 12, currently use marijuana. While the gender gap is narrowing, men remain significantly more likely to use marijuana than women (11.7% vs. 7.3%, respectively).

In 2017, approximately 1.9 million men, between the ages of 26 and 29, reported using marijuana in the past month. Given that the average age of first-time fathers in the U.S. is around 30, these findings suggest that a substantial number of “fathers-to-be” are using marijuana at the time of conception. Little is known, however, about the impact of paternal marijuana use on reproductive outcomes.

Epigenetics, which literally translates to “above” or “on top of” genetics, refers to the biological mechanism through which genes are activated and expressed. This process acts like a light switch, turning on or off how cells read certain heritable traits written within an individual’s unique genetic code. Sperm matures continually throughout adulthood, making it particularly vulnerable to potential epigenetic modifications, such as DNA methylation, that may result from marijuana use. This study explores differences in sperm profiles, based on cannabis exposure in both humans and rats, to better understand potential heritable effects.

Key Findings

  • Individuals who used marijuana can have higher and also can have significantly lower sperm concentrations, compared to those who did not, posing potential complications for fertility.

  • THC-exposed sperm was associated with significantly altered DNA, in both rat and human samples.

*Associations were even stronger among individuals with higher levels of THC in their urine, implying a “dose-response relationship” such that chronic marijuana users may be impacted more severely.

  • Authors identified three unique potential genetic pathways modified by THC exposure.

Looking to the Future

Past research suggests that offspring born to rats exposed to THC during adolescence demonstrate significant DNA alterations in their brains, display heightened drug-seeking behavior, and are at increased risk of developing opioid dependency over time, compared to controls. The present study is the first to extend this line of research to men of childbearing age, lending additional evidence for potential intergenerational, heritable consequences, resulting from paternal marijuana use. Just as other environmental triggers, such as air pollution, cigarette smoking, certain pesticides (i.e. DDT), and exposure to radiation are known to affect sperm health, THC may also increase the potential for genetic mutations.

For Clinicians

  • Primary care physicians and healthcare professionals, both inside and outside of substance use disorder treatment landscapes, should take time to educate patients about the impact of THC on sperm so individuals may consider potential implications for fertility and children conceived during periods of active use.

For Researchers

  • This article adds to a growing literature on the potential epigenetic impact of paternal marijuana use prior to conception. Findings must first be replicated in larger samples. Additionally, future longitudinal studies are necessary to explore the extent to which THC induced DNA alterations in sperm are passed down to offspring, as well as their long-term consequences.

For Policymakers

  • Marijuana potency continues to increase rapidly, with THC level increasing 300% over the past 20 years. Within the current political landscape and shift towards increased access to medical and recreational marijuana, policymakers should work closely with scientists to stay informed on the extent to which increased THC levels and evolving public attitudes impact men’s reproductive health.

For General Public

  • The full impact of passing THC-related DNA modifications onto offspring, and whether or not these changes are reversible is still unknown. Evidence of DNA alterations to existing Hippo signaling and Cancer genetic pathways may disrupt growth, enhance the potential for miscarriage, or impede healthy embryo development.

Methods

The authors employed a quantitative genome-scale approach, referred to as reduced representation bisulfite sequencing, to compare DNA methylation alterations in sperm across human and rat samples. A number of factors including, time since last ejaculation, semen volume, pH, morphology, and motility were controlled for across participants. Pyrosequencing, a DNA synthesizing method that relies on light detection, was implemented to identify genes with significant methylation differences. Data were then analyzed to uncover specific genetic pathways potentially impacted by paternal, preconception cannabis use.

Study Limitations

  • A relatively small sample size of human subjects, limiting the generalizability of study findings.

*24 males, age 18-40 years: (12 marijuana users & 12 non-users)

  • The methodological approach may fail to identify epigenetic modifications that affect multiple genes simultaneously.

Source: What you should know about Marijuana and Sperm (addictionpolicy.org) March 2019, updated October 2022

The study by Sadananda et al published in the current issue of the IJMR highlights the neurophysiological basis of altered cognition in subjects with opioid addiction. The study demonstrated aberrant network activity between the default mode network (DMN) and fronto-parietal attentional network (FAN) as a major cause for working memory deficits in drug addiction. Working memory is an important to retain the cognitive information essential for goal directed behaviours. Human beings are endowed with an efficient cognitive faculty of working memory, essential for efficient functioning of the executive network system of the brain. As working memory is the key to carry out any cognitive process involving attention, volition, planning, goal directed behaviour, etc., consciousness is linked largely to working memory processing. The importance of integrating neuroscience knowledge especially the executive functions of human brain in leadership has been taught in neuro-leadership programs as a mean to maximize the human capabilities, productivity, creativity, leadership, wellness, positive attitude.

Aberrant network activities and structural deficits in brain areas of executive functioning impede most of our intellect including mental flexibility, novel problem solving, behavioural inhibition, memory, learning, planning, judgement, emotion regulation, self-control and other social functioning. Deficits in working memory and attention owing to reduced fronto-parietal network (FPN) activity is reported in schizophrenia, autism, attention deficit hyperactive disorder (ADHD) and anxiety disorders. Opioid addiction is reported to impede such dynamicity of the executive system leading to a wide range of deficits in cognition. Opioid addiction alters the network integrity between DMN and FPN networks and weakens the cognitive information processing in cognitively challenging paradigms. Dysfunctional dynamics of DMN activity is believed to contribute to impaired self-awareness, negative emotions and addiction related ruminations. Aberrant DMN activity and reduced medial prefrontal cortical functions are common neural phenotypes of cognitive deficits in conditions like mental illness, drug addiction, sleep deprivation and neurodegenerative disorders. People with substance use disorders develop mental illnesses as a serious comorbidity that in turn, leads to severe behavioural impairments at the social, emotional and cognitive domains. Chronic sleep deprivation associated with drug addiction and substance abuse is another predisposing factor that worsen the behavioural impairments. Over all, drug addiction, substance abuse and the subsequent maladaptive behaviours including mental illness and sleep deprivation trigger a complex set of network instability in the domains of cognition and affect. The euphoria and hallucinating experience of drugs of abuse would soon lead to psychological distress and to cognitive and emotional behavioural impairments due to the disruption of various top down and bottom-up network dynamics.

Substance use disorders are an imminent socio-economic burden and have become a major public health concern worldwide. Despite knowing the harmful effects and consequences of drug use, reports say that the youth especially the adolescents have a tendency to continue the habit. There is a need to have effective measures in place such as educational programmes to improve the self-efficacy of parents and family members to help their children to develop the right behavioural attitude, enhance the capacity building in teachers to strengthen the self-esteem and wellness of students to organize substance use control awareness programmes in coordination with NGOs at educational institutions, involvement of television and other visual and social media platforms to organise substance abuse control programmes and for interactive opportunity for children/youth with educators, researchers and professionals, organization of knowledge dissemination programmes to the public/schools/colleges to highlight the adverse effects of drug abuse on mental health and cognition. Introduction to such knowledge sharing platforms such as the Virtual Knowledge Network (VKN) at NIMHANS, Bengaluru, provide interactive skill building opportunities to safeguard them from substance abuse and addiction. People should have easy access to such services and rehabilitation centers. Various behavioural intervention strategies such as cognitive retraining, psychotherapy, yoga therapy, mindfulness-based intervention programmes etc. are reported to improve cognitive abilities, regulation of negative emotions and restoration of motivational behaviours. A study on single night exposure to olfactory aversive conditioning during sleep helped to quit addiction to cigarette smoking temporarily. Such studies highlight the possibility of learning new behaviours during sleep and its positive impact on wake associated behaviours. Such approaches are quite useful, easily testable and cost-effective. Thanks to the incredible phenomenon of adult brain plasticity, it is possible to re-establish social intelligence, prosocial motivation among people with substance abuse.

Source: Drug addiction – How it hijacks our cognition & consciousness – PMC (nih.gov) October 2021

A growing number of countries are deciding to ditch prohibition. What comes next?

In an anonymous-looking building a few minutes’ drive from Denver International Airport, a bald chemotherapy patient and a pair of giggling tourists eye the stock on display. Reeking packets of mossy green buds—Girl Scout Cookies, KoolAid Kush, Power Cheese—sit alongside cabinets of chocolates and chilled drinks. In a warehouse behind the shop pointy-leaved plants bask in the artificial light of two-storey growing rooms. Sally Vander Veer, the president of Medicine Man, which runs this dispensary, reckons the inventory is worth about $4m.

America, and the world, are going to see a lot more such establishments. Since California’s voters legalised the sale of marijuana for medical use in 1996, 22 more states, plus the District of Columbia, have followed suit; in a year’s time the number is likely to be nearer 30. Sales to cannabis “patients” whose conditions range from the serious to the notional are also legal elsewhere in the Americas (Colombia is among the latest to license the drug) and in much of Europe. On February 10th Australia announced similar plans.

Now a growing number of jurisdictions are legalising the sale of cannabis for pure pleasure—or impure, if you prefer. In 2014 the American states of Colorado and Washington began sales of recreational weed; Oregon followed suit last October and Alaska will soon join them. They are all places where the drug is already popular (see chart 1). Jamaica has legalised ganja for broadly defined religious purposes. Spain allows users to grow and buy weed through small collectives. Uruguay expects to begin non-medicinal sales through pharmacies by August.  

Canada’s government plans to legalise cannabis next year, making it the first G7 country to do so. But it may not be the largest pot economy for long; California is one of several states where ballot initiatives to legalise cannabis could well pass in America’s November elections. A majority of Americans are in favour of such changes (see chart 2).

Legalisers argue that regulated markets protect consumers, save the police money, raise revenues and put criminals out of business as well as extending freedom. Though it will be years before some of these claims can be tested, the initial results are encouraging: a big bite has been taken out of the mafia’s market, thousands of young people have been spared criminal records and hundreds of millions of dollars have been legitimately earned and taxed. There has so far been no explosion in consumption, nor of drug-related crime.

To get the most of these benefits, though, requires more than just legalisation. To live outside the law, Bob Dylan memorably if unconvincingly claimed, you must be honest; to live inside it you must be regulated. Ms Vander Veer points to a “two-inch thick” book of rules applicable to Medicine Man’s business.

Such rules should depend on which of legalisation’s benefits a jurisdiction wants to prioritise and what harms it wants to minimise. The first consideration is how much protection users need. As far as anyone has been able to establish (and some have tried very hard indeed) it is as good as impossible to die of a marijuana overdose. But the drug has downsides. Being stoned can lead to other calamities: in the past two years Colorado has seen three deaths associated with cannabis use (one fall, one suicide and one alleged murder, in which the defendant claims the pot made him do it). There may have been more. Colorado has seen an increase in the proportion of drivers involved in accidents who test positive for the drug, though there has been no corresponding rise in traffic fatalities.

The chronic harm done by the drug is still a matter for debate. Heavy cannabis use is associated with mental illness, but researchers struggle to establish the direction of causality; a tendency to mental illness may lead to drug use. It may also be the case that some are more susceptible to harm than others.

Jonathan Caulkins of Carnegie Mellon University has found that cannabis users are more likely than alcohol drinkers to say the drug has caused them problems at work or at home. It is an imperfect comparison because most cannabis users are, by definition, lawbreakers, and therefore perhaps more prone to such problems. Nonetheless it is clear that pot is, in Mr Caulkins’ words, a “performance-degrading drug”.

What’s more, some struggle to give it up: in America 14% of people who used pot in the past month meet the criteria by which doctors define dependence. As in the alcohol and tobacco markets, about 80% of consumption is accounted for by the heaviest-using 20% of users. Startlingly, Mr Caulkins calculates that in America more than half of all cannabis is consumed by people who are high for more than half their waking hours.

To complicate matters, the public-health effects of cannabis should not be looked at in isolation. If taking up weed made people less likely to consume cigarettes or alcohol it might offer net benefits. But if people treat cannabis and other drugs as complements—that is, if doing more pot makes them smoke more tobacco or guzzle more alcohol—an increase in use could be a big public-health problem.

No one yet knows which is more likely. A review of mostly American studies by the RAND Corporation, a think-tank, found mixed evidence on the relationship between cannabis and alcohol. Demand for tobacco seems to go up along with demand for cannabis, though the two are hard to separate because, in Europe at least, they are often smoked together. The data regarding other drugs are more limited. Proponents of the Dutch “coffee shop” system, which allows purchase and consumption in specific places, argue that legalisation keeps users away from dealers who may push them on to harder substances. And there is some evidence that cannabis functions as a substitute for prescription opioids, such as OxyContin, which kill 15,000 Americans each year. People used to worry that cigarettes were a “gateway” to cannabis, and that cannabis was in turn a gateway to hard drugs. It may be the reverse: cannabis could be a useful restraint on the abuse of opioids, but a dangerous pathway to tobacco.

More bong for your buck

Danger and harm are not in themselves a reason to make or keep things illegal. But the available evidence persuades many supporters of legalisation that cannabis consumption should still be discouraged. The simplest way to do so is to keep the drug expensive; children and heavy users, both good candidates for deterrence, are particularly likely to be cost sensitive. And keeping prices up through taxes has political appeal that goes beyond public health. Backers of California’s main legalisation measure make much of the annual $1 billion that could flow to state coffers.

Setting the right level for the tax, though, is challenging. Go too low and you encourage use. Aim too high and you lose one of the other benefits of legalisation: closing down a criminal black market.

Comparing Colorado and Washington illustrates the trade-off. Colorado has set its pot taxes fairly low, at 28% (including an existing sales tax). It has also taken a relaxed approach to licensing sellers; marijuana dispensaries outnumber Starbucks. Washington initially set its taxes higher, at an effective rate of 44%, and was much more conservative with licences for growers and vendors. That meant that when its legalisation effort got under way in 2014, the average retail price was about $25 per gram, compared with Colorado’s $15. The price of black-market weed (mostly an inferior product) in both states was around $10.

The effect on crime seems to have been as one would predict. Colorado’s authorities reckon licensed sales—about 90 tonnes a year—now meet 70% of total estimated demand, with much of the rest covered by a “grey” market of legally home-grown pot illegally sold. In Washington licensed sales accounted for only about 30% of the market in 2014, according to Roger Roffman of the University of Washington. Washington’s large, untaxed and rather wild-west “medical” marijuana market accounts for a lot of the rest. Still, most agree that Colorado’s lower prices have done more to make life hard for organised crime.

Uruguay also plans to set prices comparable to those that illegal dealers offer. “We intend to compete with the illicit market in price, quality and safety,” says Milton Romani, secretary-general of the National Drug Board. To avoid this competitively priced supply encouraging more use, the country will limit the amount that can be sold to any particular person over a month. In America, where such restrictions (along with the register of consumers needed to police them) would probably be rejected, it will be harder to stop prices for legal grass low enough to shut down the black market from also encouraging greater use. Indeed, since legalisation consumption in Colorado appears to have edged up a few percentage points among both adults and under-21s, who in theory shouldn’t be able to get hold of it at all; that said, a similar trend was apparent before legalisation, and the data are sparse.

If, starved of sales, the black market shrinks beyond a point of no return, taxes could later go up, restoring the deterrent. There is precedent for this. When the prohibition of alcohol ended in 1933, Joseph Choate of America’s Federal Alcohol Control Administration recommended “keeping the tax burden on legal alcoholic beverages comparatively low in the earlier post-prohibition period in order to permit the legal industry to offer more severe competition to its illegal competitor.” After three years, he estimated, with the mob “driven from business, the tax burden could be gradually increased.” And so it was (see chart 3).

Those taxes reflected the strength of what was for sale; taxing whiskey more than beer made sense as a deterrent to drunkenness. Here, so far, the regulation of cannabis lags behind. The levies on price or weight used by America’s legalising states are easy to administer, but could push consumers towards stronger strains. In the various lines sold by Medicine Man, for example, the concentration of tetrahydrocannabinol (THC), the chemical compound that gets you high, varies from 7% to over 20%. The prices, though, are mostly the same, and there is no difference in tax. Some like it weak, but on the whole, Ms Vander Veer says, the stronger varieties are what people ask for. If they cost no more, why not? The average potency on sale in Denver is now about 18%, roughly three times the strength of the smuggled Mexican weed that once dominated the market.

Barbara Brohl, the head of Colorado’s Department of Revenue, says THC-based taxation is something the state may try in the future. But the speed with which the regulatory apparatus was set up—sales began just over a year after the ballot initiative passed in November 2012—meant that they had to move fast. “We’re building the airplane while we’re in the air,” she says. Uruguay, clear that it wants to be “a regulated market, not a free market”, as Mr Romani puts it, plans a more direct way of discouraging the stronger stuff. Dispensaries will sell just three government-approved strains of cannabis, their potencies ranging from 5% to 14%.

