The Pot President

Hendrik Hertzberg on the hypocrisy of the hip.

In a blog post at the New Yorker last week, Hendrik Hertzberg spotlighted a recent joke made by the President of the United States at the White House Correspondents dinner. In reference to the rapidly changing media landscape, Obama said: “You can’t keep up with it. I mean, I remember when BuzzFeed was just something I did in college around two A.M. (Laughter.) It’s true! (Laughter.)”

The days of expressing a cringing contrition for your “youthful experimentation,” or claiming that you didn’t inhale, or clearly over.

But of course, the president’s joke wasn’t really that funny. Hertzberg cites statistics from Ethan Nadelmann of the Drug Policy Alliance, suggesting that “from fifty to a hundred thousand Americans are behind bars for pot, and only pot, on any given night.” The Office of National Drug Control Policy (ONDCP) disputes those figures, but the point is not so much whose numbers are closer to the truth, but rather the simple fact that while the president made his joke, too many people are locked up in federal and state prisons for an offense that a growing number of states are backing away from enforcing.

As Hertzberg put it, the subtext of the president’s pot joke was that it “allowed the tuxedoed, evening-gowned, middle-aged audience at the Washington Hilton to feel, for a precious moment, hip. The subtext was that smoking pot, whether a lot or a little, is just a normal part of growing up…. Nor has it done much to blight the lives of the other people in the Hilton ballroom, most of whom, like the rest of the media, political, and Hollywood elites, have smoked pot, too.”

Obama, they say, was a champ stoner in school. He was, writes David Maraniss in his biography of Obama, skilled at “interceptions”—sneaking an extra hit off the joint when it hadn’t gotten all the way around yet.  Obama, writes Hertzberg, really ought to feel “a smidgen of shame that the government he heads treats people who do exactly what he used to do, and now casually jokes about, as criminals.”

We haven’t heard much lately about the Boomer hypocrisy inherent in such roomfuls of high achievers who used to get high. (Some of them still do.) Jobs and reputations and bank loans are not endangered by these sly references and knowing winks. What hurts jobs and reputations is a stretch in federal prison—the unwilling route taken by many less fortunate Americans.

Hertzberg is wrong when he says that “marijuana-associated suffering enters the picture only when prohibition does.” Like most pro-legalization commentators, he does not mention addiction liability, or lasting cognitive effects on younger smokers.  But it is true that a disproportionate amount of suffering is caused by marijuana prohibition laws. The farthest corners of the debate are staked out, but decriminalization—the missing middle ground—still offers society a more balanced starting point than full-tilt legalization. Merriam-Webster says that to decriminalize is “to repeal a strict ban on, while keeping under some form of regulation.” State policy makers, although they don’t use the term very often, are pursuing what amounts to decriminalization. Nobody other than world-peace-through-weed zealots is arguing for a repeat of the track record with cigarettes (a drug in the process of being re-criminalized). And the regulation of alcohol does not offer a compelling model for marijuana’s future as a semi-legal drug. Happily, marijuana is not nearly as dangerous as alcohol or nicotine, so that helps.

It might surprise some readers to know that a majority of the Dutch aren’t interested in legalizing marijuana. They are concerned about keeping it out of the hands of minors. They’re not very happy with the trend towards higher and higher levels of THC. This is expressed in the fact that marijuana is, and likely will remain, illegal in The Netherlands. The narrow coffee shop exception is misleading in this regard. It was not designed to make marijuana more acceptable, but to deal creatively with the problem of street sales. You almost never see a drug deal going down on the streets of Amsterdam. That’s because a) It’s stupid, you can just waltz into a coffee shop if you’re over 21. b) Dealers have a hard time beating coffee shop prices. c) Dutch police come down heavily on street dealers.  Why? See a) above. The Dutch are no freer to wander their canal-lined streets with a joint in hand than Americans are free to wander Capitol Mall Boulevard with an open bottle of Jack.

Now that’s decriminalization. And an unfair comparison, of course, since the Dutch nation is so much smaller and more homogenous than the U.S. But lately, the talk has been about states, not the country at large. And at the state level, some of the Dutch lessons may apply.

