Why the CDC Director Hates E-Cigarettes

The pros and cons of getting your vape on.

Last month, the Food and Drug Administration (FDA) began a new era—regulating e-cigarettes. With a non-controversial first step, the FDA banned the sale of e-cigarettes to minors, required health warnings, prohibited health claims, and outlined a plan to register and license all electronic nicotine products at some future date. The FDA’s proposed rules would also give the agency the power to regulate the currently unregulated mixture of chemicals and flavorings that are heated during e-cigarette use.  Whatever regulations the FDA promulgates for electronic cigarettes will also apply to nicotine gels, water pipe tobacco, and hookahs.

Perhaps what rankles e-cigarette activists the most is the FDA’s insistence that companies will have to provide scientific evidence before making any implied claims about risk reduction for their product, compared with cigarettes. The FDA did not restrict advertising or prohibit flavorings (bubble gum, apple-blueberry, gummi bear, and cappuccino are popular).

Within a few days after the FDA’s announcement, Chicago, New York City, and other major cities placed e-cigarettes under the same municipal smoking bans as cigarettes. 

The battle over e-cigarettes is both a public health issue and a private enterprise war for market share. Corporate giants Altria and Lorillard, which dominate the corporate tobacco landscape in the U.S., are fighting for a piece of what has become nearly a $2 billion market in a few short years. (Altria recently boosted  its growth forecast to 6-9% growth for 2014). Lorillard has been making heavy acquisitions of its own, and commands more than half the present market with its Blu brand. Altria has made its own vapor acquisitions, and is launching its own brand, MarkTen.

So far, the moves being contemplated by the FDA do not have these companies shaking in their boots. They anticipated the ban on sales to minors, a system of formal FDA approval, a disclosure of ingredients, and health warnings about the addictive nature of nicotine. And Congress gave the FDA legal authority to draft a set of rules for e-cigarettes five years ago, so the FDA’s reluctance to step in on liquid nicotine delivery systems has been evident.

In an interview with the Los Angeles Times, Tom Frieden, director of the Center for Disease Control and Prevention (CDC), listed the reasons for his opposition to electronic cigarettes:

—E-cigarettes are an additional means of hooking another generation of kids on nicotine, making them more likely to become adult smokers.

—Smokers who might have quit smoking will maintain their nicotine addiction, remaining highly vulnerable to tobacco craving.

—Ex-smokers might make themselves more vulnerable to relapse if they take up vaping.

—Smokers might forego medications that could help them quit, in favor of the unproven promise of tobacco abstention via e-cigarette.

—E-cigarettes might have the cultural effect of “re-glamorizing” smoking.

—E-cigarette users might be exposing children and pregnant women to nicotine via secondhand smoke mechanisms.

—E-cigarette users can refill cartridges with liquid cannabis products and other drugs.

Dr. Michael Siegel, a tobacco expert at the Boston University School of Public Health, worries that smaller players will be squeezed out due to costs associated with the FDA approval process, driving sales toward the traditional cigarette industry leaders. Go-go analysts have predicted market penetration of as much as 50% for e-cigarettes, but Siegel is more pessimistic, and believes the e-cigarette share could top out at 10% if FDA regulations set back efforts by vaping proponents to position their product as a safer and healthier alternative to tobacco cigarettes. And that, says Siegel, would be a shame. He told the Boston Globe: “There simply is no product on the market that’s more dangerous than tobacco cigarettes, and nobody in their right mind would argue that cigarette smoking is less hazardous or even equally hazardous to vaping.”

Frieden at the CDC is sympathetic to the fact that many smokers have indeed quit smoking tobacco with the aid of e-cigarettes. “Stick to stick, they’re almost certainly less toxic than cigarettes.” But like many tobacco experts, he sees the possibility of a new generation of nicotine addicts. Almost two million high school kids have tried e-cigarettes, Frieden told the LA Times, “and a lot of them are using them regularly…. That’s like watching someone harm hundreds of thousands of children.”  The CDC reported that the percentage of high school students who have used an e-cigarette jumped from 4.7% in 2011 to 10% in 2012. Calls to poison control centers involving children and e-cigarettes have increased sharply as well.

Frieden views the Food and Drug Administration as David under siege by Goliath. The FDA, he said, “tried to regulate e-cigarettes earlier, and they lost to the tobacco industry…. So the FDA has to balance moving quickly with moving in a way that’s going to be able to survive the tobacco industry’s highly paid legal challenge.” If E-cigarette makers really want to market to people trying to quit smoking, Frieden told the LA Times, “then do the clinical trials and apply to the FDA. But they don’t want to do that.” (See my post on Big Tobacco’s move into the e-cigarette market).

“It’s really the wild, wild West out there,” a beleaguered FDA commissioner Margaret Hamburg told the press.   “They’re coming in different sizes, shapes and flavors in terms of the nicotine in them.”