Another issue for regulators is the increasing number of ways in which cannabis is consumed. The star performer of the legalised pot market is the “edibles” sector, which includes THC-laced chocolates, drinks, lollipops and gummy bears. There are also concentrated “tinctures” to be dropped onto the tongue and vaping products to be consumed through e-cigarettes. Foria, a California company, sells a THC-based personal lubricant (“For all my vagina knew, I was laying on one of San Diego’s fabulous beaches!” reads one testimonial).

The popularity of these products looks set to grow; users appreciate the discretion with which they can be consumed, producers like the ease with which their production can be automated (no hand-picking of buds required). But edibles, in particular, make it easy to take more than intended. A hit on a joint kicks in quickly; cakes or drinks can take an hour or two. Inexperienced users sometimes have a square of chocolate, feel nothing and wolf down the rest of the bar—only to spend the next 12 hours believing they are under attack by spiders from Mars.

The three cannabis-related deaths in Colorado all followed the consumption of edibles. Hospitals in the state also report seeing an increasing number of children who have eaten their parents’ grown-up gummy bears. In response the authorities have tightened their rules on packaging, demanding clearer labelling, childproof containers, and more obvious demarcation of portions.

A second concern about new ways of taking the drug is that they could attract new customers. Ms Vander Veer says that edibles offer a “good way to get comfortable with how THC makes you feel”; women, older people and first-timers are particularly keen on them. If you see cannabis as a harmless high, this is not a problem. If you want to keep usage low, it is.

The innovation seen to date is just a taste of what entrepreneurs might eventually dream up. On landing in Denver—which, uncoincidentally, is now the most popular spring-break destination for American students—you can call a limo from 420AirportPickup which will drive you to a dispensary and then let you smoke in the back while you cruise on to a cannabis-friendly hotel (some style themselves “bud ‘n’ breakfast”). You can take a marijuana cookery course, or sign up for joint-rolling lessons. Dispensaries offer coupons, loyalty points, happy hours and all the other tricks in the marketing book.

Legalisation has also paved the way for better branding. Snoop Dogg, a rap artist, has launched a range of smartly packaged products called “Leafs by Snoop”. The estate of Bob Marley has lent its name to a range of “heirloom marijuana strains” supposedly smoked by the man himself.

Roll up for the mystery tour

Branding means advertising, which may itself promote use. Many in America would like to follow Uruguay’s example and ban all cannabis advertising, but the constitution stands in their way. When Colorado banned advertising in places where more than 30% of the audience is likely to be under-age cannabis companies objected on the grounds of their right to free speech, though the suit was later dropped.

As well as moving into advertising, the industry is growing more professional in its lobbying. In legalisation initiatives the “Yes” side increasingly outspends the “No” side: in Alaska by four to one, in Oregon by more than 50 to one. Rich backers help—in California Sean Parker, an internet billionaire, has donated $1m to the cause. In some states, ballot initiatives have been heavily influenced by the very people who are hoping to sell the drugs once they are legalised. In November 2015 voters in Ohio soundly rejected a measure that would have granted a cannabis-cultivation oligopoly to the handful of firms that had backed it.

Worries about regulatory capture will increase along with the size of the businesses standing to gain. Big alcohol and tobacco firms currently deny any interest in the industry. But they said the same in the 1960s and 1970s, a time when Philip Morris and British American Tobacco, it has since been revealed, were indeed looking at the market. Brendan Kennedy, the chief executive of Privateer Holdings, a private-equity firm focused on the marijuana industry, says that several alcohol distributors have invested in American cannabis firms.

Even without such intervention big companies are likely to emerge. Sam Kamin, a law professor at Denver University who helped draft Colorado’s regulations, suspects that eventual federal legalisation, which would make interstate trade legal, could well see cannabis cultivation become something like the business of growing hops, virtually all of which come from Washington, Oregon and Idaho. Big farms supplying a national market would be much cheaper than the current local-warehouse model, driving local suppliers out of the market, or at least into a niche.

The industry has so far been helped by the fact that many on the left who might normally campaign against selling harmful substances to young people are vocal supporters of legalisation. That could change with the growth of a business lobby that, although understanding that an explosion in demand would trigger a backlash, may have little long-term interest in restraint. The prospect of such a lobby could also serve as an incentive for states to take the initiative on legalisation, rather than waiting for their citizens to demand it. Fine-tuning Colorado’s regime, Mr Kamin says, has been made harder by the fact that the ballot of 2012 enshrined legalisation in the state constitution. Other states “might want [their rules] to be defined instead by legislation, not citizens’ initiative,” suggests Ms Brohl, the Colorado tax chief.

Different places will legalise in different ways; some may never legalise at all; some will make mistakes they later think better of. But those that legalise early may prove to have a lasting influence well beyond their borders, establishing norms that last for a long while. It behoves them to think through what needs regulating, and what does not, with care. Over-regulation risks losing some of the main benefits of liberalisation. But as alcohol and tobacco show, tightening regimes at a later date can be very difficult indeed.

Source:  http://www.economist.com/news/briefing/21692873   13 Feb. 2016

Tragically, the last few months of music festivals repeatedly resembled scenes from a hospital emergency ward, witnessing this season’s highest number of drug related hospitalisations and the deaths of predominately young adults ranging from 19 to 25 years-old.
In the aftermath of these heart wrenching events, harm reduction advocates have taken to media on mass advocating for pill testing as the next risk minimisation strategy that could potentially save lives.
Often, supporters are quick to highlight that pill testing is “not a silver bullet”, just one measure among a plethora of strategies. But the metaphor is a false equivocation. Rather, pill testing is more like Russian Roulette.
Similar to Russian Roulette, taking psychotropic illicit drugs is a deadly, unpredictable high stakes ‘game’. It’s the reason they’re illegal. There is no ‘safe’ way to play.
But arguments and groups supporting pill testing construct this false perception, regardless of how strenuously advocates claim otherwise. Organisations such as STA-SAFE, Unharm, Harm Reduction Australia, the ‘Safer Summer’ campaign all exploit the context of harm and safety within an illicit drug taking culture.
To continue the metaphor of Russian Roulette, it’s rather like insisting on testing a ‘bullet’ for velocity or the gun for cleanliness and handing both back. It’s pointless. The bullet might not kill at first, but the odds increase exponentially after each attempt.

No Standard Dose Available and the Limitations of Pill Testing
In reality, no testing of the hundreds of new psychoactive substances flooding nations every year can make a dose safe.

As Drug Watch International succinctly puts it, “Most people have been conned into using the word ‘overdose’ regarding illicit drugs. No such thing. Why? Because it clearly implies there is a ‘safe’ dose which can be taken – and everyone knows that’s a lie. The same goes for the words, ‘use’ and ‘abuse’. Those terms can only be applied to prescribed pharmaceuticals because they have a prescribed safe dose. I have asked each jurisdiction in Australia if the legal amount of alcohol when driving, up to 0.49, is considered safe for driving. All said no – they would not state that.”
These substances remain prohibited because they are not manufactured to a pharmaceutical standard and are poisonous, unpredictable toxins that make it impossible to test which dose either in isolation or in a myriad of combinations proves fatal.
The limitations of pill testing4 have been discussed by Dr John Lewis (University of Technology Sydney) and prominent toxicologist Dr John Ramsey, emphasising that it is:
• Complex process
• Costly and time consuming
• Detects mainly major components of a sample that may not be the active substance
For example, even a relatively small amount of ingredients such as Carfentanil are lethal.
Speaking after Canberra’s pill trial in 2017, forensic toxicologist, Andrew Leibie, warned that pill testing trial is no “magic bullet” for preventing drug deaths but also expressed deep concern surrounding the freedom for scientific debate because public sector employees feared repercussions.

Leading harm reduction activist, Dr David Caldicott, in a 2015 interview admitted that the quality and type of pill testing would affect pill taking behaviour at festivals. When told that users potentially wouldn’t get their drugs back and the lengthy 45-minute process involved, “‘I think there’ll be a lot of people who will say forget it completely.’ His reasoning being that a lot of young people don’t have the money to spare a pill and it would slow down the momentum of the party.”

Could this be the motivation behind current trial of pill testing at Goovin’ the Moo where volunteering attendees where given the choice between testing the entire pill – effectively destroying it – or scraping the contents and handing back the remainder, despite the fact that the latter approach brings even less accuracy. This is another example of drug users, not evidence informing policy procedure.
The irony of course is that many of the advocates for pill testing would object to sugary drinks, foods and caffeinated energy drinks in school cafeterias on the basis these hinder the normal development of healthy children but do not object to the infinitely direr situation facing kids at music festivals.

Purity vs Contaminated – Another Misleading Contrast
The fallacious arguments surrounding safe dosage remain the same irrespective of whether the substance is tested as seemingly pure. Take MDMA that goes by various street names Molly and Ecstasy. It is the most popular recreational drug in Australia and was responsible for many of the deaths at music festivals.
In 1995, 15-year old, Anna Woods, died after several hours from consuming a single pill of pure MDMA at a Rave Party. Pill testing would not have changed this outcome. Anna’s case also highlights the idiosyncratic nature of drug taking in that while her three friends ingested the same tablets, Anna was the only one to have a reaction. Russian Roulette is again the most appropriate metaphor.
The Coroner’s report on Anna Wood’s death stated, “It is not unlikely that a tragedy such as this will occur again in N.S.W. In an effort to reduce the chance of that happening, I propose to recommend that the N.S.W. Health Department publishes a pamphlet, which will have the twofold effect of educating those who use the drug as to its dangers, and also educating the community as to the appropriate care of the individual who becomes ill following ingestion of the drug.”
Nearly twenty-five years later the fatalities involving MDMA keep mounting. In the only Australian study of 82 drug related deaths between 2001 to 2005, MDMA featured predominately. The fluctuating potency of this drug is further established as it is not only fifteen-year-old girls but grown men dying.

“The majority of decedents were male (83%), with a median age of 26 years. Deaths were predominantly due to drug toxicity (82%), with MDMA the sole drug causing death in 23% of cases, and combined drug toxicity in 59% of cases. The remaining deaths (18%) were primarily due to pathological events/disease or injury, with MDMA a significant contributing condition.”
The indiscriminate nature of MDMA was also witnessed with the latest fatalities at music festivals. For example, very different amounts of MDMA accounted for the five young people that died across New South Wales.
“In one case, a single MDMA pill had proved lethal while another young man who ingested six to nine pills over the course of the day had an MDMA purity of 77 per cent… (That is) a very high rate of purity,” Dr Dwyer said.”
Comparable stories are found all over the world including the UK case of Stephanie Jade Shevlin that is eerily similar to Anna Woods.
Drug dealers aware of the naïvely misleading narrative of pure and impure illicit drugs have been caught bringing pill testing kits to concerts in a bid to convince potential buyers of quality and hike up prices.

High Risk-Taking Culture

The prevailing culture at music festivals is one of blissful abandon and haste. It is a no longer fringe groups at the edges of society but the mainstream choice for generations of children and young adults fully embracing the legacy of, “tune in, turn on and drop out”.
Yet despite the prevailing culture, harm reductionists insist that pill testing will better inform partygoers of drug contents and provide the necessary platform for ‘further conversations about the drug dangers.’ (All of which of course can be achieved outside a venue.)
But this is conjecture and another attempt at experimental based policy.
As cited earlier, Dr Caldicott admitted, anything that stops the party momentum experience is likely rejected. This is because when dealing with high-risk behaviour removing too many risks takes away the thrill of reward.

In an age that has more educated men and women than ever before, it’s not the lack of information that is driving this level of experimentation but the growing indifference to it.
In the aftermath of the death of 25-year-old pharmacist, Sylvia Choi (2015), it was discovered that security staff at the Stereosonic festival were consuming and dealing drugs.
Further, the report often cited purporting to show a growing body of research for drug users wanting pill testing actually confirms that those with college degrees were less likely than those with high school qualifications to test their pills.
This seems to be a trend in Australia also with one judge fed up with groups of “well-off pill poppers” and “privileged” young professionals, including nurses and bankers – filling the court.
Another article describes the attitude of drug taking among festival goers (including University students) as not so much concerned about what is on offer but demand for cheap designer drugs.
The author notes, “A few deaths don’t deter experimentation, and if you’re going to experiment, you need to be sure you don’t die.”
But the determination for experimentation with different forms of self-destructive drugs is making staying alive increasingly less likely, as the levels of polydrug use is also on the rise.
According to Global Drug Survey, “Over 90% of people seeking Emergency Medical Treatment each year after MDMA have used other drugs (often cocaine or ketamine) and/or alcohol and more frequent use of MDMA is associated with the higher rates of combined MDMA use with other stimulant drugs and ketamine.”

Australia’s enquiry into MDMA supports this finding, “Nevertheless, the fact that half of the toxicology reports noted the detection of methamphetamine in the blood is consistent with the polydrug use patterns of living MDMA users.”

Pill Testing Overseas Failing to Stop Drug Demand and Supply

The push continues for Australia to adopt front of house or front-line pill testing at music festivals as in Europe and the UK. But not everyone is convinced of its resounding success.
Last year, UK’s largest festival organiser reversed its previous support for drug testing facilities. Managing director, Melvyn Benn, stating, “Front of house testing sounds perfect but has the ability to mislead I fear.”
Mr Benn details those fears, “Determining to a punter that a drug is in the ‘normal boundaries of what a drug should be’ takes no account of how many he or she will take, whether the person will mix it with other drugs or alcohol and nor does it give you any indicator of the receptiveness of a person’s body to that drug.”
In 2001, The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) produced its scientific report, On-Site Pill-Testing Interventions In The European Union.
Incomplete evaluation procedures have hindered the availability for empirical evidence on the effectiveness of pill testing. “The conclusions one can draw from that fact remain ambiguous.”
Perhaps the most disturbing feature of the report is the admission that decreasing black market activity isn’t within the scope of pill testing goals. “Overall, to alter black markets is ‘not a primary goal’ or ‘no goal at all’ for most pill-testing projects.” Within that same report drug users are classed as ‘consumers’ with an entitlement to know what their pills contain.
The report goes on to list the range of services offered alongside pill testing at venues. These include everything from: brain machines, internet consultations, needle exchange, presenting on-site results of pill-testings, chill-out zones, offering massage, giving out fruits, giving out free drinking water and giving out condoms.
And in another twist of just how far the common sense boundaries are stretched, for number of participating nations, tax payer funded pill testing is also offered at illegal rave venues.

Given the overwhelming lack of evidence that pill testing indeed saves lives, Australian toxicologist, Andrew Liebie’s claim is not easily dismissed, “the per capita death rate from new designer drugs was higher in Europe – where pill testing was available in some countries – than in Australia.”
The antipathy to drug taking was also witnessed by the Ambulance Commander at the latest pill testing trial, again in Canberra, Groovin’ the Moo.

No War on Drugs Just a Submission to Harm Reduction Promotion
The narrative for pill testing will at some stage mention the failed “war on drugs” and by association hard line but failing law enforcement measures either explicitly or implicitly such as in the statement below.
“Regardless of the desirability of treating it as a criminal issue rather than a health one, policing at festivals has limited impact on drug consumption, as research presented at the Global Cities After Dark conference last year suggests: 69.6 per cent of survey respondents said they would use drugs if police were present.”
But what this article completely fails to grasp is that police presence makes little impact because the law is rarely or, at best, laxly enforced and a climate of de facto decriminalisation has been the norm for decades. This was the situation with Portugal before finally decriminalising drugs for personal use in 2001.
Journalists for The Weekend Australian attempting to report events at a recent dance party stated sniffer dogs did nothing to stop the “rampart” stream of drugs. They described a scene of disarray; discarded condoms with traces of coffee grounds within toilets (believed to mask the smell of drugs), bodies strewn on the ground littered with drug paraphernalia, others were rushed to waiting ambulances, while one attendant told them “I got away with it” and another admitting popping two pills a night was “average”. Had they been allowed to stay longer maybe more party goers would be openly stating what many know, drugs supply and demand are at all-time highs irrespective of police presence.

Journalists instead were treated as criminal trespassers, threatened by security and ordered to leave under police escort.
The basis of Australia’s National Drug Strategy includes harm minimisation efforts as part of an overall strategy that also supports reductions in drug supply and demand.
The inadvertent admission that pill testing is not about curbing drug demand comes from another harm reduction stalwart, Alex Wodak, “It’s a supposition that this (pill testing) might increase drug use, but if it does increase drug use but decrease the number of deaths, surely that’s what we should be focusing on.”
In fact, Dr Wodak confirms that pill testing would incentivise drug dealers to provide a better product. “There was no commercial pressure on drug dealers to ensure their products were safe. But if we had testing and 10% of drug dealer A’s supply was getting rejected at the drug testing counter, then word would get around.”
A similar focus on consequences rather than causes is expressed by Dr David Caldicott, “I don’t give a s**t about the morality or philosophy of drug use. All I care about is people staying alive.”
In other words, take the pill, just don’t die…this time. What the long-term affects are to those drug users that survive hospitalisation, the impact on development, mental health, employment loss, families, the growing cost to taxpayers and the crushing weight on emergency services, hospitals and physicians let alone the constant appetite and entrenchment for more drugs will have to wait. Just don’t die.
The ongoing dilution of law enforcement is also seen by various experts all but demanding that police and sniffer dogs be removed entirely from music festivals. No doubt to be replaced with on-site massages, electrolyte drinks, brain machinery, chill out zones, fruit and more free condoms.
Prof Alison Ritter from the University of NSW and Fiona Measham from the University of Durham both agree that intensive policing combined with on-site dealing “could significantly increase drug related harm.” How intensive could police efforts be with such blatant on-site dealing was not explained.