What should our president do about all of this? Hertzberg has three proposals:

—Tell the Justice Department to “end the absurd classification of marijuana as a supremely dangerous Schedule I drug, like heroin.” Alcohol, let us recall, does not have a drug classification because it is not a scheduled substance at all. This American ambivalence is reflected by the names of the country’s premier drug research groups, the National Institute on Drug Abuse (NIDA), and the Monty Pythonesque National Institute on Alcohol Abuse and Alcoholism (NIAAA).

—Promise to “avoid making life unnecessarily difficult” for the states that have made provisions for medical marijuana or legalization.

—Change the name of the Drug Czar’s Office of National Drug Control Policy to something like the “Office of National Harm Reduction Drug Policy.”

Adopting any or all of these changes would be a useful step toward a decriminalized future for marijuana. Here’s the essential point: We have to make a space for marijuana use in American culture. I mean above the ground, and unassociated with jail time. While still murky from a medical point of view, there is just no doubting that millions of Americans prefer pot to alcohol as a recreational drug. Given alcohol’s role in the American death toll, and the lack of any such grim trail of the dead in marijuana’s case, there’s no shame in that decision, from my point of view.

Graphics Credit: http://www.anonymousartofrevolution.com/

Drug Czar Kerlikowske Interviewed in Foreign Policy Magazine

Drug War goes international in a big way.

Gil Kerlikowske, Director of the Office of National Drug Control Policy--a.k.a. the Drug Czar--finds himself in a curious position. Kerlikowske can be forgiven for feeling a little like J. Edgar Hoover, when the FBI director found that domestic security at home seemed to require some rather active investigations into Cubans and other Communists abroad. Kerlikowske is now riding a horse he never had much say in buying. The U.S. is in the midst of launching a new international drug strategy consisting of “interlocking plans” in Central and South America aimed at “transnational criminal groups.”

AFP reporter Jordi Zamora wrote that “the strategy will merge a handful of existing programs, including Plan Colombia, which has received more than $6 billion in U.S. aid since it was launched in 2000, and the Merida Initiative for Mexico, for which Congress has appropriated $1.5 billion since 2008.” Kerlikowske said that the global nature of the drug threat “requires a strategic response that is also global in scope.” With various crackdowns and battles over smuggling routes, the drug trade in the region has led to thousands of deaths, and has created “complex and evolving threats” from crime syndicates,” according to Assistant Secretary of State William Brownfield.  However, “progress in Central America will only push drug traffickers elsewhere if we do not support strong institutions throughout the hemisphere,” he said.  It seems like the Office of National Drug Control Policy continues to be internationalist in scope.

With all that as background, Foreign Policy magazine spoke with Kerlikowske in search of more detail, and got some--including a strange paean to America’s ability to produce and distribute its own illegal drugs, with no help from Mexico, thank you very much. Kerlikowske seems almost to be bragging. And if he’s right, what are all those border killings about, anyway?

FP: What's your big-picture sense of the drug situation in Latin America?

GK: It used to be fairly easy to categorize countries as production countries, transit countries, or consumer countries. I think those lines have been--if not completely obliterated--generally blurred. The amount of drug use in Mexico is significant. It's also clear from my most recent trip to visit drug treatment centers in Colombia that they're concerned as well. 

FP: U.S. Ambassador Carlos Pascual was forced to leave his position in Mexico two weeks ago because of comments he made in WikiLeaks cables about the perception that the drug war in Mexico is failing and about pervasive corruption in Mexican law enforcement. Are those concerns you share?

GK: As a police officer, I can say that cynicism just comes with the territory, and it's pretty easy to adapt that kind of attitude to Mexico. I'm not overly optimistic, but I think there has been some progress and we have an administration that's courageously taking on these criminal organizations, who are now involved in so many other kinds of crimes.

FP: It does seem that there have been a number of recent scandals involving U.S.-Mexico drug partnership: the Pascual resignation, the reports of the ATF allowing cross-border gunrunning, the controversial use of drones over Mexican territory. Has that relationship become more difficult lately?