On May 4, the New York Times published a report by Matt Richtel, based on an upcoming paper in the journal Nicotine and Tobacco Research. Nicotine researchers discovered that high-end electronic cigarette systems with refillable tanks produce formaldehyde, a known carcinogen, as a component of the exhaled nicotine vapor. Moreover, unlike disposable e-cigarettes, tank systems require users to refill them with liquid nicotine, itself a potent toxin. “Nicotine is a pesticide, fundamentally,” Michael Eriksen, dean of the School of Public Health at Georgia Statue University, told CNN. “We take so many precautions about pesticides for our lawns and how to wear gloves. But what precautions do consumers take when they put the nicotine vials in?”

This was not good news for harm reductionists, who view the advantages of e-cigarettes as self-evident. The New York Times report says that the toxin is formed “when liquid nicotine and other e-cigarette ingredients are subjected to high temperatures,” according to the research. “A second study that is being prepared for submission to the same journal points to similar findings.” In addition, a new study by researchers RTI International documents the release of tiny metal particles, including tin, chromium and nickel, which may worsen asthma and bronchitis.

Eric Moskowitz at the Boston Globe  reported that “thousands of gas stations and convenience stores statewide carry e-cigarettes, usually stocking disposable or cartridge-based versions that resemble traditional cigarettes.”

In U.S. News, Gregory Conley, president of the trade group American Vaping Association, predicted “a huge influx of anti-e-cigarette legislation in the last half of 2014 and especially in 2015 when the legislative sessions get going again.” 

According to Carl Tobias, a law professor at the University of Richmond, “it may be years before  regulations are imposed. The lobbying at FDA and Congress will be intense.”

Effectively regulated, e-cigarettes have the potential to drastically reduce deaths from tobacco-related diseases among cigarette smokers. In an editorial for the journal Addiction, Sara Hitchman, Ann McNeill, and Leonie Brose of King’s College, London, wrote: “E-cigarettes may offer a way out of the smoking epidemic or a way of perpetuating it; robustly designed, implemented and accurately reported scientific evidence will be the best tool we have to help us predict and shape which of these realities transpires.”

Photo credit: http://ecigarettereviewed.com

Will Power and Its Limits

How to strengthen your self-control.

Reason in man obscured, or not obeyed,
Immediately inordinate desires,
And upstart passions, catch the government
From reason; and to servitude reduce
Man, till then free.
—John Milton, Paradise Lost

What is will power? Is it the same as delayed gratification? Why is will power “far from bulletproof,” as researchers put it in a recent article for Neuron? Why is willpower “less successful during ‘hot’ emotional states”? And why do people “ration their access to ‘vices’ like cigarettes and junk foods by purchasing them in smaller quantities,” despite the fact that it’s cheaper to buy in bulk?

 Everyone, from children to grandparents, can be lured by the pull of immediate gratification, at the expense of large—but delayed—rewards. By means of a process known as temporal discounting, the subjective value of a reward declines as the delay to its receipt increases. Rational Man, Economic Man, shouldn’t behave in a manner clearly contrary to his or her own best interest. However, as Crockett et. al. point out in a recent paper in Neuron “struggles with self-control pervade daily life and characterize an array of dysfunctional behaviors, including addiction, overeating, overspending, and procrastination.”

Previous research has focused primarily on “the effortful inhibition of impulses” known as will power. Crockett and coworkers wanted to investigate another means by which people resist temptations. This alternative self-control strategy is called precommitment, “in which people anticipate self-control failures and prospectively restrict their access to temptations.” Good examples of this approach include avoiding the purchase of unhealthy foods so that they don’t constitute a short-term temptation at home, and putting money in financial accounts featuring steep penalties for early withdrawal. These strategies are commonplace, and that’s because people generally understand that will power is far from foolproof against short-term temptation. People adopt strategies, like precommitment, precisely because they are anticipating the possibility of a failure of self-control. We talk a good game about will power and self-control in addiction treatment, but the truth is, nobody really trusts it—and for good reason.  The person who still trusts will power has not been sufficiently tempted.

The researchers were looking for the neural mechanisms that underlie precommitment, so that they could compare them with brain scans of people exercising simple self-control in the face of short-term temptation.

After behavioral and fMRI testing, the investigators used preselected erotic imagery rated by subjects as either less desirable ( smaller-sooner reward, or SS), or more highly desirable ( larger-later reward, or LL). The protocol is complicated, and the analysis of brain scans is inherently controversial. But previous studies have shown heightened activity in three brain areas when subjects are engaged in “effortful inhibition of impulses.” These are the dorsolateral prefrontal cortex (DLPFC), the inferior frontal gyrus (IFG), and the posterior parietal cortex (PPC). But when presented with opportunities to precommit by making a binding choice that eliminated short-term temptation, activity increased in a brain region known as the lateral frontopolar cortex (LFPC).  Study participants who scored high on impulsivity tests were inclined to precommit to the binding choice.