The Unrelenting Push for Drug Legalisation
The real end game behind the dubious safety and harm messaging is drug legalisation. Pill testing, minus the caveat of being called a ‘trial’, would unlikely find full approval without a corresponding change in the law.
The limitations of pill testing and the legal ramifications in giving back a tested pill that proved lethal would become a public liability minefield.
This is clearly seen from the article in the Daily Telegraph, Pill Test Death Waiver Revealed, Jan 5, “The testing capabilities are so limited that revellers would be required to sign a death waiver, which includes a warning that tests cannot accurately determine drug purity levels or give any indication of safety.”
Later the article reports, “Mr Vumbaca said he had been given extensive legal advice to include the warnings on the waiver because of the limitations of testing information … we are not a laboratory and we have one piece of equipment … the test gives you an indication of purity, but you can’t tell the exact amount.”
The waiver would release everyone in testing from, “any liability for personal injury or death suffered … in any way from the services.”
Scattered within the pages of countless articles on pill testing released over the last few months, this admission of pill testing tied in within a broader agenda of drug legalisation is repeatedly made but easily missed among the hype.
Gary Barns from the Australian Lawyers Alliance said the latest deaths could be avoided or risk of death could be minimised with a “law change”.
Sydney Criminal Lawyers are more explicit, “And it seems clear that if adults were able to purchase quality controlled MDMA over the counter in plain packaging with the contents marked on the side, it would be far safer than buying from some backyard manufacturer with no oversight or guarantees.”
And disappointingly, even former AFP and DPP speaking on Four Corners state drug legalisation as a necessary public conversation.
It seems that these same advocates for policy and law change are willing to give a platform for the rights of those determined to self-destruct but not the rest of the law abiding community and their common good.

Pill testing – The Climate Change of Drugs
If comparing pill testing as a ‘silver bullet’ was an inaccurate metaphor, then the comparison to climate change shows the extent of not only erroneous but deliberate obfuscation. “This issue of pill-testing is climate change for drugs,” says Dr David Caldicott.
And yet the dark environment which produces the pills and wreaks so much unnecessary destruction to countless thousands of people all over the world is never fully understood or exposed to those that would blissfully take one small pill for a few hours of entertainment.
But talk of boycotting products that pollute the atmosphere, meat that is packaged from abused animals, clothing produced from exploited workers, or products genetically modified, most likely those same illicit pill takers would passionately relinquish and possibly even risk their personal safety to protest these injustices.
Yet, these are dwarfed by illicit drugs. The most barbaric network of human, economic and environmental exploitation.
Some of the social miseries are well known, including international crime syndicates and narco-terrorism. While others such as environmental damage due to deforestation, chemical waste and the recent drug toxicity detected in Adelaide waterways are often overlooked in an age of socially conscientious consumerism.
But the list of downward consequences is always local and personal, with illicit drugs linked to preventable death, disease and poverty. In cases of domestic violence, alcohol and drugs contributed to 49 per cent of women assaulted in the preceding 12 months.

Those who suffer the most are those who can least afford the consequences; the poor, young, vulnerable, indigenous and rural communities as revealed in the Australian Criminal Intelligence Commission report.
Faced with such overwhelming statistics pro-drug lobbyists use inevitability mantras such as, “they’re doing it anyway” to sway public opinion toward legalisation; but fail to apply the same arguments to other societal abuses such as paedophilia, obesity, gambling, domestic violence, alcohol or tobacco.
It is time to stop the dishonest rhetoric of harm reductionist activists and the deliberate intellectual disconnect that has greatly influenced the Australian government drug strategy and peak medical bodies toward policies emphasising reducing drug harms (injecting rooms, needle distribution, methadone and now pill testing) while minimising the need to reduce demand and supply.
Eleni Arapoglou
– Writer and Researcher, Drug Advisory Council of Australia (DACA)

Source: PillTestingDACA_PoliticianBrief05-02-19.pdf (drugfree.org.au) February 2019

Three decades ago, I would have been over the moon to see marijuana legalized. It would have saved me a lot of effort spent trying to avoid detection, constantly looking for places to hide a joint. I smoked throughout my teens and early 20s. During this period, upon landing in a new city, my first order of business was to score a quarter-ounce. The thought of a concert or a vacation without weed was simply too bleak.

These days it’s hard to find anybody critical of marijuana.

The drug enjoys broad acceptance by most Americans — 63 percent favoured ending cannabis prohibition in a recent Quinnipiac poll — and legislators on both sides of the aisle are becoming more likely to endorse than condemn it. After years of loosening restrictions on the state level, there are signs that the federal government could follow suit: In April, Senate Minority Leader Charles E. Schumer (D-N.Y.) became the first leader of either party to support decriminalizing marijuana at the federal level, and President Trump (his attorney general notwithstanding) promised a Republican senator from Colorado that he would protect states that have legalized pot.

And why not? The drug is widely thought to be either benign or beneficial. Even many of those apathetic toward its potential health benefits are ecstatic about its commercial appeal, whether for personal profit or state tax revenue. Legalization in many cases, and for many reasons, can be a good thing. I’m sympathetic.

But I am also a neuroscientist, and I can see that the story is being oversimplified. The debate around legalization — which often focuses on the history of racist drug laws and their selective enforcement — is astoundingly naive about how the widespread use of pot will affect communities and individuals, particularly teenagers. In our rush to throw open the gate, we might want to pause to consider how well the political movement matches up with the science, which is producing inconveniently alarming studies about what pot does to the adolescent brain.

Marijuana for sale at a Colorado dispensary.    (Matthew Staver/Bloomberg Creative Photos)

I took a back-door route to the science of marijuana, starting with a personal investigation of the plant’s effects. When I was growing up in South Florida in the 1980s, pot was readily available, and my appreciation quickly formed the basis for an avid habit. Weed seemed an antidote to my adolescent angst and ennui, without the sloppiness of alcohol or the jaw-grinding intensity of stimulants.

Of the many things I loved about getting high, the one I loved best was that it commuted the voice in my head — usually peevish or bored — to one full of curiosity and delight. Marijuana transformed the mundane into something dramatic: family outings, school, work or just sitting on the couch became endlessly entertaining when I was stoned.

Like any mind-altering substance, marijuana produces its effects by changing the rate of what is already going on in the brain. In this case, the active ingredient delta-9-THC substitutes for your own natural endocannabinoids and mimics their effects. It activates the same chemical processes the brain employs to modulate thoughts, emotions and experiences. These specific neurotransmitters, used in a targeted and judicious way, help us sort the relentless stream of inputs and flag the ones that should stand out from the torrent of neural activity coding stray thoughts, urges and experience. By flooding the entire brain, as opposed to select synapses, marijuana can make everything, including the most boring activities, take on a sparkling transcendence.

Why object to this enhancement? As one new father told me, imbibing made caring for his toddler much more engrossing and thus made him, he thought, a better parent. Unfortunately, there are two important caveats from a neurobiological perspective.

As watering a flooded field is moot, widespread cannabinoid activity, by highlighting everything, conveys nothing. And amid the flood induced by regular marijuana use, the brain dampens its intrinsic machinery to compensate for excessive stimulation. Chronic exposure ultimately impairs our ability to imbue value or importance to experiences that truly warrant it.

In adults, such neuro-adjustment may hamper or derail a successful and otherwise fulfilling life, though these capacities will probably recover with abstinence. But the consequences of this desensitization are more profound, perhaps even permanent, for adolescent brains. Adolescence is a critical period of development, when brain cells are primed to undergo significant organizational changes: Some neural connections are proliferating and strengthening, while others are pared away.

Although studies have not found that legalizing or decriminalizing marijuana leads to increased use among adolescents, perhaps this is because it is already so popular. More teenagers now smoke marijuana than smoke products with nicotine; between 30 and 40 percent of high school seniors report smoking pot in the past year, about 20 percent got high in the past month, and about 6 percent admit to using virtually every day. The potential consequences are unlikely to be rare or trivial.

The decade or so between puberty and brain maturation is a critical period of enhanced sensitivity to internal and external stimuli. Noticing and appreciating new ideas and experiences helps teens develop a sense of personal identity that will influence vocational, romantic and other decisions — and guide their life’s trajectory. Though a boring life is undoubtedly more tolerable when high, with repeated use of marijuana, natural stimuli, like those associated with goals or relationships, are unlikely to be as compelling.

It’s not surprising, then, that heavy-smoking teens show evidence of reduced activity in brain circuits critical for  flagging newsworthy experiences, are 60 percent less likely to graduate from high school, and are at substantially increased risk for heroin addiction and alcoholism. They show alterations in cortical structures associated with impulsivity and negative moods; they’re seven times more likely to attempt suicide.

Recent data is even more alarming: The offspring of partying adolescents, specifically those who used THC, may be at increased risk for mental illness and addiction as a result of changes to the epigenome — even if those children are years away from being conceived. The epigenome is a record of molecular imprints of potent experiences, including cannabis exposure, that lead to persistent changes in gene expression and behavior, even across generations. Though the critical studies are only now beginning, many neuroscientists prophesize a social version of Rachel Carson’s “Silent Spring,” in which we learn we’ve burdened our heirs only generations hence.

Might the relationship between marijuana exposure and changes in brain and behavior be coincidence, as tobacco companies asserted about the link between cancer and smoking, or does THC cause these effects? Unfortunately, we can’t assign people to smoking and nonsmoking groups in experiments, but efforts are underway to follow a large sample of children across the course of adolescent development to study the effects of drug exposure, along with a host of other factors, on brain structure and function, so future studies will probably be able to answer this question.

In the same way someone who habitually increases the volume in their headphones reduces their sensitivity to birdsong, I followed the “gateway” pattern from pot and alcohol to harder drugs, leaping into the undertow that eventually swept away much of what mattered in my life. I began and ended each day with the bong on my nightstand as I floundered in school, at work and in my relationships. It took years of abstinence, probably mirroring the duration and intensity of my exposure, but my motivation for adventure seems largely restored. I’ve been sober since 1986 and went on to become a teacher and scholar. The single-mindedness I once directed toward getting high came in handy as I worked on my dissertation. I suspect, though, that my pharmacologic adventures left their mark.

Now, as a scientist, I’m unimpressed with many of the widely used arguments for the legalization of marijuana. “It’s natural!” So is arsenic. “It’s beneficial!” The best-documented medicinal effects of marijuana are achieved without the chemical compound that gets users high. “It’s not addictive!”  This is false, because the brain adapts to marijuana as it does to all abused drugs, and these neural adjustments lead to tolerance, dependence and craving — the hallmarks of addiction.

It’s true that a lack of benefit, or even a risk for addiction, hasn’t stopped other drugs like alcohol or nicotine from being legal, used and abused. The long U.S. history of legislative hypocrisy and selective enforcement surrounding mind-altering substances is plain to see. The Marihuana Tax Act of 1937, the first legislation designed to regulate pot, was passed amid anti-Mexican sentiment (as well as efforts to restrict cultivation of hemp, which threatened timber production); it had nothing do with scientific evidence of harm. That’s true of most drug legislation in this country. Were it not the case, LSD would be less regulated than alcohol, since the health, economic and social costs of the latter far outweigh those of the former. (Most neuroscientists don’t believe that LSD is addictive; its potential benefits are being studied at Johns Hopkins and New York University, among other places.)

Still, I’m not against legalization. I simply object to the astounding lack of scepticism about pot in our current debate. Whether or not to legalize weed is the wrong question. The right one is: How will growing use of delta-9-THC affect individuals and communities?

Though the evidence is far from complete, wishful thinking and widespread enthusiasm are no substitutes for careful consideration. Instead of rushing to enact new laws that are as nonsensical as the ones they replace, let’s sort out the costs and benefits, using current scientific knowledge, while supporting the research needed to clarify the neural and social consequences of frequent use of THC. Perhaps then we’ll avoid practices that inure future generations to what’s really important.

                                       By Judith Grisel,    May 25, 2018

Source:  https://www.washingtonpost.com/ posteverything/wp/2015/04/30/yes-pot-should-be-legal-but-it-shouldnt-be-sold-for-a-profit/   

(Denver, CO) – Today, a new study on the impact of marijuana legalization in Colorado conducted by the Centennial Institute found that for every one dollar in tax revenue from marijuana, the state spends $4.50 as a result of the effects of the consequences of legalization.

This study used all available data from the state on hospitalizations, treatment for Cannabis Use Disorder (CUD), impaired driving, black market activity, and other parameters to determine the cost of legalization. Of course, calculating the human cost of addiction is nearly impossible, we can assume the cost estimated for treating CUD is a gross underestimate due to the fact that it is widely believed among health officials that CUD goes largely untreated…yet rates have been increasing significantly in the past decade.

That, in conjunction with the fact that there is no way of quantifying the environmental impact the proliferation of single use plastic packaging common within the marijuana industry, leads us to believe this is indeed a very conservative estimate.

“Studies such as this show that the only people making money off the commercialization of marijuana are those in the industry who profit at the expense of public health and safety,” said Dr. Kevin Sabet, president of Smart Approaches to Marijuana (SAM). “The wealthy men in suits behind Big Marijuana will laugh all the way to the bank while minority communities continue to suffer, black markets continue to thrive, and taxpayers are left to foot the bill.”

“The data collected in this study, as in similar studies before it, continues to show the scope of the cost of commercialization. The effects of legalization are far and wide, and affect just about every resident in the state directly and indirectly,” said Jeff Hunt, Vice President of Public Policy for Colorado Christian University.

“The pot industry doesn’t want this dirty truth to be seen by law makers and the taxpayers, who were promised a windfall in tax revenue,” said Justin Luke Riley, president of the Marijuana Accountability Coalition. “The MAC will continue to shine a light on the industry and urge our lawmakers to reign in Big Pot before it brings more harm on Coloradans.”

Source: New Colorado Report: Cost of Marijuana Legalization Far Outweighs Tax Revenues – Smart Approaches to Marijuana (learnaboutsam.org) November 2018

Fullerton, California, police officer Jae Song conducts a field sobriety test on a driver suspected of driving while impaired by marijuana. A growing number of drugged drivers have been killed in crashes. Bill Alkofer/The Orange County Register/SCNG via AP

As legal marijuana spreads and the opioid epidemic rages on, the number of drugged drivers killed in car crashes is rising dramatically, according to a report released today.

Forty-four percent of fatally injured drivers tested for drugs had positive results in 2016, the Governors Highway Safety Association found, up more than 50 percent compared with a decade ago. More than half the drivers tested positive for marijuana, opioids or a combination of the two.

“These are big-deal drugs. They are used a lot,” said Jim Hedlund, an Ithaca, New York-based traffic safety consultant who conducted the highway safety group’s study. “People should not be driving while they’re impaired by anything and these two drugs can impair you.”

Nine states and Washington, D.C., allow marijuana to be sold for recreational and medical use, and 21 others allow it to be sold for medical use. Opioid addiction and overdoses have become a national crisis, with an estimated 115 deaths a day.

States are struggling to get a handle on drugged driving. Traffic safety experts say that while it’s easy for police to test drivers for alcohol impairment using a breathalyzer, it’s much harder to detect and screen them for drug impairment.

There is no nationally accepted method for testing drivers, and the number of drugs to test for is large. Different drugs also have different effects on drivers. And there is no definitive data linking drugged driving to crashes.

“With alcohol, we have 30 years of research looking at the relationship between how much alcohol is in a person’s blood and the odds they will cause a traffic crash,” said Jake Nelson, AAA’s traffic safety director. “For drugs, that relationship is not known.”

Another problem is that drivers often are using more than one drug at once. The new study found that about half of drivers who died and tested positive for drugs in 2016 were found to have two or more drugs in their system.

Alcohol is also part of the mix, the report found: About half the dead drivers who tested positive for alcohol also tested positive for drugs.

Drug Testing Varies

More than 37,000 people died in vehicle crashes in 2016, up 5.6 percent from the previous year, according to the National Transportation Highway Safety Administration.