GK: In my two years of dealing with this on a closer level, I'd say these last two months are more strained than during the rest of the time I've been here, but I don't see it as a significant bump in the road or a glitch that's going to stop things.

FP: What do you say to those in Latin America who say that it’s useless to crack down on the drug trade as long as the demand persists from the United States?

GK: For one thing, we've become much better at producing drugs in the United States: hydroponic marijuana with a very high THC content -- public lands produce a lot of marijuana. And we don't get any prescription drugs smuggled in to any great extent--which, right now, are our No. 1 growing drug problem in the United States, and also methamphetamine. We're getting much better at making our own, albeit in small amounts.

FP: How do you respond to the growing number of former Latin American leaders--former Mexican President Vicente Fox, most recently--who have come out in favor of legalization or at least a radical overhaul of the current policy?

GK: Isn't it funny how people who no longer have responsibility for anyone's safety or security suddenly see the light? I think it's not a lot different from what we've heard in recent years in the United States, which is: We've had a war on drugs for 40 years and we don't see success. If we have a kid in high school, they can still get drugs or there's drugs on the street corner. So legalization must be an answer…. Heaven knows, we're not very successful with alcohol. We don't collect much in tax money to cover the costs. We certainly can't keep it out of the hands of teenagers or people who get behind the wheel. Why in heaven’s name do we think that if we legalize marijuana, we'd have a system where we could collect enough tax revenue to cover the increased health-care costs? I haven't seen that grand plan. “

Photo Credit: www.fs.fed.us

Deputy Drug Czar Goes His Own Way

Doctors are part of the problem, says McLellan.

In a March 15 cover story titled “The American Way,” Drink and Drugs News  of the UK ran an insightful interview with America’s “deputy” Drug Czar, Thomas McLellan. Professor McLellan, deputy director of the Office of National Drug Control Policy, is not a cop, like his boss Gil Kerlikowske, or a retired Army general, like former Drug Czar Barry McCaffrey. McLellan is a rare breed, a treatment specialist, and brings an entirely different viewpoint to an office that has traditionally been strongly oriented toward law enforcement.

“In the US we’ve been thinking about addiction as just a lot of drug use,” McLellan told a group of addiction specialists and policy professionals at the Institute of Psychiatry in London. “And as a result we’ve been purchasing [treatment] stupidly. We can’t decide if addiction is a crime or a disease so we’ve compromised and given them treatments that aren’t any good.”

McLellan singled out doctors for special attention: “Most physicians are not trained in how to treat substance abuse. They don’t see it as a disease and don’t see why they should look for it.”

Treating addiction like any other medical condition is still a goal rather than a reality. “You may know that the relapse rates for diabetes, hypertension and asthma are almost identical to the relapse rates for any addictive disorder…. And no one puts their hands on their hips when a diabetic comes back and says, ‘I ate half a bucket of fried chicken and I forgot to take my insulin, and now I’m back here.’ They just treat them.”

If there are doctors who don’t believe in the disease model of addiction, we can’t be surprised if members of the general public—and addicts themselves--often feel the same way.  McLellan said that less than 3 % of all referrals for addiction treatment and specialty care originate with doctors. Moreover, roughly half of 12,000 smaller treatment programs in the U.S. have no doctor, nurse, or psychologist on staff. And counselors, who make up the majority of treatment staff, suffer from a 50 % turnover rate.

In addition, McLellan took on the traditional British aversion to methadone treatment for heroin addicts: “That this has been a battle, that you are either on methadone or you are on the path of truth, beauty and light, is artificial and unfortunate…. I’m now officially wagging my finger and saying not just to Britain, but to the whole damn field; get past this, this is an artificial contrivance. People ought to have the opportunity to get the medications and other services they need.”

McLellan also had choice words for politicians and policy makers who see incarceration as the only acceptable response to drugs and drug-related crime.  He referenced studies that “suggest very clearly that in a prison situation, when you release somebody with a drug problem, they are back and you’re going to do it all over again. It’s a bad business deal.”

Ongoing care—after prison, or after treatment—is essential to success. “I think residential care is important and necessary, but not sufficient,” McLellan maintained. “It is like having a very good junior high school education.”