In that sense, impulsivity can be defined as the abrupt breakdown of will power. Activity in the LFPC has been associated with value-based decision-making and counterfactual thinking. LFPC activity barely rose above zero when subjects actively resisted a short-term temptation using will power.  Subjects who chose the option to precommit, who were sensitive to the opportunity to make binding choices about the picture they most wanted to see, showed significant activity in the LFPC. “Participants were less likely to receive large delayed reward when they had to actively resist smaller-sooner reward, compared to when they could precommit to choosing the larger reward before being exposed to temptation.”

Here is how it looks to Molly Crockett and her fellow authors of the Neuron article:

Precommitment is adaptive when willpower failures are expected…. One computationally plausible neural mechanism is a hierarchical model of self-control in which an anatomically distinct network monitors the integrity of will-power processes and implements precommitment decisions by controlling activity in those same regions. The lateral frontopolar cortex (LFPC) is a strong candidate for serving this role.

None of the three brain regions implicated in the act of will power were active when opportunities to precommit were presented.  Precommitment, the authors conclude, “may involve recognizing, based on past experience, that future self-control failures are likely if temptations are present. Previous studies of the LFPC suggest that this region specifically plays a role in comparing alternative courses of action with potentially different expected values.” Precommitment, then, may arise as an alternative strategy; a byproduct of learning and memory related to experiences “about one’s own self-control abilities.”

There are plenty of caveats for this study: A small number of participants, the use of pictorial temptations, and the short time span for precommitment decisions, compared to real-world scenarios where delays to greater rewards can take weeks or months. But clearly something in us often knows that, in the immortal words of Carrie Fisher, “instant gratification takes too long.” For this unlucky subset, precommitment may be a vitally important cognitive strategy. “Humans may be woefully vulnerable to self-control failures,” the authors conclude, “but thankfully, we are sometimes sufficiently far-sighted to circumvent our inevitable shortcomings.” We learn—some of us—not to put ourselves in the path of temptation so readily.

Crockett M., Braams B., Clark L., Tobler P., Robbins T. & Kalenscher T. (2013). Restricting Temptations: Neural Mechanisms of Precommitment, Neuron, 79 (2) 391-401. DOI: 10.1016/j.neuron.2013.05.028

Photo Credit: http://tommyboland.com/2011/05/27/white-knuckle-living/

Harm Reduction Advocate Takes on the Abstinence Question

A guest editorial on “clean and sober” vs “drinking less.”

One of the most divisive issues in the harm reduction movement is the question of abstinence versus controlled drinking. This rift has come to symbolize differences over the AA philosophy, the disease model, the role of will power, and other issues related to addiction. Those who find the disease model unconvincing at best, and some sort of fraud at worst, are more likely to bristle at the notion that total abstinence is the only course available to the addict in treatment. But disease model proponents point out that, for most alcoholics, not drinking at all turns about to be easier than drinking a little. Still, for heavy drinkers who are not addicted to alcohol, cutting down often makes the most sense.

Kenneth Anderson of the harm reduction group HAMS has written an article on the abstinence question which is as straightforward and free of special pleading as any I’ve seen from the harm reduction movement. Bear in mind that I don’t agree with all of the opinions expressed in this guest post, and remain convinced that for most people who abuse alcohol regularly, sustained abstinence is the best policy. But I definitely believe it’s worth a read.


Drinking Again
By Kenneth Anderson

If you have successfully resolved your problems with alcohol via long term (6 months or more) abstinence from alcohol then HAMS urges you to use great caution before you consider drinking again. Studies (NIAAA 2009) show that about half of persons with Alcohol Dependence resolve the problem by quitting completely. HAMS is always supportive of total abstinence as a recovery goal; since the “A” in HAMS stands for Abstinence we like to say that “Quitting drinking is our middle name.” Harm reduction strategies are aimed at those who are unwilling, unable, or not yet ready to abstain from alcohol. This includes people who have attempted abstinence and ultimately not succeeded at it but instead have gone on major benders after short abstinence periods. It also includes those who have never attempted abstinence or who currently have no interest in abstinence. Increased trauma produces increased drinking (Denning & Little 2011). The more resources people have intact, the better their odds of achieving recovery–whether abstinent or non-abstinent recovery. Harm reduction helps keep people’s resources intact enabling them to recover more quickly and easily than if they lost all.

If you are succeeding at abstinence and your alcohol related problems have disappeared or are disappearing then we strongly urge you to continue with what you find to be working–i.e. abstinence. However, if you have already decided that you are going to dink again then HAMS is a safe place to experiment with controlled drinking and you will be far safer here than if you attempt this on your own with no support at all.

If you are wavering and have not yet decided whether or not you wish to drink again then we strongly suggest that you do a Cost Benefit Analysis (aka a Decisional Balance Sheet) which compares the pros and cons of continuing to abstain with the pros and cons of drinking again. We also suggest that you write out a list of alcohol related losses and problems and a list of what you have gained as a result of abstinence from alcohol.