Using fatality data from the federal agency, Hedlund, the governors’ highway safety group’s consultant, found that 54 percent of fatally injured drivers that year were tested for drugs and alcohol. Of those who had drugs in their system, 38 percent tested positive for marijuana, 16 percent for opioids and 4 percent for both. The remaining 42 percent tested positive for a variety of legal and illegal drugs, such as cocaine and Xanax.

That means more than 5,300 drivers who died in fatal crashes in 2016 tested positive for drugs, Hedlund said. Those numbers don’t include all drivers killed in crashes or those who drove impaired but didn’t have a crash.

Driver drug testing varies from state to state. States don’t all test for the same drugs or use the same testing methods.

“A lot of the tools we developed for alcohol don’t work for drugs,” said Russ Martin, government relations director for the highway safety group. “We don’t have as clear a method for every officer to conduct roadside tests.”

Police who stop drivers they think are impaired typically use standard sobriety tests, such as asking the person to walk heel to toe and stand on one leg. That works well for alcohol testing, as does breathing into a breathalyzer, which measures the blood alcohol level.

But these standard sobriety tests don’t work for drugs, which can only be detected by testing blood, urine or saliva. Even then, finding the presence of a drug doesn’t necessarily mean the person is impaired.

With marijuana, for example, metabolites can stay in the body for weeks, long after impairment has ended, making it difficult to determine when the person used the drug.

States have dealt with drugged driving in different ways. In every state it is illegal to drive under the influence of drugs, but some have created zero tolerance laws for some drugs, whereas others have set certain limits for marijuana or some other drugs.

That creates another challenge because policymakers are trying to make changes that aren’t necessarily based on research, said Richard Romer, AAA’s state relations manager.

“The presence of marijuana doesn’t necessarily mean impairment,” Romer said. “You could be releasing drivers who are dangerous and imprisoning people who are not impaired.”

State Statistics

In Colorado, the first state to legalize recreational marijuana, there were 51 fatalities in 2016 that involved drivers with THC blood levels above the state’s legal limit, according to the state department of transportation. THC is the main active ingredient in marijuana, and causes the euphoria associated with the drug.

An online survey in April by the department found that 69 percent of pot users said they had driven under the influence of marijuana at least once in the past year and 27 percent said they drove high almost daily. Many recreational users said they didn’t think it affected their ability to drive safely.

In Washington state, a 2016 report by the AAA Foundation for Traffic Safety found that fatal crashes of drivers who recently used marijuana doubled after the state legalized it.

The governors’ highway safety group is recommending that states offer advanced training to a majority of patrol officers about how to recognize drugged drivers at the roadside.

Officers in some states already are using a battery of roadside tests that focus on physiological symptoms, such as involuntary eye twitches, pulse rate and muscle tone, to determine whether a driver is impaired by drugs. And at the police station, some officers trained as drug examiners do a more extensive series of tests to identify the type of drug.

The safety group also wants states to launch a campaign to educate the public about how drugs can impair driving and work with doctors and pharmacists to make patients aware of the risks of driving while using prescription medications such as opioids.

And it is calling on states and the federal government to compile better data on drugged driving, including testing all drivers killed in crashes for drugs and alcohol.

“Not every driver in a fatal crash is tested. And plenty of drivers out there haven’t crashed and haven’t been tested,” Martin said. “We have good reason to believe there are more drug-impaired drivers out there than the data shows.”

Source: Drugged Driving Deaths Spike With Spread of Legal Marijuana, Opioid Abuse – Stateline May 2018

Substance use has often been described as “bad learning” linked with impairments in reward processing and decision-making, but there is little substantial research to support this idea. A recent study by Byrne et al. suggests that substance misuse not only promotes harmful habit formation, which might undermine survival, but also makes it difficult to stop using.

Model-free vs. Model-based Learning

The “Dual Systems” theory of reinforcement learning defines two distinct systems:

  1. The model-based, or goal-directed system, where actions are planned and purposeful, and we learn about the connection between actions and outcomes, and how to modify our behavior to achieve the desired outcome. This system requires more cognitive processing and is more flexible and controlled.

  2. The model-free, or habit-based system, where learning is informed by reflexive responses to stimuli – like compulsive substance use and cravings. This system of learning is less flexible and is more controlled by automatic processing.

The differences between the two systems of learning have been highlighted by researchers in relation to harmful habitual behaviors such as substance use. One school of thought suggests that learning informed by the model-free system, with more of a focus on instinctual response to stimuli and less of a focus on conscious and informed decision-making, sets a person up to be more likely to engage in detrimental behaviors like substance use.

There is evidence that progressing from first use to misuse and addiction is paralleled by a shift from planned, purposeful, and goal-directed behavior to behavior that is habitual and reflexive. This progression and subsequent loss of control has been discussed by National Institutes on Drug Abuse Director Dr. Nora Volkow in her keynote speech at the APA and in her blog about free will. Model-free, conditioned learning means it is harder for a person to engage their frontal lobes, the part of the brain that helps us prioritize healthy, long-term and rational decisions. Repeated problematic substance use initiates a process where humans begin to respond more instinctually to the substance, wanting more and more of it over time. Use begets use, which leads to maladaptive behaviors centered around obtaining and using the substance to trigger the very same dopamine response that drives and reinforces model-free, habitual learning.

Substance Use and Reward Devaluation

Reward devaluation is a process that occurs in the brain where the value of a desirable outcome, like singing in a band, mentoring, or maintaining sobriety is reduced significantly. This process plays into why improving treatment outcomes can be so hard – treatment for addiction is not as “reinforcing” in the brain as substance use. Compulsive drug use is considered “highly pleasurable” by the parts of the brain that control decision-making when people are heavily addicted and feel as though they need the substance to survive. But treatment? not so much — long-term treatment is difficult to complete without continual support and a long-term treatment plan. Many patients stop attending treatment and/or support groups, and taking prescribed medications unless they are compelled to follow a set treatment plan and have adequate supports in place to help keep them on track.

Addiction is correlated to a considerable decrease in a person’s ability to devalue or disengage from habits learned through the model-free system. This means that problematic substance use affects our ability to make decisions and as the disorder progresses, we begin to put less value on long-term rewards and more value on immediately satisfying a need. Gradually, short term needs, like substance use, override long-term needs, like maintaining employment or investing in personal relationships.

Goals of Study

  1. To examine the associations between model-based and model-free learning with a wide array of substance use behaviors. The process used to determine this was measuring individual variations in eye-blink rate, an indirect proxy for dopamine functioning, a key neural process related to model-free learning.

  2. To assess whether problematic substance use predicted reward disengagement.

Why is This Important?

Patients with substance use disorders are driven to use despite harmful consequences, and although addiction is understood more and more as an acquired brain disease, many are still mystified as to why those suffering can’t manage to break their “habit.” This study helps foster a greater understanding of the mechanisms that explain why. Use may be thought of as “recreational” by the user, but it poses a challenge to the brain, reinforcement systems, and reward hierarchies, which can change a person quickly and in a way that is hard for those around them to understand. Once reward-outcome associations are well established— i.e., taking drugs makes a person “feel good”— individuals with substance use disorders have changed the most basic mechanisms in their brain, and will have more difficulty disengaging from the habitual tendencies. It is not clear how individual experiences, genetics, trauma, and other factors change the speed of these changes. That said, the results of this study are consistent with previous data depicting how alcohol dependence indicates a greater likelihood that a person has habit-based learning strategies over goal-directed strategies. The results do not, however, provide us with more information about whether biological recovery is possible, and how we could make recovery more likely and sustainable for patients.

Authors state that current findings highlight how problems with substance use go beyond the realms of habit formation: they also influence the process of disengaging or “breaking” habits by making it more difficult for individuals with substance use disorders to stop using substances. A better understanding of the mechanisms in the brain that take over once substance use becomes problematic may help us create more effective prevention campaigns and treatments once substance use progresses to a harmful habit.

Source: Why are habits so hard to break? (addictionpolicy.org) May 2019, updated October 2022

Tell Your Children:
The Truth About Marijuana, Mental Illness, and Violence

by alex berenson

free press, 272 pages, $26

The smoking of marijuana, with its careful preparation of the elements and the solemn passing around of the shared joint, was the unholy communion of the counterculture in the late 1960s, when our present elite formed its opinions. Many of them allowed their children to follow their bad examples, and resent that this exposes their young to a (tiny) risk of persecution and career damage. As a result, those who still disapprove of marijuana are much disliked. The book I wrote on the subject six years ago, The War We Never Fought, received a chilly reception and remains so obscure that I don’t think Alex ­Berenson, whose book has received much friendlier coverage, even knows it exists. As a writer who naturally covets readers and sales, I find this mildly infuriating.

But let me say through clenched teeth that it is of course very good news that a fashionable young metropolitan person such as Mr. ­Berenson is at last prepared to say openly that marijuana is a dangerous drug whose use should be severely discouraged. For, as ­Berenson candidly admits, he was until recently one of the great complacent mass of bourgeois bohemians who are pretty relaxed about it. He confesses in the most important passage in the book that he once believed what most of such people believed. He encapsulates this near-universal fantasy thus:

Marijuana is safe. Way safer than alcohol. Barack Obama smoked it. Bill Clinton smoked it too, even if he didn’t inhale. Might as well say it causes presidencies. I’ve smoked it myself, I liked it fine. Maybe I got a little paranoid, but it didn’t last. Nobody ever died from smoking too much pot.

These words are a more or less perfect summary of the lazy, ignorant, self-serving beliefs of highly educated, rather stupid middle-class metropolitans all over the Western world in such places as, let’s just say for example, the editorial offices of the New York Times. Thirty years from now (when it’s too late), they will look as crass and irresponsible as those magazine advertisements from the 1950s in which pink-faced doctors wearing white coats recommended certain brands of cigarettes. But just now, we are in that foggy zone of consciousness where the truth is known to almost nobody except those with a certain kind of direct experience, and can be ignored by everyone else.

One of the experienced ones, thank heaven, is Alex ­Berenson’s wife Jacqueline. She is a psychiatrist who specializes in evaluating mentally ill criminals. One evening, the Berensons were discussing one of her cases, a patient who had committed a terrible, violent act. Casually, Jacqueline remarked, “Of course he was high, been smoking pot his whole life.” Alex doubtfully interjected, “Of course?,” and she replied, “Yeah, they all smoke.” (She didn’t mean tobacco.) And she is right. They all do. You don’t need to be a psychiatrist to know this. You just have to be able to do simple Internet searches.

Most violent crime is scantily reported, since local newspapers lack the resources they once had. The exceptions are rampage mass killings by terrorists (generally in Europe) and non-political crazies (more common in the United States). These crimes are intensively reported, to such an extent that news media find things out they were not even looking for, such as the fact that the perpetrator is almost always a long-term marijuana user. Where he isn’t (and it is almost always a he), some other legal or illegal psychotropic, such as steroids or “antidepressants,” is ­usually in evidence. But you do have to look, and most people don’t. Then you have to see a pattern, one that a lot of important, influential people specifically do not want to see.

That husband-and-wife conversation in the Berenson apartment is the whole book in a nutshell, the epiphany of a former apostle of complacency from the college-­educated classes who suddenly discovers what has been going on around him for years. What he repeats over and over again is very simple: Marijuana can make you permanently crazy. (This is a long-term cumulative effect, not the effect of immediate intoxication.) And once it has made you crazy, it can make you violent, too.

You’ll only find out if you’re susceptible by taking it. It is not soft. It is not safe. It is one of the most dangerous drugs there is, and we are on the verge of allowing it to be advertised and put on open sale. Berenson has gotten into predictable trouble for asserting that the connection is pretty much proved. Alas, this is not quite so. But the correlation is hugely powerful. The chance that it is meaningful is great. Who would be surprised if a drug with powerful psychotropic effects turned out to be the cause of mental illness in its users? Correlation is not causation, but it is one of the main tools of ­epidemiology. Causation, ­especially in matters of the brain, is extraordinarily difficult to prove, and so we may have to base our actions, or our refusals to take action, on something short of total certainty.

Tell Your Children is filled with persuasive, appalling individual case histories of wild violence, including the abuse of small children. It also lists and explains the significance of powerful, large-scale surveys of Swedish soldiers and New Zealand students, which connect the drug to mental illness and lowered school performance. Berenson provides facts and statistics about violent crime in places where marijuana is widely available, and anecdotes so repetitive that they cease to be anecdotes. The puzzle remains as to why it is necessary to say all this repeatedly when a sensible person would listen the first time.

Perhaps it is because of the large, and very well-funded, campaigns for marijuana legalization described by Berenson. People who drink fair-trade coffee and eat vegan, who loathe other greed lobbies—such as pharmaceuticals, tobacco, fast food, or sugary drinks—smile on this campaign to make money from the misery of others.

Berenson shows how mental illness has grown in our midst without being noticed in public statistics. A comparable growth in, say, measles or tuberculosis would have shown up. But deteriorating mental health does not, thanks to privacy concerns, and to the fact that mental illness is not easily classified. It is also a sad truth that rich, advanced Western societies nowadays begrudge money for the mental hospitals needed to house and protect those who have overthrown their own minds. They are reluctant to record the existence and prevalence of the very real suffering that ought to be treated in the hospitals they have sold off, demolished, or never built.

Berenson also witheringly describes the propaganda devised by those who want to legalize the drug, from the mind-expanding zealots who view drug use as liberating to the hard-headed entrepreneurs and political professionals. Argue against them at your peril. Your audience may learn something, but your opponents will not. Wilful ignorance is the most powerful barrier to communication. It seals the human mind up like a fortress. You might as well read the works of Jean-Paul Sartre to a hungry walrus as try to debate with such people. I have attempted it. They don’t hear a word you say, but they hate you for getting in their way.

Berenson gives a fairly thorough account of the “medical marijuana” campaign, an almost comically absurd attempt to portray a poison as a medicine. This campaign is so bogus that it will vanish from the earth within days of full legalization, because in truth there is very little evidence that marijuana-based medicines are of much use. Berenson quotes one refreshingly candid marijuana defender as admitting, “Six percent of all marijuana users use it for medical purposes. Medical marijuana is a way of protecting a subset of society from arrest.”

In the U.S., legalizers are poised to win the modern civil war over the legalization of marijuana which has been dividing the country for half a century. It looks now as if marijuana will soon be legalized, on general sale, advertised and marketed and taxed. This worrying process has already begun in Canada. The United States has approached the issue sideways, conceding states’ rights in a way that would have delighted the Confederates.

The United Kingdom has taken a similar route: It pretends to maintain the law and, when asked, insists it has no plans to change it. But the police and the courts have gradually ceased to enforce it, so that it is now impossible to stroll through central London without nosing the reek of marijuana. Europe has gone the same way, with minor variations. Among the free law-governed nations, only Japan and South Korea still actively and effectively enforce their drug possession laws, and benefit greatly from it. But how long can they hold out?

The legalization campaigners are working like termites to undo the 1961 U.N. Convention that is the basis of most national laws against narcotics, using all the money and dishonesty at their command. They have plenty of both. So, besides the two disastrous, irrevocably legal poisons of alcohol and tobacco, we shall before long have a third—and probably a fourth and fifth not long afterward. If marijuana is legal, how will we keep cocaine and ecstasy illegal for long? Next will come heroin and LSD.

One reason for the default in favor of legalization and non-enforcement is the false association made by so many between marijuana and liberty. The belief that a dangerous, stupefying drug is an element of human liberty has taken hold of two, perhaps three generations. They should know better. Aldous Huxley warned in his much-cited but infrequently read dystopian novel Brave New World that modern men, appalled by the disasters of war and social conflict, would embrace a world where thinking and knowledge were obsolete and pleasure and contentment were the aims of a short life begun in a test-tube and ended by euthanasia. He predicted that they would drug themselves and one another to banish the pains of real life, and—worst of all—come to love their own servitude. In one terrible scene, the authorities spray protesting low-caste workers with the pleasure drug soma, and the workers end up hugging one another and smiling vaguely before returning to their drudgery. (Soma, unlike its real-life modern equivalents, is described as harmless, something easier to achieve in fiction than in reality.) What ruler of a squalid, wasteful, unfair, and ugly society such as ours would not prefer a stupefied, flaccid population to an angry one? Yet somehow, the freedom to stupefy oneself is held up quite seriously by educated people as the equal of the freedoms of thought, speech, and assembly. This is the way the world ends, with a joint, a bong, and a simper.

Whatever was wrong with my intense little segment of the 1960s revolutionary generation (and plenty was wrong with it), we believed that when we saw injustice we should fight it, not dope ourselves into a state of mind where it no longer mattered. But my tiny strand of puritan Bolsheviks was long ago absorbed into a giggling mass of cultural revolutionaries, who scrawled “Sex, Drugs, and Rock and Roll” on their banners instead of “Liberty, Equality, and Fraternity,” or even “Workers of All Lands, Unite!”