Photo Credit: http://www.csam-asam.org/

McCain on Drugs

Full speed ahead on the Drug War.

One issue largely missing in action during the presidential campaign has been the Drug War, and all the policy implications for addiction treatment that go with it. Our thanks go out to OnTheIssues blog for compiling the admittedly skimpy record of public statements about drug policy by both candidates. In this post, we examine the on-the-record views of Republican candidate John McCain.

In his long career in the U.S. Senate, John McCain’s support for the Drug War has never wavered. Campaigning for president in 2000, McCain’s positions were the most hawkish of the four major candidates, the Boston Globe reported. “He wants to increase penalties for selling drugs, supports the death penalty for drug kingpins, favors tightening security to stop the flow of drugs into the country, and wants to restrict availability of methadone for heroin addicts.”

This latter position was embodied in the “Addiction Free Treatment Act” that McCain introduced in the Senate in 1999, which called for defunding any drug program that used methadone, unless the program followed a restrictive set of guidelines.

McCain has criticized the former Clinton administration for going “AWOL on the war on drugs,” and has pushed tirelessly for greater military assistance to drug-exporting nations like Columbia.

In more recent activity, Senator McCain sponsored a a 2005 bill, “The Clean Sports Act,” mandating drug testing in all major professional sports leagues. And in 2006, McCain signed on to the “Safe Streets Act Amendment,” which called for federal grants to Indian tribes to fight methamphetamine addiction.

This year, “McCain met with Mexican President Felipe Calderon to discuss immigration, trade and the recently passed Merida Initiative, a $400 million U.S. aid package to help Mexico fight an increasingly bloody drug war that has claimed more than 1,800 lives this year.”

“Drugs is a big, big problem in America,” McCain said in a fact-finding trip to Columbia in July. “The continued flow of drugs from Colombia through Mexico into the United States is still one of our major challenges for all Americans.”

McCain’s response last year to a New Hampshire police officer’s question about the failure of the Drug War does not bode well for the prospects of responsible changes in drug awareness and addiction treatment in a McCain administration: “Look, I've heard the comparison between drugs and alcohol. I think most experts would say that in moderation, one or two drinks of alcohol does not have an effect on one's judgment, mental acuity, or their physical abilities. I think most experts would say that the first ingestion of drugs leads to mind-altering and other experiences, other effects, and can lead over time to serious, serious problems."

A search of the McCain-Palin campaign website for the term “drug war” came up empty.

Paul Wellstone’s legacy

House passes Mental Health and Addiction Equity Act.

I live in Minnesota, so it is with great pride that I report that the U.S. House of Representatives recently passed mental health and addiction legislation named after the late U.S. Sen. Paul Wellstone of Minnesota, involving issues that were very close to his heart.

Wellstone, who died in a plane crash in northern Minnesota in 2002, was a two-term Democratic Senator who championed the cause of full medical insurance for the coverage of addiction treatment and mental illness. The Paul Wellstone Mental Health and Addiction Equity Act of 2007, sponsored by Rep. Patrick Kennedy of Rhode Island, passed the U.S. House on a vote of 268-148. The legislation will now be the subject of negotiations with the U.S. Senate, which earlier passed a similar but less stringent bill, sponsored by Rep. Patrick Kennedy’s father, Sen. Ted Kennedy.

Rep. Jim Ramstad of Minnesota, one of the bill’s key backers, and a recovering alcoholic, told Kevin Diaz of the Minneapolis Star Tribune: “This is not just another policy issue. It’s a matter of life and death for millions of Americans.”

The bill would require insurers to cover mental illness and addiction using the same guidelines as any other physical disease or ailment. Health insurance industry spokespeople said the bill goes too far, and would drive up health insurance premiums by mandating additional expensive treatments. The Senate version does not mandate mental health coverage, and offers exemptions for smaller group health plans.

But advocates of the Wellstone Act say that the provisions in the bill are long overdue. “We’re no longer going to allow people to languish in the shadows,” said Rep. Kennedy.