Some people are more likely to succeed in drinking again than others:

People whose drug of choice was not alcohol. If you went to rehab for heroin or some other drug which was not alcohol you were probably told that you were cross addicted to all mood altering drugs and that you must never drink again or you would relapse. The simple fact is that this is not true. You may well have noticed your rehab counselors using mood altering drugs like caffeine and nicotine all the time and not calling this a relapse. The fact is that if you try to use alcohol as a direct substitute for heroin and get as drunk as possible all the time instead of shooting heroin then you will certainly have alcohol problems. However, if you get your life together and become a whole new person with a whole new life there is no chemical reason in your brain why you should not have an adult beverage at times. Opioids are directly cross-tolerant with each other; they are only slightly cross-tolerant with alcohol. Other drugs like speed are not cross tolerant with alcohol at all.

We do, however, very strongly recommend that if you are an ex drug user who is choosing to drink in moderation that you track your drinks by charting. Keeping a drinking chart will help you keep your drink numbers under control and let you know if you are starting to slip out of bounds. If you find your drinking is showing a tendency to “creep” up more and more you might wish to opt to return to abstinence from alcohol. We also strongly suggest that you do your experimenting within the safety net of a HAMS group and that you write out a Cost Benefit Analysis.

Another group who may tend to succeed with drinking again are those who were sowing a lot of wild oats in high school or college and wound up in rehab or an abstinence program in their teens or early twenties. If you are now in your forties you might have matured a great deal and no longer be interested in being the wild man. If you now find that moderate drinking is appealing to you but the thought of being a drunk teenager throwing up on your date’s shoes at a party is repulsive to you then you may well find success at becoming a moderate drinking. Again we suggest that you do your experimenting within the safety of a HAMS group and that you chart and do a Cost Benefit Analysis.

If you had a long drinking career and a long history of alcohol related problems then the odds of returning to controlled drinking are greatly reduced. The longer the drinking career and the more problems the lower the chances of successful controlled drinking.

If you think that you have a shot at becoming a successful controlled drinker, then write down what it is that has changed in your situation that you believe will make you a successful controlled drinker this time around. If nothing has changed then it may well be excruciatingly difficult to try to use the HAMS harm reduction and moderate drinking tools to become a controlled drinker. Not only may you find that your odds of success are low, but you may also find that staying within the moderate drinking limits you have set for yourself is a form of torture and that abstinence is far simpler and more pleasant.

HAMS harm reduction strategies are not a magic bullet which can turn everyone into a successful controlled drinker. For many, many people abstinence remains the best choice. Abstinence is simple and clear cut and avoids the problem of shades of gray

And whether you opt to continue to abstain or you choose to drink again, always remember that you and no one but you are responsible for your choices.


REFERENCES:

Denning P, Little J. (2011). Practicing Harm Reduction Psychotherapy, Second Edition: An Alternative Approach to Addictions. The Guilford Press.

NIAAA (2009). Alcoholism Isn’t What It Used To Be. NIAAA Spectrum. Vol 1, Number 1, p 1-3. (PDF)


Photo Credit: http://www.rehabinfo.net

An Insite-ful Decision

Canadian Supreme Court clears the way for Vancouver’s safe-injection facility.

Insite, the controversial supervised injection site for addicts in Vancouver, has won its case before the Supreme Court of Canada for a permanent exemption from the nation's drug laws. CBC News reports that, in a unanimous decision, “The court ordered the federal minister of health to grant an immediate exemption to allow Insite to operate.”

Written by chief justice Beverley McLachlin, the ruling said in part: "Insite saves lives. Its benefits have been proven. There has been no discernable negative impact on the public safety and health objectives of Canada during its eight years of operation." A member of Parliament told the CBD: "The Conservative government has been relentless in their opposition so today's decision by the court just feels like an incredible victory. It feels like a great day."

The Supreme Court of Canada was forced to determine the fate of Insite, where addicts use clean needles with a nurse on the premises, after numerous governmental attempts to shutter the facility led to lawsuits. Numerous studies have demonstrated the benefits of such programs, but Insite remains the only long-term injection facility in North America. The eight-year old clinic has increasingly won both professional and popular support as a workable method of harm reduction in high-risk drug areas. As the Vancouver Sun sensibly notes: “It is increasingly mainstream thinking in Canadian health care as reflected by other interveners in the Supreme Court case--Canadian Nurses Association, Association of Registered Nurses of British Columbia, Registered Nurses Association of Ontario, Canadian Medical Association, and Canadian Public Health Association.” You can’t get much more mainstream than that. 

As The Fix recently reported, Insite has reduced drug overdose deaths by 35% in its notorious Downtown Eastside headquarters in a neighborhood housing the highest population of needle addicts in Canada. A recent study found  that drug overdoses do occur at Insite—but among its recorded 2,000 ODs, there has not been a single fatality (doctors are on hand with a ready supply of the anti-OD drug Naloxone). Injection centers offer other public health benefits, including steering addicts into treatment and reducing hepatitis C and HIV infections. Opposition in the U.S. has centered on the notion that safe injection facilities will encourage the use of injectable narcotics by somehow sanctioning the activity.