While Berenson’s facts are devastating, his own response to the crisis is feeble. He opposes marijuana legalization—and what intelligent person does not? He babbles of education and warning our children. But he declares that “decriminalization is a reasonable compromise.” Actually, it is not. It cannot be sustained. If matters are left as they are, legalization—first de facto and then de jure—will follow, because there will be no impetus to resist it. Unless the law decisively disapproves of and discourages the actual use of the drug, it is neither morally consistent nor practically effective.

The global drug trade would be nowhere without the dollars handed over to it by millions of individuals who are the end-users. We search for Mr. Big and never catch him. But we ignore or even indulge Mr. Small, regarding him as a victim, when in truth he keeps the whole thing going. In the end, the logic leads relentlessly to the stern prosecution and deterrent punishment of individual users. It is because I recognize this grim necessity that I remain a pariah. It is because he doesn’t that Alex Berenson is still just about acceptable in the part of the Western world that believes marijuana is a torch of ­freedom. 

Peter Hitchens is a columnist for The Mail on Sunday.

Source:  https://www.firstthings.com/article/2019/05/reefer-sadness

DRP0013

 1.Aims Cannabis Skunk Sense (also known as CanSS Ltd) provides straight-forward facts and research-based advice on cannabis. We raise awareness of the continued and growing dangers to children, teenagers and their families of cannabis use.

2.We provide educational materials and information for community groups, schools, colleges and universities; and guidance to wide range of professions, Parliament and the general public – with a strong message of prevention not harm reduction.

3.The Inquiry document says: ‘Government’s stated intention in its 2017 drug strategy is to reduce all illicit and other harmful drug use…….’

4.Missing from this Inquiry document is the following 2017 Strategy statement: ‘preventing people – particularly young people – from becoming drug users in the first place’. Prevention should be first and foremost in any statement as well as in the minds of us all. FRANK was mentioned just once in this strategy; ‘develop our Talk to FRANK service so that it remains a trusted and credible source of information and advice for young people and concerned others’. This claim will be challenged in this report.

5.If prevention (pre-event) were to be successful, there would be little need for a policy of reducing harmful use. Unfortunately, for fifteen or sixteen years now, prevention has taken a back seat.

6.In 1995 Prime Minister John Major’s government produced ‘Tackling Drugs Together’ saying, ‘The new programme strengthens our efforts to reduce the demand for illegal drugs through prevention, education and treatment’.

7.Objectives included: ‘to discourage young people from taking drugs’ and to ensure that schools offer effective programmes of drug education, giving pupils the facts, warning them of risks, and helping them to develop the skills and attitudes to resist drug use – all good common sense.

8.On harm reduction, the government said, ‘The ultimate goal is to ensure people do not take drugs in the first place, but if they do, they should be helped to become and remain drug-free. Abstinence is the ultimate goal and harm reduction should be a means to that end, not an end in itself’.

9.In 1998 the Second National Plan for 2001-2, ‘Tackling Drugs to Build a Better Britain’ was published. Although prevention was still the aim, the phrase ‘informed choice’ appeared, the downhill slide from prevention had started.

10.The` Updated Strategy in 2002 contained the first high-profile mention of ‘Harm Minimisation (Reduction)’. David Blunkett in the Foreword said, ‘Prevention, education, harm minimisation, treatment and effective policing are our most powerful tools in dealing with drugs’.

Some bizarre statements appeared, e.g.: ‘To reduce the proportion of people under 25 reporting use of illegal drugs in the last month and previous year substantially’. Is  infrequent use of drugs acceptable?

In October 2002 at a European Drugs Conference, Ashford, Kent, Bob Ainsworth, drugs spokesman for the Labour government, said that harm reduction was being moved to the centre of their strategy. Prevention was abandoned, ‘informed choice’ and ‘harm reduction’ ruled.

The official government website for information on drugs is FRANK set up in 2003. It continued with the harm reduction policy of the Labour Government.

From the beginning, FRANK was heavily criticised. The Centre for Social Justice (CSJ), founded by Iain Duncan-Smith MP in 2004, consistently criticised FRANK for being ill-informed, ineffective, inappropriate and shamefully inadequate, whilst citing a survey conducted by national treatment provider Addaction who found that only one in ten children would call the FRANK helpline to talk about drugs. Quite recently, when asked about sources where they had obtained helpful information about alcohol or smoking cigarettes, young people put FRANK at the bottom.

The CSJ recommended that FRANK be scrapped, and an effective replacement programme developed to inform young people about the dangers of drug and alcohol abuse based on prevention rather than harm reduction.

The IHRA (International Harm Reduction Alliance) gives the following definition of harm reduction:

Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support.   

The use of Harm reduction instead of Prevention is tantamount to condoning drug use – a criminal activity. The legitimate place for harm reduction is with ‘known users’ on a one to one basis as part of a treatment programme to wean them off completely and attain abstinence in a safer manner than abrupt stoppage which can be very dangerous. One example of this is to inhale the fumes of heroin rather than injection, thus avoiding blood-borne diseases such as AIDS, hepatitis and septicaemia.

An opioid substitute drug for heroin addiction, methadone has the advantage of being taken orally and only once/day. As the dosage is reduced, abstinence will be attained more safely. However, methadone users are often ‘parked’ for months on this highly addictive drug without proper supervision or monitoring. In 2008 in Edinburgh, more addicts died of methadone than heroin.

Harm reduction is a green light. If children are encouraged to use drugs by being given tips on how to use them more safely, many will do it. The son of a friend told his mother. ‘It’s OK we go on to the FRANK website and find out how to take skunk safely by cutting our use and inhaling less deeply’. He is now psychotic!

Prevention works. Between 1997 and 1991 America saw drug use numbers plummet from 23 to 14 million, cocaine and cannabis use halved, daily cannabis use dropped by 75%.

In 2005, Jonathan Akwue of In-Volve writing in Drink and Drugs News, criticised the campaign for lacking authenticity; its ill-judged attempts at humour which try to engage with youth culture; and diluting the truth to accommodate more socially acceptable messages.

The conservatives regained power under David Cameron. FRANK did not change.

In 2005, Mr Iain Duncan Smith again criticised FRANK, saying “Drugs education programmes, such as Talk to FRANK, have failed on prevention and intervention, instead progressively focussing on harm reduction and risk minimisation, which can be counter-productive”

In 2011 it was announced FRANK would be re-launched and the team commissioned ‘A Summary of Health Harms of Drugs’ from The John Moore’s University Liverpool, a hotbed of harm reduction. A psychiatrist from The FRANK Team was involved. Their section on cannabis is totally inadequate, out of date, no recognition of deaths, brain shrinkage, violence, homicides, suicides, the huge increase of strength of THC etc. Professor Sir Robin Murray’s research on mental illness (2009) and the discovery that CBD is virtually absent from skunk are of vital importance.

Many worrying papers have been written since, especially about brain development, all of which are ignored.  CanSS met with the FRANK team prior to their re-launch in 2011 where it was agreed that the cannabis section would, with their assistance, be re-written. All but two very small points were ignored, one about driving after taking alcohol with cannabis and the effect on exam results. The harm reduction advice about cannabis was removed at the request of CanSS.

Scientific evidence detailing FRANK’s inaccuracies was given to the Government by CanSS and other drug experts over the years – all of it ignored. Complaints and oral evidence were submitted to the HASC in April and September 2012 and the Education Select Committee in 2014. Government drugs spokesmen have also been contacted with concerns about FRANK.

As the official government source of information on drugs for the UK public, the FRANK site must be regularly updated and contain the many new accurate findings from current scientific research. The public is owed a duty of care and protection from the harm of drugs, especially cannabis, the most commonly used.

The following list contains some of the glaring omissions and vital details from the FRANK website:

Deaths from cancers except lung, road fatalities, heart attacks/strokes, violent crime, homicides, suicides. Tobacco doesn’t cause immediate deaths either.

Alcohol with cannabis can be fatal. An alcohol overdose can be avoided by vomiting but cannabis suppresses the vomiting reflex.

Cases of severe poisoning in the USA in toddlers are increasing, mostly due to ‘edibles’ left within reach. Accidental ingestion by children should be highlighted.

Hyperemesis (violent vomiting) is on the increase.

Abnormally high levels of dopamine in the brain cause psychosis (the first paper on this was written in 1845) and schizophrenia, especially in those with genetic vulnerabilities, causing violence, homicides and suicides. Skunk-induced schizophrenia costs the country around £2 billion/year to treat.

Young people should understand how THC damps down the activities of the whole brain by suppressing the chemical messages for several weeks. It is fat soluble and remains in the cells. Messages to the hippocampus (learning and memory) fail to reach its cells, some die, causing permanent brain damage. IQ points are lost. Few children using cannabis even occasionally will achieve their full potential.

Serotonin is depleted, causing depression and suicides. The huge increase in the strength of THC in cannabis due to the prevalence of skunk (anything from 16% to over 20%) and the almost total lack of CBD is ignored as is the gateway theory, medical cannabis, passive smoking and lower bone mineral density, bronchitis, emphysema and COPD.

They need to be taught that there is reduced ability to process information, self-criticise and think logically. Users lack attention and concentration, can’t find words, plan or achieve routines, have fixed opinions, whilst constantly feeling lonely and misunderstood. They should know of the risk of miscarriages and ectopic pregnancies.

Amazingly, the fact THC damages our DNA is virtually unknown among the public. In the 1990s, scientists found new cells being made in the adult body (white blood, sperm and foetal cells), suffered premature ‘apoptosis’ (programmed cell death) so were fewer in number. Impotence, infertility and suppressed immune systems were reported.  This is important.

In 2016 an Australian paper discovered THC badly interferes with cell division i.e. where chromosomes replicate to form new cells. They fail to segregate properly causing numerous mutations as chromosomes shatter and randomly rejoin.  Many cells die (about 50% of fertilized eggs (zygotes). Any affected developing foetus will suffer damage. Resultant foetal defects include gastroschisis (babies born with intestines outside the body), now rising in areas of legalisation, anencephaly (absence of brain parts) and shortened limbs (boys are about 4 inches shorter). Oncogenes (cancer-causing) can be switched on. Bladder, testicle and childhood cancers like neuroblastoma have all been reported. The DNA in mitochondria (energy producers in cells) can also be damaged.

Parliament controls the drug laws, so why are the police able to decide for themselves how to deal with cannabis possession?

Proof of the liberalisation of the law on cannabis possession appeared in the new Police Crime Harm Index in April 2016, where it appeared 2nd bottom of the list of priorities. In the following November it fell to the bottom. Class ‘A’ drug possession was immediately above. Possession has clearly become a very low priority. In 2015, Durham Police decided they would no longer prosecute those smoking the drug and growing it ‘for their own use’. Instead, officers will issue a warning or a caution. Then Durham Chief Constable Mike Barton announced that his force will stop prosecuting all drug addicts from December 2017 and plans to use police money to give free heroin to addicts to inject themselves twice a day in a supervised ‘shooting gallery’.  This surely constitutes dealing. The police can it seems, alter and ‘soften’ laws at will. 

Several weeks ago, I happened to check the FRANK website. Quietly, stealthily and without fanfare, a new version had appeared – completely changed. Absent were the patronising videos, games and jokes. Left were A to Z of Drugs, News, Help and Advice (e.g. local harm reduction information) and Contact.

There is poor grammar, i.e. ‘are’ instead of ‘is’ and ‘effect’ where it should be ‘affect’. Mistakes like these do not enhance its credibility.

The drug information is still inadequate with scant essential detail, little explanation and still out of date. This is especially true of cannabis. THC can stay in the brain for many weeks – still sending out its damping-down signals.

What shocked me though were the following:

Our organisation recently received an email about a call to FRANK requesting advice. A friend, a user who also encouraged others to use as well, had lied in a court case where her drug use was a significant factor. He contacted FRANK about her disregard for the law for a substance that was illegal. The advisor raised his voice whilst stating the friend has the right to do what she wants in her own home and mocked him about calling the police. He was shocked and upset by the response.

Ecstasy – Physical health risks

  • Because the strength of ecstasy pills are so unpredictable, if you do decide to take ecstasy, you should start by taking half or even a quarter of the pill and then wait for the effects to kick in before taking anymore – you may find that this is enough.
  • If you’re taking MDMA, start by dabbing a small amount of powder only, then wait for the effects to kick in.
  • Users should sip no more than a pint of water or non-alcoholic drink every hour.

The ‘NEWS’ consisted of 8 pictures with text. In 2 of the 8 items, opportunity is taken to give more ecstasy harm reduction advice. One is titled, ‘Heading out this weekend with Mandy or Molly?’ This is blatant normalisation. The others aren’t ‘news’ items either, but more information about problems.

The section on each drug entitled, ‘Worried about drug x’ mostly consists of giving FRANK’s number. ‘If you are worried about your use, you can call FRANK on 0300 1236600 for friendly, confidential advice’. Any perceptions that FRANK is anything but a Harm Reduction advice site are dispelled completely.

Mentor International is a highly respected worldwide Prevention Charity.  Government-funded Mentor UK is in charge of school drug-education with their programme, ADEPIS (Alcohol and Drug Education and Prevention Information Service). Mentor UK masquerades as a ‘Prevention’ charity but practices ‘Harm Reduction’ and has done so from its inception in 1998. A founding member, Lord Benjamin Mancroft, is currently prominent in the APPG: Drug Policy Reform, partly funded by legaliser George Soros’s Open Society Foundation.

Professor Harry Sumnall of John Moores University Liverpool, a trustee on Mentor UK’s board, signed a ‘Legalisation’ letter in The Telegraph 23rd November 2016 along with the university, Professor David Nutt, The Beckley Foundation, Nick Clegg, Peter Lilley, Transform, Volte-face and other well-known legalisation advocates. Eric Carlin, former Mentor UK CEO (2000-2009), is now a member of Professor David Nutt’s Independent Scientific Committee on Drugs (ISCD). At a July 2008 conference in Vienna, he said “we are not about preventing drug use, we are about preventing harmful drug use”.

Examples of their activities:

The ‘Street Talk’ programme, funded by the Home Office, carried out by the charities Mentor UK and Addaction and completed in March 2012 was aimed to help vulnerable young people aged 10 – 19, to reduce or stop alcohol and drug misuse. Following the intervention, the majority of young people demonstrated a positive intention to change behaviour as follows: “I am confident that I know more about drugs and alcohol and can use them more safely in the future” – 70% agreed, 7% disagreed’.

 Two CanSS members attended a Mentor UK meeting on 7th January 2014 at Kent University, where Professor Alex Stevens, a sociology professor favouring the opening of a ‘coffee shop’ in Kent and supporting ‘grow your own’ was the main speaker. The audience consisted mainly of young primary school teachers. He became increasingly irritated as CanSS challenged his views, becoming incandescent when told knowledge of drug harms is the most important factor in drug education. The only mention of illegality (by CanSS) was met by mirth!

In a Mentor UK project ‘Safer at school’ (2013), the greatest number of requests from pupils, by 5 to 6 times, were: – effects of drugs, side-effects, what drugs do to your body and consequences. Clearly it had been ignored. Coggans 2003 said that, ‘the life skills elements used by Mentor UK may actually be less important than changing knowledge, attitudes and norms by high quality interactive learning’.

Paul Tuohy, the Director of Mentor UK in February 2013 emailed CanSS, ‘Harm reduction approaches are proven and should be part of the armoury for prevention……..there are many young people harming their life chances who are already using and need encouragement to stop, or where they won’t, to use more safely’.

In 2015 Mentor incorporated CAYT (Centre for Analysis of Youth Transitions) with their ‘The Climate Schools programmes’. Expected Outcomes: ‘To show that alcohol and drug prevention programmes, which are based on a harm minimisation approach and delivered through the internet, can offer a user-friendly, curriculum-based and commercially-attractive teaching method’.

In November 2016, Angelus and Mentor UK merged, ‘The Mentor-Angelus merger gives us the opportunity to reach a wider audience through the delivery of harm-prevention programs that informs young people of the harms associated with illicit and NPS drug-taking, to help support them in making conscientious healthy choices in the future’.

The under-developed brains in young people are quite incapable of making reasoned choices. Nor should they. Drug-taking is illegal.

Michael O’Toole (CEO 2014 –2018) said in an ACMD Briefing paper.

Harm reduction may be considered a form of selective prevention – reducing frequency of use or supporting a narrowing range of drugs used’. “It is possible to reduce adverse long-term health and social outcomes through prevention without necessarily abstaining from drugs”. 

It is a puzzle that any organisation, including the Government, can condone drug-taking, an illegal activity, either by testing drugs or dishing out harm reduction advice, without being charged with ‘aiding and abetting’ a crime.