The House and Senate will also have to grapple with how the new bill will effect existing state legislation. According to Victoria Colliver in the San Francisco Chronicle, more than 25 states already have laws on the books mandating mental health coverage. Said California State Assemblyman Jim Beall Jr., who supports the Wellstone Bill: “If you don’t cover moderate mental problems or substance abuse, which often go together… you would not treat the person until their problems become acute—that’s not good health care.”

Heroin Overdose Kits: The Debate Goes On

More states back naloxone programs, but Feds aren’t convinced.

Since the first trial run in Chicago several years ago, efforts to provide heroin addicts with naloxone overdose kits has gained ground in Baltimore, New York, Boston, and several other cities and states. As reported here at Addiction Inbox last month, Dr. Peter Moyer, medical director of Boston’s fire, police and emergency services, applauded the recent Massachusetts decision to expand the Boston program to the entire state and offer Massachusetts heroin addicts the overdose reversal kit. Approved by the Food and Drug Administration (FDA) 35 years ago, Naloxone, or Narcan, is the standard emergency room treatment for heroin overdose. Naloxone instantly reverses life-threatening overdoses by crowding out heroin molecules at the brain receptor sites where they bind.

Predictably, the Office of National Drug Control Policy in the White House does not support the Massachusetts program. Drug Policy officials do not like the idea of addicts medically treating other addicts and have argued repeatedly against distribution of the naloxone kits, claiming that distributing the Narcan antidote will only encourage heroin use and delay treatment.

But the move among states and cities for direct naloxone distribution to addicts continues to gain momentum. In Baltimore, assistant commissioner of health Richard W. Matens maintains that the direct-to-addicts model had been “extremely successful” in his city. Death by heroin overdose reached its lowest level in a decade in 2005, and Matens says the naloxone distribution program played an important role in that reduction.

At the New York State Health Department, which oversees 20 naloxone distribution programs in New York City, Dan O’Connell told the New York Times (reg. required) that from a public health perspective, heroin overdose kits were “a no-brainer.” O’Connell, director of the department’s H.I.V. prevention division, said: “For someone who is experiencing an overdose, naloxone can be the difference between life and death.”

Wisconsin, Minnesota, Connecticut, New Mexico, Rhode Island, and several other states are also embarking on naloxone distribution programs. Thousands of lives are likely to be saved if the idea continues to gain ground.

So what could be the worm in the apple?

“It is not based on good scientific data,” contends Dr. Bertha Madras, deputy director with the White House Office of National Drug Control Policy, which continues its steadfast opposition to such programs. “It’s based on what some people would consider the right thing to do. But the studies supporting it are so sparse it’s painful.” As evidence, Madras and other federal substance abuse officials point to a survey of San Francisco drug addicts done in 2003, the year San Francisco first began funding naloxone distribution. About one-third of the addicts in the survey said they might use more heroin if they had naloxone to protect against overdose. “In the absence of scientific evidence,” Madras told the Times, “we don’t engage in policies that would bring more harm than benefit.”

However, a more recent survey of San Francisco addicts casts major doubt on those findings. In 2005, when the city began a trial program giving out two free needles loaded with naloxone, local officials claimed that fatal overdoses began to fall markedly, and city officials were soon claiming that heroin overdose deaths were at their lowest mark in ten years. California programs train addicts in the use and administration of naloxone. “I’m glad they’re showing us this stuff,” one addict said. “I don’t want to just sit there if someone ends up in a bad situation.”

According to figures reported by the Harm Reduction Coalition, 3,691 California drug users died of overdose in 2003, the latest year of official records. This represents an increase of 42 per cent since 1998, resulting in an annual death rate greater than that from firearms, homicides, and A.I.D.S.

But so far, states are on their own, as Federal drug policy officials continue to maintain that naloxone should only be prescribed and administered by doctors. And yet, many doctors refuse to treat heroin addicts, on the grounds that there is nothing that can be done for them, or that they are recalcitrant patients.

Dan Bigg, director of the Chicago Recovery Alliance, told the New York Times he has seen firsthand that such overdose kits are effective. “What we have here is an antidote to the problem [of heroin overdose],” Bigg said. “Now we just have to convince people it’s worth it.”