The Globe and Mail editorialized that when the Supreme Court of Canada convened in May to take evidence on Vancouver’s supervised injection site, it heard “detailed arguments that hinge on the fine print of the Canadian Constitution. But besides being a landmark showdown between federal and provincial powers, the hearing also sets the stage for a ruling expected to affect not only the daily lives of injection drug users on Vancouver’s Downtown Eastside but drug policy across the country and potentially farther afield.”

This was a big one, a verdict much awaited, because it will be widely seen as playing a crucial role in determining whether facilities like Insite will be allowed to operate in North America. Technically, a court ruling against Insite would not have automatically put the operation out of business, but would have left it in the twilight zone of operating under a federal government exemption that could be pulled at any time—and the current Canadian government has broadly hinted that it would do so.

The Supreme Court victory means that Insite can operate without benefit of any kind of federal government legal exemption from drug laws, a situation that has always put Insite at the mercy of political posturing.

Photo Credit:
http://www.canada.com/story_print.html?id=af132f6b-2099-407d-af87-13c12016af5a&sponsor=

Today is Overdose Awareness Day

Annual global day of action coordinated by Red Cross.

According to the most recent figures from the Centers for Disease Control and Prevention (CDC),  more than 26,000 Americans die needlessly, pointlessly, from accidental drug overdoses.  For example, in San Francisco, there were more drug-related accidental deaths in 2007 than there were deaths by automobile crash. These days, oxycodone is  our leading killer, followed by cocaine and heroin.

The Harm Reduction Coalition notes the success of the DOPE project (Drug Overdose Prevention and Education) in San Francisco. DOPE is a community group composed of members trained to recognize and respond to drug overdoses. In San Francisco, one person dies every other day from a preventable drug overdose death.

"Overdose Awareness Day is a time for us to remember the thousands of lives lost to accidental drug overdose every year and to restate our commitment to effective strategies to reduce overdose deaths in our community," said DOPE Project Director Eliza Wheeler.  "This year, we would like to publically thank the courageous people who have successfully revived their friends, family members and partners using naloxone."

Over at Injecting Advice, they have gathered together twitter hashtag posts about Overdose Awareness Day:

“Today (31st August) is International Overdose Awareness day and all around the world there are services (and individuals) working hard to raise awareness of the main course of death for people who use drugs. As you'd expect a lot of these people are now using social media like twitter, so I've decided to collect together the mentions of the official 'hashtag' for overdose awareness day.”

In addition, www.injectingadvice.com offers a downloadable OD Awareness Workshop. 

No Urine Test for Addiction

Drug wars never work.

The recognition that drug wars create crime is long overdue. More than fifteen years ago, a study of the economics of street drug dealing by the Rand Corporation confirmed that most drug dealers make more money illegally than they could possibly make through any form of legitimate employment. That equation has not changed.  For minors, drug dealing is without a doubt the best-paying job available to them. 

The effort to combat drugs has poisoned our relationships with other countries. Farmers in Latin America, Southeast Asia, and Afghanistan are not the source of the drug problem. The danger of concentrating on the interdiction of foreign shipments is that it breeds the fantasy solution—a belief that the nation’s drug problem can be solved offshore, if the barriers and borders of the United States are vigorously defended.

Drug wars weaken the force of law at home. Minor drug laws are flouted with impunity, while basic civil rights are under attack in the name of national security. Drug wars ask a lot from citizens:  weakened rules of evidence, the erosion of the doctrine of probable cause, and an end to the presumption of innocence, for starters.

A different strategy would obviate the need for these enhanced powers of repression and control. Drug wars foster a form of social hypocrisy. Many of the country’s finest doctors, scientists, judges, and legislators have routinely used illegal drugs in their past. Yet their lives were not irreparably damaged, their futures thrown on the trash heap. Millions of productive citizens now in their 40s and 50s know that youthful drug use need not be permanently deleterious. They dare not speak up, of course. The people who have the most experience with these drugs have been systematically excluded from the public debate. The emerging models of addictive disease call into question almost every aspect of drug wars as they have been historically waged.

For many Americans, the use of alcohol, cocaine, or any other addictive drug is a matter of personal recreational choice. None of the strategies employed in the drug wars of the past four decades has been able to override the fact that prohibition can only be effective with the cooperation of the citizenry. Without voluntary compliance, the only recourse is federal coercion; some Orwellian nightmare of detection, control, forced detoxification, and detention.

Only a fraction of the nation’s corporations had drug-testing programs in place in 1990, but the number has climbed dramatically ever since. Inaccuracies and false positives have bedeviled drug-testing programs from the outset. Ibuprofen, available over the counter as Advil or Motrin, registers on some tests as positive for marijuana. Cold remedies such as Nyquil, Allerest, Contac, Dimetapp, and Triaminicin all contain a substance, phenylpropanolamine, which sometimes shows up as positive for amphetamine. The list of potential false positives is a long one.