Mary Brett, Chair CanSS and Lucy Dawe,Administrator CanSS www.cannabisskunksense.co.uk    

Source: http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/drugs-policy/written/97965.html March 2019

— Effect on sperm quality, testicular function worse than cigarettes

CHICAGO — Men who smoked marijuana had significantly degraded sperm quality and testicular function, worse than tobacco users and comparable to men with diagnosed infertility, according to a long-term Brazilian study.

As compared with smokers, marijuana users had lower median values for sperm concentration, motility, and morphology (P<0.01). Marijuana use also was associated with reduced testicular volume and an increased rate of nonobstructive azoospermia, clinical features often found in male infertility.

Marijuana’s deleterious effects on reproductive parameters resulted from increased production of reactive oxygen species (ROS), as seminal ROS concentrations were 20 times higher in marijuana users as compared with smokers, reported Jorge Hallak, MD, of the University of Sao Paulo, at the American Urological Association (AUA )annual meeting.

“Overall, the marijuana group had semen quality equivalent to the infertile group, with the exception of higher ROS and DNA damage than infertile men,” Hallak said during an AUA press briefing. “DNA damage is higher in all groups (marijuana users, smokers, and infertile men) as compared to controls, but higher levels were found in the marijuana group and infertile men. Basic semen parameters are not sufficient to identify changes of magnitude in sperm cell function.”

A second study summarized at the press briefing provided the first reported evidence of an association between marijuana use and development of benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS).

recent international study showed a consistent and statistically significant decline in sperm quality (count and motility) over the past 40 years. The explanation for the decline remains elusive, but multiple factors have been proposed: environmental exposures, poor nutrition, genetics, and social/behavioral factors.

Over the past 2 decades, technologic advances allowed more detailed examination of sperm. Showed that sperm are highly vulnerable to oxidative stress, which has been implicated in a multitude of major human diseases and disorders. Subfertility and infertility almost almost always arise as a consequence of oxidative stress, said Hallak.

The rationale for evaluating marijuana’s effect on male fertility parameters included a lack of information on the topic and the worldwide use of the drug. With an estimated 200 million users worldwide, marijuana is the most widely used psychoactive drug, including more than 20 million regular users in the U.S.

Since 2000, Hallak and colleagues have studied the effects of marijuana and tobacco on spermatozoa and testicular function and relationships with male infertility, hypogonadism, and sexual dysfunction. Each study participant has two comprehensive semen analyses that go well beyond usual lab assessments and include ROS, sperm DNA integrity, creatinine kinase activity, and antisperm antibodies.

Unlike many prior studies, enrollment was limited to users of cannabis and excluded use of cannabinoid-containing products. The study population comprised 125 men with diagnosed infertility, 144 tobacco smokers, 74 marijuana users, and a control group of 279 men (prevasectomy with no clinical factors for testicular dysfunction).

Current marijuana use was ascertained by self-report at the time of enrollment. Median age at first use of marijuana was 18.6, and median duration of marijuana use was 8 years.

Clinical characteristics of the infertile men included increased levels of prolactin; decreased sperm concentration, motility, and morphology; and increased seminal pH and ROS. Tobacco smokers had decreased follicle-stimulating hormone, luteinizing hormone, and prolactin; decreased testicular volume; and decreased seminal volume.

Marijuana users had a significantly lower median estradiol level (10.04 ng/dL) as compared with all the other groups (P<0.001). Marijuana use was associated with the highest median seminal ROS: 14.31 x 104 cpm/20 x 106 versus 5.66 for infertile men, 0.70 for smokers, and 0.68 for the fertile control group. Hallak noted that marijuana induces production of intracellular ROS whereas tobacco smoke creates extracellular oxidative stress.

The study of marijuana use and BPH/LUTS included 20,548 men (age >45) who had prescriptions for finasteride and or a super-selective alpha blocker during the period from January 2011 to October 2018. The primary objective was to identify factors significantly associated with BPH/LUTS, said Granville Lloyd, MD, of the University of Colorado Anschutz School of Medicine in Aurora.

A multivariable analysis identified marijuana use as a statistically significant player in the development of BPH/LUTS (odds ratio 1.253, P<0.001). Other significant predictors were depression (OR 2.015), erectile dysfunction (OR 1.847), metabolic syndrome/obesity (OR 1.586), hypertension (OR 1.576), hypogonadism (OR 1.392), and diabetes (OR 1.280, P<0.001 for all). Alcohol use did not have a significant association with BPH/LUTS (OR 0.982).

Noting that BPH/LUTS etiology is poorly understood, Lloyd said, “From this analysis we can conclude that BPH is associated with systemic diseases, depression, and marijuana use but not alcohol.”

“Men who use marijuana are more likely to be treated for BPH,” he stated. “This is a novel finding. Cannabinoids are pharmacologically active and influence voiding, which raises the question of whether marijuana is a risk factor or self-treatment?”

Source: Studies: Weed Degrades Sperm, Spurs LUTS | MedPage Today May 2019

At the center of America’s deadly opioid epidemic, non-pharmaceutical fentanyl appears to be finding its way into illegal stimulants that are sold on the street, such as cocaine. Adulteration with fentanyl is considered a key reason why cocaine’s death toll is escalating. Cocaine and fentanyl are proving to be a lethal combination – cocaine-related death rates have increased according to national survey data. This has important emergency response and harm reduction implications as well—naloxone might reverse such overdoses if administered in time. A recent study by Nolan et. al. assessed the role of opioids, particularly fentanyl, in the increase in cocaine-involved overdose deaths from 2015 to 2016 and found these substances to account for most of this increase.

Fentanyl and Cocaine

Fentanyl is a synthetic, short-acting opioid that is 50 to 100 times more powerful than morphine and increasingly associated with a heightened risk of fatal overdose. The combination of heroin and cocaine, also known as “speedballing,” was popular in the 1970s.  Recently, there has been an uptick in cocaine being adulterated with other powerful substances like the synthetic opioid fentanyl. Unlike in the intentional combination of cocaine with other substances in the 70s, many modern users are not aware that their cocaine may be mixed with another substance, leaving them vulnerable to an accidental overdose.

Cocaine deaths have moved up to the second most common substance present in fatal overdoses—after opioids. Before 2015, fentanyl was involved in fewer than 5% of all overdose deaths each year. This rate increased to 16% in 2015 and continues to rise. At the beginning of 2016, 37% of cocaine-related overdose deaths in New York City involved fentanyl. By the end of the year, fentanyl was involved in almost half of all overdose deaths in NYC. Since then, several US cities have reported similar outbreaks of overdose fatalities involving fentanyl combined with heroin or cocaine. The combination of fentanyl and cocaine has been a considerable driver of the rising death toll since 2015, and opioid-naive cocaine users are at an especially high risk of unintentional opioid overdose.

Why is Fentanyl Appearing in Cocaine?

One theory is that the adulteration is an accident and occurs by residual fentanyl being present in the same space and on the same surfaces where cocaine is being processed. Another theory is that the increasing presence of fentanyl in cocaine concerns cost and supply. Drug cartels can add other cheaper drugs and medications as fillers to stretch out their product.1 By adding fentanyl they may also be producing a more potent and addictive product to expand their market. This, however, is risky since even a small amount of fentanyl can result in death. The Drug Enforcement Agency (DEA) explains that even 2 milligrams of fentanyl, about the size of a grain of rice, can be deadly to an adult. In light of that fact, it’s distinctly possible that street-level illicit drug dealers do not have insight into the contents of their product and are unknowingly selling cocaine adulterated with fentanyl.

Present Study

Data in this study was acquired from death certificates from the New York City Bureau of Vital Statistics and toxicology results from the New York City Office of the Chief Medical Examiner. Age-adjusted rates per 100,000 residents were calculated for 6-month intervals from 2010 to 2016.

Results suggested that individuals using cocaine in New York City were vulnerable to a greater risk of a fatal overdose due to the increasing presence of fentanyl in the city’s drug supply. In fact, 90% of the increase in cocaine overdose fatalities from 2010 to 2016 also involved fentanyl.

Public Health Challenges

This study highlighted some public health challenges caused by fentanyl-adulterated cocaine:

  1. First responders and those present at the scene of a cocaine overdose may consider administering Naloxone even if the patient denied using opioids.

  2. Fentanyl is very dangerous and powerful and dramatically increases the risk of lethal overdose.

  3. Opioid-naïve individuals that have been using fentanyl-free cocaine lack a potentially life-saving tolerance for opioids. Adding fentanyl to their drug of choice puts this group at an even higher risk of fatal overdose.

  4. Opioid-naïve cocaine users are typically not targeted by current harm reduction strategies and public messages concerning opioid overdose. A lack of education and access to critical resources, including naloxone —the lifesaving overdose reversal drug— render this population more vulnerable to a fatal overdose.

Looking to the Future

As the issue continues to get worse — 19,000 of the 42,000 reported opioid overdose deaths in 2016 were related to fentanyl — the authors of the study emphasize the importance of overdose prevention intervention for cocaine users, with a strong emphasis on access to naloxone and information about fentanyl.

Future prevention efforts must be widened to include cocaine users, especially those who are opioid-naïve, to prevent more fatal overdoses. Cocaine overdose awareness, treatment for dependence, and relapse prevention must be prioritized in a comprehensive response to addiction that puts us on a better path forward and ensures that this country does not repeat past mistakes by implementing substance-centric policy and education efforts.

Citation

Nolan, M. L., Shamasunder, S., Colon-Berezin, C., Kunins, H. V., & Paone, D. (2019). Increased presence of fentanyl in cocaine-involved fatal overdoses: implications for prevention. Journal of Urban Health, 1-6.

Source: Fentanyl-adulterated Cocaine: Strategies to Address the New Normal (addictionpolicy.org) Updated October 16th 2022

It is not all that long since people seriously tried to pretend that cigarettes were safe. Most of them were motivated by greed, and by fear that the truth would destroy their profits.

Everyone now agrees that cigarettes cause lung cancer and many other diseases. But we forget the struggle that doctors and scientists had to fight, against Big Tobacco, to get this accepted.

Sir Richard Doll and Sir Austin Bradford-Hill established in 1950 that there was a clear link between smoking and cancer. A wider study in 1954 absolutely confirmed this.

Yet such was the power and wealth of the tobacco giants that it was decades before anything serious was done to discourage smoking. It was not until 1971 that the first feeble warning was placed on cigarette packets in this country.

As late as 1962, the cigarette-makers were still pretending there hadn’t been enough research, and even that tobacco was good for you, claiming ‘smoking has pharmacological and psychological effects that are of real value to smokers’.

A Tory MP, Ted Leather, denounced the doctors’ warnings as ‘unscientific tosh’ and ‘hysterical nonsense’. Lung cancer was blamed on air pollution. The prominent journalist Chapman Pincher proclaimed ‘cigarette risks are being exaggerated’. It was seriously argued that restrictions on smoking were an attack on liberty.

I’d guess that many who made such claims lived to regret, bitterly and with some embarrassment, their part in covering up a terrible danger. Those who listened to them died, early and often horribly. They are still dying now, in cancer wards up and down the country.

Earlier, firmer action would have saved them and their families from much grief. Those tobacco apologists all have their parallels now.

I know, but will not name here, drug lobbyists, a Tory MP and several prominent journalists, who make the same excuses for marijuana, just as the evidence of its grave dangers piles up. They claim the evidence against it is exaggerated. They claim it has medical benefits. They claim its effects are caused by something else. May God forgive them. I cannot.

Our society, learning nothing from the tobacco disaster, has for years been appallingly complacent about this terribly dangerous drug, whose effect on the brains and minds of its users can be utterly devastating. Knowledge of its dangers does not show up in statistics which pay little attention to the sort of damage it does.

The victims of marijuana seldom die (though they increasingly frequently kill others, in mad car crashes and violent crime).

School failure, delinquency, delusional behaviour, persecution mania, young lives wholly blighted and continued only thanks to a devastating cocktails of antipsychotic drugs, do not register much in NHS figures. Nor do the special miseries of the families of these people, compelled to care, for life, for a husk of the person they once knew and had hopes for, and still love. Such families keep their grief to themselves. But there are many of them.

Look, I am right about this. But it is no good being right if you are not believed. I and my allies are roughly where the doctors who warned against lung cancer were in the mid-1950s. The evidence keeps on coming. Last week’s report linking marijuana use to depression and suicidal feelings among the young is just the latest in a great mountain of such studies. But the popular culture continues to act as if there’s nothing to worry about.

It is now seven years since I published a book which pointed out the truth – that the police and courts have given up prosecuting the major crime of marijuana possession. Back in 2012 I was denounced, snubbed, sneered at and told by distinguished academics that I was wrong and that there was a stern regime of cruel prohibition.

Now everybody recognises that what I said seven years ago is absolutely true. It is hard not to do so when so much of our country openly stinks of marijuana. Even if the Commissioner of the Metropolitan Police, Cressida Dick, cannot smell it, the rest of us can.

Sooner than seven years from now, I suspect that the connection between marijuana and severe mental illness will also be widely understood and accepted. But will it be too late?

Today’s Big Dope lobby wants to silence warnings about the dangers of marijuana until they have it legalised, and we can’t go back. They are like the Big Tobacco of the 1950s, a cynical greed campaign prepared to cause misery to others in the pursuit of riches.

This is the reason for its busy Trojan Horse operation to portray marijuana as a medicine, a claim for which there is very little evidence. And in any case, what use would a medicine be whose users risked irreversible mental illness?

Thalidomide was wonderful at treating morning sickness. But what does that matter compared with its terrible side effects?

Be on your guard. Make sure your MP isn’t fooled by Big Dope propaganda. Write to your MP when you see reports of crimes whose perpetrators were cannabis smokers. Your local papers will be full of them, if you look. Ask your MP to read the many reports linking this drug with mental illness.

And don’t be fooled. All of us sympathise with the mothers of very sick children who seek remedies for them. But beware of the shadowy figures who often stand behind such stories, and who use this suffering to promote a nasty cause.

It’s a race against time. If we lose it, the suffering which follows will be at least as bad as the suffering caused by cigarettes, and probably far worse.

Peter Hitchens  Mail on Sunday  

Source: Cigarettes are healthy! (And if you believe that, you’ll fall for Big Dope’s marijuana propaganda, too) – Mail Online – Peter Hitchens blog (mailonsunday.co.uk) February 2019

DEA says Houston is both a big market for synthetic pot and a major source

More than 1 million packets of a dangerous, unpredictable new breed of drug were seized in the Houston area by the DEA in the past two years, yet criminal charges are rare for those who make, sell or use them.

The packets, sold as potpourri or incense, are among the more popular brands of so-called synthetic marijuana taking center stage in a new front in the war on drugs.

On a recent afternoon, glossy packets of strawberry-flavored “Kush” lay side by side in a lighted glass display case, just past the bongs and pipes, at a Houston-area shop. The mixture inside looks like dried, finely crushed green leaves. It is smoked like pot but packs a far different punch – and is fueling the never-ending search for ways to get high.

“This is a new frontier for drugs and drug traffickers,” said Rusty Payne, a spokesman for the Drug Enforcement Administration. “I want to shout it from the roof tops: This is nasty stuff.”

Despite pressure from law enforcement, users still don’t have to go to underground dealers to score. Instead, they just visit smoke shops and convenience stores that sell the products.

Houston has a key role in the popularity of the drugs. It is not only a large marketplace for them, but they are covertly made here and shipped to other regions, according to court documents.

Doctors said the substances – technically classified as synthetic cannabinoids – can be aggressive, unstable and damaging.

Hearts race. Blood pressure soars. Seizures can be unleashed.

Paranoia is known to grip some users, as well as agitation and suicidal tendencies that can last five or six hours and land them in emergency rooms.

“They come in, and they are wild and psychotic and sometimes have a distinct smell,” said Dr. Spencer Greene, director of medical toxicology for Baylor College of Medicine. “They are going to be kind of wild and kind of crazy, and potentially very sick.”

Part of the problem is that the potency of the drugs can vary so greatly, and that users can never be sure what they are smoking.

Emily Bauer, a 17-year-old former user who lives in Cypress, learned just how bad they can be on a Friday night in 2012.

She smoked a packet, as she had done many times before, and ended up suffering what her family has been told was a series of strokes.

“I am improving constantly, and my vision is getting better,” she said, noting that she continues with high school thanks to people who read textbooks aloud to her and help her write.

Bauer and her parents have been sharing her story publicly in hopes that others will avoid the drugs. She said it just is not accurate to compare what she smoked to marijuana.

“It is more like smoking bleach,” she said.

Banned at trade shows

They come in colorful packets with dozens of other brand names, including Scooby Snax and Hello Kitty. The packages look like packets of candy and cost from $6 to $20, depending on the size.

They carry warnings that the contents are not for human consumption and sometimes incorrectly note contents are legal.

Authorities contend the language is just an attempt to dodge state and federal laws.

In schemes reminiscent of the popular crime drama “Breaking Bad,” rogue chemists repeatedly tweak compounds to create new generations of designer drugs faster than laws can catch them.