Many drug testing programs do not test for alcohol, and even if such constitutionally dubious testing programs were unerringly accurate in what they do test for, there would still be valid reasons not to adopt them. Few people would insist that the presence of alcohol metabolites in the bloodstream is incontrovertible proof of incompetence on the job. But we frequently make this assumption in the case of illegal drugs, in part because the drug tests themselves are not refined enough to reliably distinguish between casual use and consistent abuse. There is no urine test for addiction. 

Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction by Dirk Hanson © 2008.

Drug Abuse Coverage Leaves Out the Science

How the media covers harm reduction.

Lewis Mehl-Madrona, a graduate of the Stanford University School of Medicine, recently wrote a piece for Futurehealth.org that zeroes in on a series of highly pertinent questions about the manner is which the America media tends to cover drug policy stories. Questions like: Why is the existence of credible scientific research rarely mentioned when drug controversies are in the headlines? Why does science not matter when it comes to the coverage of drug policy issues?

Mehl-Madrona cites the example of U.S. television coverage of Vancouver’s Insite project in Canada, which provides addicts with clean needles and a supervised injection room. Such “consumption rooms” are also available in Europe, and are being tried sporadically in the U.S. (See my earlier post on drug injection sites) Here is his reaction:

“The American TV was awash with criticisms of this policy, the primary one being that it promoted drug abuse and caused people to abuse drugs even more than they otherwise would. What amazed me was the complete lack of attention to data in the American media. Substantial research has been conducted on Insite and on harm reduction models. It is known that programs like Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.”

One of the primary concerns raised by the media was whether the Insite facility would encourage addiction by making injections safer and easier. Yet a reliable study in the British Medical Journal showed no substantial increase in relapse or decrease in quit rates among a group of Insite users.

Another concern was that the Insite facility would discourage drug addicts from seeking treatment. However, a study published in the New England Journal of Medicine in 2006, involving more than 1,000 users of the facility, found that “individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently,” according to Mehl-Madrona.

Moreover, the study confirmed that onsite addiction counselors were successfully increasing the number of addicts who signed up for detox. Rather than discouraging addicts from seeking treatment, the study confirmed that Insite was “facilitating entry into detoxification services among its clients.”

“I don't have an answer for why ideology trumps scientific evidence in the United States and its media” Mehl-Madrona writes. “Why are the opinions of ordinary people in cities across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?”

Graphics Credit: http://abortmag.com

The Dutch Smoke Less Pot

One of those inconvenient truths.

Government drug policy experts don’t like the numbers, which is one of the reasons why you probably haven’t seen them. Among the nations of Europe, the Netherlands is famous, or infamous, for its lenient policy toward cannabis use—so it may come as a surprise to discover that Dutch adults smoke considerably less cannabis, on average, than citizens of almost any other European country.

A recent report by Reed Stevenson for Reuters highlights figures from the annual report by the European Monitoring Centre for Drugs and Drug Addiction, which shows the Dutch to be at the low end for marijuana usage, compared to their European counterparts. The report pegs adult marijuana usage in the Netherlands at 5.4 %. Also at the low end of the scale, along with the Netherlands, were Romania, Greece, and Bulgaria.

Leading the pack was Italy, at 14.6 %, followed closely by Spain, the Czech Republic, and France.

While cannabis use rose steady in Europe throughout the 1990s, the survey this year says that the data “point to a stabilising or even decreasing situation.” The study by the European Monitoring Centre did not include figures for countries outside Europe.

According to the Dutch government, Amsterdam is scheduled to close almost 20 per cent of its existing coffee shops—roughly 50 outlets--because of their proximity to schools. However, some local coffee shop proprietors maintain that far fewer shops, perhaps no more than 10 or 20, will actually be required to close.

What are the Dutch doing right? Are coffee shops the answer? It may be prove to be the case that cannabis coffee shops can’t be made to work everywhere—that the Dutch approach is, well, Dutch. However, the fact that it works reasonably well, if not perfectly, in the Netherlands is strong testimony on behalf of the idea of harm reduction.
Here are some excerpts from a flyer given out at some Dutch coffee shops by a group of owners known as the BCD, or Union of Cannabis Shop Owners:

--Do not smoke cannabis every day.
--There are different kinds of cannabis with different strengths, so be well informed.
--The action of alcohol and cannabis can amplify each other, so be careful when smoking and drinking at the same time.
--Do not use cannabis during pregnancy!
--Consult your doctor before using cannabis in combination with any medications you may be taking.
--Note that smoking is bad for your health anyway.
--Do not buy your drugs on the street, just look for a coffeeshop.

Customers must be over the age of 18, and in most coffee shops, as in bars and restaurants in the Netherlands and elsewhere, cigarette smoking is no longer allowed.

Photo Credit: www.us.holland.com

addiction drugs

Needle Exchange in America

AIDS/harm reduction activists press Obama.

First, the good news: After 20 years, the U.S. Congress has voted to remove the funding ban on syringe exchange programs designed to combat AIDS and to bring hard drug users within the orbit of the medical health community.