“Trained chemists know exactly what they are doing,” said Jeff Walterscheid, a toxicologist with the Harris County Institute of Forensic Sciences.

He noted that tweaking one molecule can make a new drug.

Dozens of such deviations of synthetic cannabinoids have been identified in the past few years, according to the DEA, and the list of what is out there is believed to be growing weekly.

To prepare the drugs for consumption, chemicals – usually white powdery mixtures – are often imported from China where they were prepared by chemists who keep an eye on U.S. laws, according to the DEA.

After U.S.-based manufacturers get those chemicals, they are often dissolved in acetone and then sprayed over leafy material, dried and spritzed with flavors such as grape, strawberry or cherry. Then they are poured into packages that are delivered in bulk to stock the shelves of retailers.

A manufacturing operation in Stafford was shut down by police in September after five day laborers staggered to an ambulance company looking for help. They had been overcome by fumes.

The factory was in an industrial park and a few hundred yards from a day care center. All that was left behind on a recent visit to the site was a scattering of crushed leaves in a carpeted office and a small black and blue packet labeled Amsterdam Dreams Potpourri.

Manufacturers of these substances aren’t considered nearly as violent as drug-cartel gangsters, but turf wars flare up.

Authorities point to a brutal dispute between two manufacturers. One stormed into the other’s business on Harwin, doused him with gasoline, and threatened to set him ablaze if he didn’t stop stealing a brand name.

The dispute faded. No one was arrested.

Jeff Hirschfeld, president of Champs, which holds national trade shows for thousands of smoke shop owners, said two years ago he decided to ban synthetic marijuana vendors from his events.

“There are so many states that don’t allow it, we just did not think it was proper,” he said.

“I am a grandfather of six, and I would not really recommend it for my grandkids,” he said. “I have not tried it, but I know people who have. Some say good, some say bad, but I’m not comfortable with it.”

Users vary from high school kids to working professionals. The drug also doesn’t show up in urine tests for marijuana, which might appeal to people on parole or job applicants.

Not meant for humans

In the past two years in Houston, synthetic cannabinoids were in the system of a person who hanged himself, another who was hit by an allegedly drunken driver while walking along a tollway, and another who was shot to death, according to the Harris County Institute of Forensic Sciences.

Users are playing roulette with their lives, said Walterscheid, the Harris County toxicologist.

“You cannot look at a container of Kush Apple and know what is in it,” he said. “When buying a package that looks the same every day for a year, you could be getting something different every single time.”

John Huffman, a South Carolina chemist who years ago led a team that developed synthetic cannabinoids while researching under a federal grant, said some strains now being copied could easily be 50 times more potent than marijuana.

“They are all dangerous. Don’t use them,” said Huffman, who retired four years ago. “They were never designed for this.”

The substances were tested on animals but were never to be used by humans.

Criminal charges rarely are filed as cases involving these emerging drugs bring on a host of new scientific, medical and legal complexities.

Clinical tests have not yet been conducted on humans on any of these drugs, so it can be tough to prove the extent of their harm. Experts could also clash over whether the ingredients of a given drug make it illegal, among other issues.

People who knowingly make or sell synthetic cannabinoids for human consumption can face federal charges. Possession of some of those substances, regardless of weight, can in some cases be a misdemeanor in Texas.

“We have been taking an active role trying to classify more of these, make more of them fall in the penal code,” said Marcy McCorvey, division chief of the major narcotics division of the Harris County District Attorney’s Office.

She said that prosecutors are handcuffed by insufficient laws, but if they can make a case, they will take it to court.

“It is very frustrating. I know of police officers who are out there trying to combat the problem,” McCorvey said. “I understand parents who want it off the shelves. I wish I could prosecute sellers and suppliers in a more harsh manner, but the state law does not allow for a harsher penalty as it is written.”

Few criminal charges

Despite the DEA seizing more than 1 million packets of the drugs, as well as the pending forfeitures of more than $8 million, federal prosecutors in Houston have yet to charge anyone, according to officials.

The U.S. Attorney for the Southern District of Texas, who is based in Houston, declined to comment.

In June, federal authorities in San Antonio announced Operation Synergy. At least 17 people were arrested in San Antonio, Houston and elsewhere for alleged roles in a synthetic cannabinod ring.

In another case, Houston resident Issa Baba was charged federally in Pennsylvania with using the Web to sell synthetic pot and other designer drugs. More than $5 million was seized from his bank accounts. Baba has signed a guilty plea.

Another Houston-area man has not been charged with a crime, but more than $2 million was taken from him in May on the grounds that it was proceeds from making synthetic cannabinoids. Bundles of $100 bills wrapped in rubber bands were stashed at his ex-wife’s home in La Marque.

Lawyer Chip Lewis, who represents Baba and the other man, said the cases against his clients come at a tricky time, as the Department of Justice has decided not to challenge laws that permit the medical and recreational use of marijuana.

“It is a slippery slope we are on here,” Lewis said. “Yes, we will prosecute you for this. No, we are not going to prosecute you for something else on the books.”

Javier Pena, chief of the DEA’s Houston Division, said getting this breed of drugs off the streets has become a moral mission as much as a legal one.

“We are trying to say to store owners: You know who you are. You need to stop selling this poison.”

Source: https://www.houstonchronicle.com/news/investigations/article/Houston-gains-key-role-in-synthetic-marijuana-5024607.php  November 2013

Britain snorts more of the drug than almost anywhere in Europe, more young people are taking it and deaths are rising. Why?

The moment Dan (not his real name) realised he had a problem with cocaine, he had been off work for a week, sick with flu. His phone buzzed. It was his cocaine dealer, calling to check he was OK. When Dan, one of his favoured customers, hadn’t been in touch to buy the cocaine he usually took several times a week, the dealer knew something was wrong.

“I don’t like thinking about that,” Dan says, shaking his head as we sit in a London pub. Now 36, Dan estimates he has spent £25,000 on cocaine. Lines in the pub on a Friday night after work. Lines on a Wednesday evening at a friend’s house while earnestly discussing 90s hip-hop. Lines at house parties, weddings, birthday parties and for no reason at all, other than that cocaine – the white powder that makes no one a better version of themselves, but that many of us continue to do anyway – is everywhere and freely available.

Britain is a cocaine-loving country, and its love for the drug is growing. The country snorts more cocaine than almost anywhere in Europe. “Cocaine use is going up,” says João Matias of the European Monitoring Centre for Drugs and Drug Addiction. In the UK in 2017-2018, 2.6% of people aged 16-59 took powdered cocaine (as opposed to crack cocaine, the more potent variant of the drug, which was taken by 0.1% of the population in the same period), up from 2.4% in 2013-2014, according to Home Office figures.

More young people are taking cocaine than ever before: 6% of 16- to 24-year-olds have tried it, despite the fact that, overall, fewer young people take drugs in general. It is also likely that Home Office figures, which often exclude students, prisoners and homeless people, underestimate cocaine use because those groups typically have above-average illegal drug use.

Most of this cocaine ends up in our sewage system, and researchers have been finding increasing levels in Britain’s water supply since 2012, Matias says. Levels are highest at weekends, indicating recreational use.

Cocaine used to be the sole preserve of affluent City workers and dissolute rock stars. They continue to favour the drug: data from the crime survey of England and Wales showed that powdered cocaine use increased from 2.2% in 2014/15 to 3.4% in 2017/18 in households earning £50,000 a year or more. (Use among those earning less than £10,000 a year fell during this period, although researchers believe the use of crack cocaine may be on the rise in poorer communities.) But powdered cocaine now appeals to those in more modest income brackets, too. “Coke is pretty classless now,” says Ian Hamilton, a senior lecturer in mental health at the University of York. “It’s not for financiers in the City of London any more. It’s more affordable, so that’s opened up the market to people who wouldn’t have tried it before.” And dealers are savvy marketers. Dan pulls out his phone to show me a “bargain bucket offer” he has received: five grams of cocaine for £210.

Users come from all backgrounds. In Hyndburn – the once-prosperous centre of England’s textile industry, which is now in decline – 17 young people died of cocaine overdoses in a nine-month period in 2017. In Newcastle, according to a Vice report, cocaine has become “an important factor in the city’s legitimate economy”, with bars offering privacy curtains for patrons who wish to snort lines off their phones.

According to the National Crime Agency, recent years have seen the Albanian mafia take control of the UK’s lucrative cocaine market with a brutally effective business model. By negotiating directly with the cartels in drug-producing Latin America, cutting out traditional international importers, the Albanian mafia have been able to deliver a purer, more affordable product to market: cocaine hasn’t been this cheap since 1990.

Ironically, anti-drug laws have also improved the quality of cocaine. The 2015 Serious Crime Act criminalised the import of cutting agents such as benzocaine. When it is harder to cut the product, purity increases. This, along with the fact that cocaine production has increased in Latin America, has created a perfect powder storm. Cocaine purity, which has been increasing since 2010, is at its highest level in a decade. What happens when a product becomes cheaper, more plentiful and better quality? More people try it.

As purity and availability increase, so, too, does the misery wreaked by cocaine. Hospital admissions for mental health disorders linked to cocaine have almost trebled in the past decade. Cocaine-related deaths have increased for the sixth year running, up to 432 deaths in England and Wales in 2017, compared with 112 in 2011. (It’s worth noting that these figures refer to powdered and crack cocaine, as official statistics do not differentiate between the two when establishing cause of death. Many of these deaths will involve users who have longstanding addictions to crack cocaine, as well as other co-dependencies.) Users leap from balconies, or fall from mountain paths while under the effects of the drug. Or their bodies give out on them: many deaths take place when users mix cocaine with alcohol, producing the toxic chemical cocaethylene.

“There are a number of risks when it comes to mixing any drugs together,” says the consultant addiction psychiatrist Dr Prun Bijral of the drug treatment service Change Grow Live. As “alcohol is a depressant and cocaine is a stimulant,” combining the two in large quantities can overstimulate the heart and nervous system, leading to, in extreme circumstances, heart attacks. Mixing the two also “impairs your ability to measure and make a judgment on risks”, Bijral adds, meaning that you are far more likely to get yourself into a dangerous situation while drinking and taking cocaine. And it is not just your heart you should be worried about: cocaine abuse can cause the soft inner cartilage of your nose to erode, and it has been linked to brain abnormalities in regular users.

Lucy White, a student at the University of the West of England, knew the dangers of messing with drugs: she saw 19-year-old Drake Morgan-Baines collapse and die in front of her, of MDMA (ecstasy) poisoning, while she was working in Motion nightclub in Bristol. “She was really disturbed by it,” her sister, Stacey Jordan, tells me. But just seven months later, White herself died of a lethal cocktail of cocaine and prescription drugs. “It was the drugs that killed her, but it was also the people she was with, and the peer pressure,” Jordan says. “I don’t think she realised how dangerous it was.”

Cocaine use creates subtler forms of misery, too. “I’m the most confident person for those few hours when I’m on it,” Dan says, “but afterwards I’m having horrendous, almost suicidal, thoughts.” Paranoia lasts for days after a bender. “It’s crushing. The depression outweighs the good times so much,” he says. “It’s the feeling of being a disappointment to my parents. What the fuck am I doing?”

Dan thinks Britons love cocaine because we work so hard (on average, we work the longest hours in Europe). “You can do coke tonight and go to work tomorrow and no one will know,” he says. “I may be a bit less productive, but only I know that.” Even though mixing alcohol and cocaine can prove deadly, many continue to do it. “Coke and alcohol go really well together,” Hamilton says. “You can drink for longer, and it makes you more confident.”

“After two drinks, I wouldn’t be able to relax unless I knew the coke was sorted,” Dan says. “That was my mentality.”

At a time of welfare cuts and ever-longer NHS mental health waiting lists, cocaine also seems to offer a quick fix for those struggling with stress or anxiety. “If you are a young person who is a bit anxious, lacking in confidence or not sure of your place in the grand scheme of things, coke sorts all that out for you,” Hamilton says. “If you can offer me a line now that makes me feel better, or the alternative is that I’m going to have to wait at least four weeks to see a counsellor, it’s an absolute no-brainer.” He pauses. “I’m not recommending it. But austerity has created a real bottleneck in people getting the support they need, and drugs are far more instant. They have no opening and closing hours.”

Recently, I was in the sort of pub you bring your parents to: an upmarket affair with chalkboard menus. I went to the bathroom and there, dusted across the toilet-roll holder like icing sugar on a Victoria sponge, was a fine but unmistakable layer of cocaine. For someone like Dan, who is trying to avoid taking the drug, “you have to be very careful. It’s everywhere.” Recently, he was eating dinner in a Greek restaurant when a nearby stranger offered him cocaine. Did he accept? He drops his voice. “I did, yeah.”

Cocaine’s resurgence is also linked to our changing night-time economy. The number of nightclubs in the UK halved between 2005 and 2015, and more than 25% of pubs have closed since 2001. As these places shutter, British people increasingly socialise behind closed doors. Unlike the club drug ecstasy, cocaine is best taken at home. Dan and his friends would often avoid bars to head back to someone’s flat, turn on some music and get a bag of cocaine in. “Bars are full of dickheads, so I’d say: ‘Let’s get out of here – I’m done.’ Only I wouldn’t be done: I’d stupidly stay up until 7am, having the same conversation.”

To many people, a line of cocaine with a glass of wine on Saturday night is an ordinary sort of thing – and they certainly don’t think of the devastation wreaked by drug cartels in cocaine-producing parts of the world. “It’s not seen as a hard drug,” says Hamilton. “It’s snorted, not injected, so you don’t have to cross that line.”

“The Chelsea flower show, the opera, churches, a Momentum fundraiser, Peppa Pig World …” The former Sun journalist Matt Quinton lists the places he and his colleagues found cocaine traces while working undercover for the newspaper. “Peppa Pig World was unexpected,” he says. The most shocking place Quinton found cocaine? A toilet that was only accessible to NHS staff. Because these exposés were popular with readers, and cheap to put together, Quinton or his colleagues would be sent out by editors to swab pretty much anywhere. As well as becoming extremely proficient at wiping down lavatories, Quinton learned one thing. “Coke is absolutely everywhere, especially if alcohol is being served,” he says. In the 18-month period Quinton only failed to find cocaine once: in the bathroom at a children’s festival. “That was because they had these toilets that were entirely plastic and clearly being blast-washed on a regular basis.” And, he adds, “they didn’t serve alcohol”.

Even Jordan’s friends don’t see a bit of coke as much of anything, really, despite the fact she lost her sister to the drug. It angers her. “You can’t get away from it if all your friends do it,” she says. “I’ve been at weddings and people are doing it in the toilet. I’m looking on in pure horror.” After witnessing someone snorting cocaine off their hand at a nightclub bar, she avoids going clubbing. “I start lecturing strangers because I get too angry.” She understands why people do it. “I don’t think people understand the butterfly effect that it has – unless something happens to you.”

Recent months have seen attempts to challenge the laissez-faire attitudes. Last July, London’s mayor, Sadiq Khan, linked escalating violence on the city’s streets to middle-class cocaine use. Days later, the Metropolitan police commissioner, Cressida Dick, denounced hypocritical middle-class users who profess to be politically aware. In October, the home secretary, Sajid Javid, told the Daily Mail that a government review would specifically look at the damage occasioned by middle-class drug users. Where did this sudden cross-party consensus on the evils of middle-class drug originate? One man: Simon Kempton.

In May last year, Kempton – who is the Police Federation’s lead on drugs – was chairing a panel discussion at its annual conference when a journalist asked for his views on prohibition. “I let my guard down a bit and said something honest, which is never a good thing,” Kempton smiles. He singled out middle-class drug users for fuelling street violence. A media storm ensued, but after Dick, Khan and Javid echoed his stance, Kempton felt vindicated. He hopes to transform middle-class users’ attitude to the drug. “If you think back to when I was a nipper, drink-driving was accepted ethically,” he says. “It took 20 or 30 years of better education to understand that drink-driving isn’t ethical. There’s similar work to be done.”

But does middle-class cocaine use really cause knife crime? “To my mind, the focus on middle-class cocaine users is a smokescreen for the failure to deal with the underlying causes of youth crime and violence,” says Prof Alex Stevens, an expert in criminal justice at the University of Kent, and the president of the International Society of the Study of Drug Policy. Since 2011, the coalition and Conservative governments have consistently attempted to link gangs and youth violence to drugs. But while street-level violence may be seen in the dealing of crack cocaine across so called county lines, powdered cocaine has a different supply chain. “Middle-class users don’t get their coke from young kids who are riding motorbikes out of council estates,” Stevens says. “There is violence in that supply chain too, but most of it happens in Latin America.”