Now, the bad news: Conservative legislators have managed to insert a provision in the bill prohibiting needle exchange centers within 1,000 feet of schools, day care centers, colleges, playgrounds, youth centers, swimming pools—and just about any other institution you care to come up with. In short, the legislation would make it virtually impossible to operate a viable needle exchange program, even if sufficient levels of federal funding can be obtained. As one harm reduction activist put it in the Seattle Stranger: The only place you could put a federally-funded needle exchange program in the entire city of Chicago... is O’Hare Airport? Gee, it’s almost like Democrats aren’t really serious about allowing funding live-saving needle programs at all.”

Clearly, needle exchange activists are still waiting for an unambiguous sign from the White House that Obama plans to uphold his campaign promises in this regard. Obama’s go-slow policy on needle exchange has frustrated AIDS activists in particular.

Physicians for Human Rights, a group that supports clean syringe exchange programs, made October 14 a National Call-in Day, noting on its web site that “Senators need to hear from President Obama that his Administration supports syringe exchange. Now is the time to urge President Obama to fulfill his campaign promise to end the ban and to urge the Senate to act.”

In a post in January of this year, I wrote: “Obama’s agenda, as spelled out at Whitehouse.gov, calls for rescinding the ban in an effort to save lives by reducing the transmission of HIV/AIDS. ‘The President,’ according to the agenda, ‘supports lifting the federal ban on needle exchange, which could dramatically reduce rates of infection among drug users.’"

Syringe exchange programs, Physicians for Human Rights declares, “do more than provide clean syringes and properly dispose of used ones; they link people into the health care system and drug treatment programs that save lives.”

In short, says the group, “the presence of syringe exchange programs in communities does not increase rates of drug use, nor does it lead to a rise in crime. What it does do: decrease transmission of HIV, Hepatitis C and other diseases.”

Moreover, during his confirmation hearings drug czar Gil Kirlikowske said that “a number of studies conducted in the US have shown needle exchange programs do not increase drug use.”

It’s a confusing picture in the field: Needle exchange programs exist, in San Francisco, Toronto, New York and other major metropolitan areas, because county and other local and regional officials have authorized it, even when funding was precarious. Alongside these programs, a plethora of illegal needle exchange operations is also in place. The Drug War Chronicle quoted the Western director of the Harm Reduction Coalition: “We need to get legislation authorizing syringe exchanges on a statewide level.... Requiring local authorization means we have to deals with 54 jurisdictions instead of just one.”

Back in May, Maia Szalavitz reported in Time that the president was planning to move deliberately as part of a broader HIV/AIDS strategy, even though groups from the World Health Organization (WHO) to the American Medical Association have gone on record with the view that giving clean needles to drug addicts is a successful strategy to reduce the spread of HIV disease. Studies by Don Des Jarlais of Beth Israel Hospital in New York suggest that infection rates in New York’s drug addict population may have dropped more than 75 % over the last few years as clean needle programs became increasingly available.

In a report last month by the Drug Reform Coordination Effort (DRCNet), a spokesperson for the AIDS Action group was determined to remain positive. “I have a pretty good feeling about this,” he said. “I’m hopeful this is the year.”

addiction drugs

The Portuguese Experiment

How has decriminalization fared in Portugal?

In 2001, amid lurid worldwide media coverage, Portugal made the decision to eliminate penalties for the personal use and possession of heroin, cocaine, and marijuana. Dire predictions were heard on all sides. According to the London Economist, this “ultraliberal legislation had set alarm bells ringing across Europe. The Portuguese were said to be fearful that holiday resorts would become dumping-grounds for drug tourists. Some conservative politicians denounced the decriminalization as 'pure lunacy'”.

Strictly speaking, Portugal did not legalize drugs. They decriminalized them—drug use and possession have been deemed administrative, not criminal, matters. Drug trafficking remains a criminal offense. Portugal is the only nation in the European Union (EU) to have made this blanket move, and Portuguese health officials have been at pains to point out that decriminalization in Portugal does not mean that drug use is in any way condoned or encouraged there.

Eight years down the road, how is this "lunatic" project faring? According to the Cato Institute, in a report issued earlier this year, pretty darn well. In “Drug Decriminalisation in Portugal: Lessons for Creating Fair and Successful Drug Policies,” Glenn Greenwald concludes that the project is in fact “a resounding success.” According to the Cato report, “decriminalization has had no adverse effect on drug usage rates in Portugal, and that “sexually transmitted diseases and deaths due to drug usage” have decreased dramatically.

Two years earlier, a study by the British Beckley Foundation, a member of the International Drug Policy Consortium (IDPC), reported that the main changes in Portugal since decriminalization in 2001 were:

--Increased use of cannabis.

--Decreased use of heroin.

--Increased use of treatment options.

--Reduction in drug-related deaths.

The Economist, in its article entitled “Treating, Not Punishing,” concludes: “The evidence from Portugal since 2001 is that decriminalisation of drug use and possession has benefits and no harmful side-effects.”

No harmful side effects? How do we square that with the worldwide unending Drug War? I am tempted to suggest that either everybody is lying about the situation in Portugal, or else it is time to put the Drug War to bed. Drug Czar Gil Kerlikowske has made clear his distaste for the term “drug war,” but has yet to solidly indicate the course that will take the country away from spending money on interdiction and prosecution and toward spending money on treatment, medical research, and harm reduction policies.

Graphics Credit: Cato Institute

addiction drugs

Harm Reduction Scorecard

A look at drug strategies worldwide.

A fascinating study released earlier this year by the International Harm Reduction Association (IHRA) provides a snapshot of the staggering country-by-country variations in drug law and policy across the globe.

While Western Europe and North America have in place a solid base of operational heroin substitution therapies, such as methadone, these same Western countries have fallen behind in prison addiction programs, including all-important needle exchanges.

Countries lacking widespread access to heroin substitution programs include Russia, Afghanistan, Pakistan, Cambodia, and most of Latin America with the exception of Mexico. These are also, coincidentally or not, all regions of substantial opium cultivation.

As it turns out, every major nation except South Africa—where the ravages of HIV are all too evident--has put in place needle and syringe exchange programs of one scope or another, in at least one location in the country.

Interestingly, the IHRA report, titled “Harm Reduction Policy and Practice Wordwide,” finds that some of the countries with the most active needle exchange programs in prisons include Armenia, Kyrgyzstan, Romania—and Iran, which also offers heroin substitution therapy in prisons. Notable countries lacking widespread needle exchange programs in prisons include the United States, Latin America, and portions of Western Europe.

Finally, regarding the most radical category in the harm reduction arsenal—drug consumption rooms, also known as safe injection facilities—the world has been significantly slower to adopt this approach to the public consumption of injectable drugs. The document lists the existence of drug consumption rooms in Canada, Australia, Germany, Norway, the Netherlands, Spain, and Switzerland.

The report, prepared by Catherine Cook, a Research Analyst with IHRA, notes that the listings do not indicated “the scope, quality or coverage of services.” And while almost all countries have national policy documents that make reference to harm reduction policies for health or drug-related policy, strategies vary widely.

“Of particular interest here is the US,” the report notes, “which includes harm reduction in its national HIV and hepatitis C strategy documents, but not in those relating to drug policy.”


Graphic Credit: Bristol Drugs Project


addiction drugs

Harm Reduction: The Dutch Experience

Does marijuana decriminalization work?

Decriminalization of certain drug offenses is one of the goals of a loosely organized movement called harm reduction. While it neither ignores the dangers of addictive drugs, nor advocates their use, harm reduction, as practiced by organizations like the Harm Reduction Coalition, is a limited step that calls for making distinctions between major and minor classes of drug crimes. Above all, it is a practical approach.

According to the International Harm Reduction Association: “In many countries with zero tolerance drug policies, funding for drug law enforcement is five to six times greater than funding for prevention and treatment.” In place of that scenario, harm reduction strategies aim for the creation of non-coercive, community-based recovery programs and resources for drug users. The association defines harm reduction as follows: “Policies and programs which attempt primarily to reduce the adverse health, social, and economic consequences of mood altering substances to individual drug users, their families and their communities.”

Harm reduction strategies do not call upon the government to eradicate the drug problem. Nor would they ultimately lead to cocaine and heroin being sold in government-owned versions of mom-and-pop drugstores. It calls for judgment and discrimination on the part of law enforcement agencies, judges, juries, lawyers, and everyday citizens. The controversial Dutch experiment with harm reduction is often the focal point of such discussions. In 1976, the Dutch made a misdemeanor out of the sale of up to one ounce of cannabis. In the Netherlands, possession of marijuana and heroin is illegal, but there are certain well-defined exceptions, such as the Amsterdam coffee houses, where marijuana and hashish may be freely purchased and consumed. The coffee houses pay taxes on their marijuana sales, just as they do with sales of beer.

The price of marijuana and hashish available in the shops is reasonably low, which cuts back on the need to commit crimes in order to pay for it, and lowers the profits available to street dealers. “If we kept chasing grass or hashish, the dealers would go underground, and that would be dangerous,” a senior Dutch police officer told The Economist (sub. required).

The Dutch officer insisted that the Dutch do not intend to reverse course, as happened in Alaska. “The Americans offer us big money to fight the war on drugs their way. We do not say that our way is right for them, but we are sure it is right for us. We don’t want their help.”

Dutch police still possess strong enforcement powers when it comes to hard drugs, but they have been instructed to view the issue as a public health problem. Heroin addicts are tolerated, but steered in the direction of treatment. By some accounts, 75 per cent of Dutch heroin addicts are involved in one treatment program or another. Local officials complain that some of their drug problem can be traced to a flood of young people coming in from other countries where stricter drug laws are in force.

The Dutch experiment rests on the belief that drug addiction is a medical problem, and that medical problems cannot be solved within the structure of the criminal justice system. “The lifetime prevalence of cannabis use in the Netherlands for 10- to 18-year-olds is 4.2 per cent,” Science (sub. required) reported, “compared with the U.S. High School Survey figure of approximately 30 per cent.”