If the evidence is shaky, why are politicians so keen to connect these dots? “It’s a strategy to keep in people’s minds the link between drugs and black youths,” says Stafford Scott, an anti-racism campaigner based in Tottenham, north London. It also allows them to shirk responsibility for dealing with the real causes of knife crime: “poverty, isolation and marginalisation”. Has Scott ever seen any evidence of cocaine dealing in the communities he works with? “You don’t see powdered cocaine in the ’hood,” he says.

Whether or not you agree that cocaine causes knife crime on our streets, one thing is for certain: cocaine causes damage. Maybe the damage takes place in a faraway country you prefer not to think about. Maybe it’s a subtler form of damage: to your relationships, finances, wellbeing or career.

Dan has pulled himself out of the depths of his cocaine addiction gingerly. Sometimes, he slides downhill. Avoiding social situations where he knows cocaine will be present helps, “because I’m weak”, he says. “If I have a drink, I know someone will have coke on them, and it’s so hard to say no.”

But it’s not easy to keep your distance. After we finish our interview, we step out of the pub into the frigid night air. We’re about to part ways when Dan notices a man outside, speaking loudly on the phone. He’s withdrawing a large sum of cash from an ATM and directing someone to his location. We look at each other, and Dan sighs.

The charity Change Grow Live (changegrowlive.org) offers further information on, and help with, the issues raised in this article

Source: The white stuff: why Britain can’t get enough cocaine | Drugs | The Guardian January 2019

What are Marijuana Concentrates or THC Concentrates? 

A marijuana concentrate is a highly potent THC concentrated mass that is most similar in appearance to either honey or butter, which is why it is referred to or known on the street as “honey oil” or “budder.”

What Does it Look Like?

Marijuana concentrates are similar in appearance to honey or butter and are either brown or gold in color. The different forms includehash or honey oil (a goey substance)wax or butter (soft, lip balm-like substance), and shatter (a hard, solid substance)(See photo gallery at the bottom of the article)

What are the Street Names?

710 (the word “OIL” flipped and spelled backwards), wax, ear wax, honey oil, budder, butane hash oil, butane honey oil (BHO), shatter, dabs (dabbing), black glass, and errl.

How is it Made?

One popular extraction method uses butane, a highly flammable solvent, which is put through an extraction tube filed with marijuana. The butane evaporates leaving a sticky liquid known as “wax” or “dab.” This method is dangerous because butane is a very explosive substance. There have been explosions in houses, apartment buildings and other locations where someone tried the extraction. 

How is it Used?

It’s used a few ways:

  • Infusing marijuana concentrates in various food or drink products
  • Smoking remains the most popular form of ingestion by use of water or oil pipes or heated in a glass bong.
  • Electronic cigarettes (also known as e-cigarettes) or vaporizers. Many users of marijuana concentrates prefer the e-cigarette/vaporizer because it’s smokeless, odorless, and easy to hide or conceal. The user takes a small amount of marijuana concentrate, referred to as a “dab,” then heats the substance using the e-cigarette/vaporizer producing vapors that ensures an instant “high” effect upon the user. Using an e-cigarette/vaporizer to ingest marijuana concentrates is commonly referred to as “dabbing” or “vaping.”

What are the Effects of Using Marijuana Concentrates? 

Marijuana concentrates have a much higher level of THC. The effects of using may be more severe, both psychologically and physically. 

Sources: “Marijuana Extracts,” National Institute on Drug Abuse (NIDA); “Marijuana Concentrates,” Drugs of Abuse – DEA.

 

Source: What You Should Know About Marijuana Concentrates/ Honey Butane Oil | Get Smart About Drugs March 2022

* Correspondence:

Albert Stuart Reece  

A leading perspectives piece in the New England Journal of Medicine recently observed the salience of assessing drug safety in children and emphasized that effects experienced in childhood can have long lasting impacts as they interfere with maturation and growth of the organism into later life.  Senior researchers from the National Institute of Drug Abuse have frequently drawn attention to the implications of adolescent cannabis exposure.  The effects of gestational exposure are even more far reaching.  These factors are given further urgency by studies showing 25% of Californian teenage mothers in California use cannabis.

Cannabis-related neuroteratology appears to clearly fall on a spectrum of deficits.

With the obvious caveats that many of the longitudinal studies of prenatal cannabis exposure (PCE) have been conducted in very different populations, that it is not easy to control for other sociodemographic factors frequently associated with drug use, and that the concentration of cannabis commonly used in the older studies was much lower, findings which together engender a fair degree of heterogeneity in the published reports, a remarkably consistent thread runs through the PCE literature.  Three major longitudinal studies have followed children exposed prenatally from white middle class Ottawa from the late 1970’s; from predominantly African-American Pittsburgh from 1982; and from the Netherlands from 2001.  Reductions in birth weight of 200-300g, slightly smaller head circumferences (2.8mm), and body length are reported in weekly users with several studies reporting dose-response effects.

In terms of neurobehavioural functioning increased neonatal startle response were seen, with specific cognitive defects in grade school, increased impulsivity, hyperactivity and depression at age 10, poor school achievement, adolescent delinquency, increased violence and aggression amongst girls, increased use of tobacco and cannabis in teens, and in the early 20’s in the longest running study, deficits in short term memory, visuospatial memory and motor impulse control.  These defects have been linked with ADHD and with autism.  Microcephaly was also noted in a large Hawaiian study.  Increased neonatal startle and later cognitive defects are also seen in rodents after PCE.

These findings are clinically significant, and may assume public health significance when one notes that autism is increasing in all USA states where it is measured, paralleling rising rates of cannabis use across the country.

Two reports from C.D.C. indicate an almost doubling of the rate of anencephaly following PCE R.R.=1.9 (95%C.I. 1.1-3.2).  In the context of the foregoing findings this major datum implies that cannabis has the unusual distinction of being a neurotoxin which interferes with brain development to the point of chemically amputating the forebrain.  Hence there is clear evidence of a graded spectrum of deficits following PCE from subtle ASD- and ADHD- like neurobehavioural defects, to smaller heads, to microcephaly and to anencephaly including foetal neurological and neonatal death.

In the context of indicative epidemiology consideration of pathophysiological mechanisms is pertinent to address the Hill principles of causality.

There are numerous compelling mechanisms by which PCE can be related to subsequent teratogenic outcomes.

Importantly the cerebellum, midbrain, diencephalon and forebrain express moderate to high levels of type 1 cannabinoid receptors (CB1R) from early in gestation.

It was recently powerfully demonstrated that opposing gradients of the ligand-receptor guidance pairs slit-Roundabout (robo) and the notch ligand dll control and determine mammalian corticogenesis in diverse organisms including snakes, birds, mice and human organoids by controlling the switch for cortical neurogenesis from directly via radial glia cells to a more indirect and proliferative pathway via intermediate progenitors (Figure 1).   Cannabinoids have been shown to reverse this natural gradient for dll, and acting via a 2AG / CB2R / slit2 / Robo1 / 2AG / CB1R / JNK / ERK pathway to stimulate robo.

Neurexin-neuroligin is a trans-synaptic ligand-receptor pair which directly induces and maintains synapse formation, and has been shown to be inhibited by cannabinoids.

Axon guidance is also controlled by robo-slit and by stathmin-induced tubulin polymerization, which are sensitive to cannabinoids.

White matter disconnection is well documented following adolescent and prenatal cannabis use, and in autism, and oligodendrocytes have CB1R’s and CB2R’s.

Mitochondria possess both CB1R’s and cannabinoid signal transduction machinery and are known to be highly sensitive to cannabinoids and interact with DNA maintenance pathways by several routes.

Cannabinoids have also been shown to alter signaling via the neurotransmitters: glutamate, GABA, opioids, dopamine, serotonin and enkephalin.

Cannabinoids have demonstrated intergenerational epigenetic effects on the medium spiny neurons of the nucleus accumbens and amygdala and also on immune cells which sculpt dendritic networks and prune synapses.

Acting via CB1R, GPR55, and vanilloid type 1 receptors cannabis has been linked with arteritis with likely downstream actions on neurogenic and other stem cell niches.

Endocardial cushions also carry high levels of CB1R’s and the American Academy of Pediatrics has a position statement noting the increased incidence of Ebstein’s syndrome and ventricular septal defect (VSD) after PCE.  Both syncytiotrophoblast and placental arteries carry high concentrations of CB1R’s and abnormalities of uterine blood flow have been documented.

Cannabinoids interfere with tubulin polymerization and mitotic spindle function and thereby act as indirect genotoxins. The implication of cannabis with four inheritable cancers implies malignant teratogenicity and genotoxicity.

Colorado reports dramatic rises of total congenital anomalies, microcephaly, VSD, ASD, Down’s syndrome and chromosomal defects, all of which are relatively straightforward to quantify.

Colorado legislators have also moved to declare a state of crisis related to an autism rate presently growing by 30% 2012-2014.  Similarly in northern California a coincident hotspot of cannabis use, gastroschisis and autism has been reported.  In New Jersey 4.5% of 8 year old boys are autistic.

The above findings comprehend both positive and negative association along with multiple plausible biological pathways linking causality.

As rising rates of community cannabis use augment rising cannabis concentrations and intersect often asymptotic cannabinoid dose-response genotoxicity curves, increased clinical teratogenesis is to be expected.  Of these anomalies the neurobehavioural teratology will likely be the most common, is arguably the most costly and severe, and is also most difficult to quantify.

Are we prepared?

Source:  Paper by Albert Stuart Reese sent to Elinore.Mccance-katz@samhsa.hhs.gov  2018

Source: 2017-Cannabis-Toxic-Trend-Report.pdf (wapc.org) 2017

Abstract

Opioid use disorder is a highly disabling psychiatric disorder, and is associated with both significant functional disruption and risk for negative health outcomes such as infectious disease and fatal overdose. Even among those who receive evidence-based pharmacotherapy for opioid use disorder, many drop out of treatment or relapse, highlighting the importance of novel treatment strategies for this population. Over 60% of those with opioid use disorder also meet diagnostic criteria for an anxiety disorder; however, efficacious treatments for this common co-occurrence have not be established. This manuscript describes the rationale and methods for a behavioral treatment development study designed to develop and test an integrated cognitive-behavioral therapy for those with co-occurring opioid use disorder and anxiety disorders.

The aims of the study are (1) to develop and pilot test a new manualized cognitive behavioral therapy for co-occurring opioid use disorder and anxiety disorders, (2) to test the efficacy of this treatment relative to an active comparison treatment that targets opioid use disorder alone, and (3) to investigate the role of stress reactivity in both prognosis and recovery from opioid use disorder and anxiety disorders. Our overarching aim is to investigate whether this new treatment improves both anxiety and opioid use disorder outcomes relative to standard treatment. Identifying optimal treatment strategies for this population are needed to improve outcomes among those with this highly disabling and life-threatening disorder.

Source: Development of an integrated cognitive behavioral therapy for anxiety and opioid use disorder: Study protocol and methods – PubMed (nih.gov) July 2017

Abstract

Among individuals with substance use disorders (SUDs), comorbidity with other psychiatric disorders is common and often noted as the rule rather than the exception. Standard care that provides integrated treatment for comorbid diagnoses simultaneously has been shown to be effective. Technology-based interventions (TBIs) have the potential to provide a cost-effective platform for, and greater accessibility to, integrated treatments. For the purposes of this review, we defined TBIs as interventions in which the primary targeted aim was delivered by automated computer, Internet, or mobile system with minimal to no live therapist involvement. A search of the literature identified nine distinct TBIs for SUDs and comorbid disorders. An examination of this limited research showed promise, particularly for TBIs that address problematic alcohol use, depression, or anxiety. Additional randomized, controlled trials of TBIs for comorbid SUDs and for anxiety and depression are needed, as is future research developing TBIs that address SUDs and comorbid eating disorders and psychotic disorders. Ways of leveraging the full capabilities of what technology can offer should also be further explored.

Source: Technology-Based Interventions for Substance Use and Comorbid Disorders: An Examination of the Emerging Literature – PubMed (nih.gov) May/June 2017

From a Colorado Springs Gazette Opinion

Last week marked the fifth anniversary of Colorado’s decision to sanction the world’s first anything-goes commercial pot trade.

Five years later, we remain an embarrassing cautionary tale.

Visitors to Colorado remark about a new agricultural smell, the wafting odor of pot as they drive near warehouse grow operations along Denver freeways. Residential neighborhoods throughout Colorado Springs reek of marijuana, as producers fill rental homes with plants.

Five years of retail pot coincide with five years of a homelessness growth rate that ranks among the highest rates in the country. Directors of homeless shelters, and people who live on the streets, tell us homeless substance abusers migrate here for easy access to pot.

Five years of Big Marijuana ushered in a doubling in the number of drivers involved in fatal crashes who tested positive for marijuana, based on research by the pro-legalization Denver Post.

Five years of commercial pot have been five years of more marijuana in schools than teachers and administrators ever feared.

“An investigation by Education News Colorado, Solutions and the I-News Network shows drug violations reported by Colorado’s K-12 schools have increased 45 percent in the past four years, even as the combined number of all other violations has fallen,” explains an expose on escalating pot use in schools by Rocky Mountain PBS in late 2016.

The investigation found an increase in high school drug violations of 71 percent since legalization. School suspensions for drugs increased 45 percent.

The National Survey on Drug Use and Health found Colorado ranks first in the country for marijuana use among teens, scoring well above the national average.

The only good news to celebrate on this anniversary is the dawn of another organization to push back against Big Marijuana’s threat to kids, teens and young adults.

The Marijuana Accountability Coalition formed Nov. 6 in Denver and will establish satellites throughout the state. It resulted from discussions among recovery professionals, parents, physicians and others concerned with the long-term effects of a commercial industry profiteering off of substance abuse.

“It’s one thing to decriminalize marijuana, it’s an entirely different thing to legalize an industry that has commercialized a drug that is devastating our kids and devastating whole communities,” said coalition founder Justin Luke Riley. “Coloradans need to know, other states need to know, that Colorado is suffering from massive normalization and commercialization of this drug which has resulted in Colorado being the number one state for youth drug use in the country. Kids are being expelled at higher rates, and more road deaths tied to pot have resulted since legalization.”

Commercial pot’s five-year anniversary is an odious occasion for those who want safer streets, healthier kids and less suffering associated with substance abuse. Experts say the worst effects of widespread pot use will culminate over decades. If so, we can only imagine the somber nature of Big Marijuana’s 25th birthday.

Source: Five Years Later, Colorado Sees Toll of Pot Legalization (illinoisfamily.org) February 2017

  • A handful of recent studies are beginning to reveal the possible health effects of e-cigarette use, and they are not all positive.
  • These findings and a reported uptick in teen vaping have spurred government regulators to act.
  • Researchers have found evidence of toxic metals like lead in e-cig vapor. Evidence also suggests that vaping may be linked to an increased risk of heart attacks.
  • Regulators and health experts are particularly concerned about a device called the Juul, which packs the same nicotine content per pod as a pack of cigarettes.

 

Smoking kills. No other habit has been so strongly tied to death.

In addition to inhaling burned tobacco and tar, smokers breathe in toxic metals like cadmium and beryllium, as well as metallic elements like nickel and chromium — all of which accumulate naturally in the leaves of the tobacco plant.

It’s no surprise, then, that much of the available evidence suggests that vaping, which involves puffing on vaporized liquid nicotine instead of inhaling burned tobacco, is at least somewhat healthier. Some limited studies have suggested that reaching for a vape pen instead of a conventional cigarette may also help people quit smoking regular cigarettes, but hard evidence of that remains elusive.

Very few studies, however, look at how vaping affects the body and brain. Even fewer specifically examine the Juul, a popular device that packs as much nicotine in each of its pods as a standard pack of cigarettes.

But a handful of studies published in the past few months have begun to illuminate some of the potential health effects tied to vaping. They are troubling.

With that in mind, the Food and Drug Administration outlined a new policy on Thursday morning designed to eventually curb the sale of e-cigs and reign in their appeal to young people.

Most recently, researchers at the Stanford University School of Medicine surveyed young people who vaped and found that those who said they used Juuls vaped more frequently than those who used other brands. The participants appeared to be insufficiently aware of how addictive the devices could be.

Most e-cigs contain toxic metals, and using them may increase the risk of a heart attack

Researchers took a look at the compounds in several popular brands of e-cigs (not the Juul) this spring and found some of the same toxic metals (such as lead) inside the device that they would normally find in conventional cigarettes. For another study published around the same time, researchers concluded that at least some of those toxins appeared to be making their way through vapers’ bodies, as evidenced by a urine analysis they ran on nearly 100 study participants.

In another study published this summer, scientists concluded that there was substantial evidence tying daily e-cig use to an increased risk of heart attack. And this week, a small study in rats suggested that vaping could have a negative effect on wound healing that’s similar to the effect of regular cigarettes.

In addition to these findings, of course, is a well-established body of evidence about the harms of nicotine. The highly addictive substance can have dramatic impacts on the deve