Friday, April 30, 2010

Medical Marijuana Needs Legal Marijuana

Medical Marijuana Needs Legal Marijuana

Fourteen states have changed their laws to allow residents to use marijuana medically and at least five or six other legislatures are examining the issue. The federal government has announced that it will not enforce the federal drug laws against those acting in compliance with the state statutes.

As these laws have come into effect their shortcomings have been revealed. For medical marijuana users to obtain full relief, total legalization of marijuana, at both state and federal levels, is needed.

Medical marijuana’s shortcomings stem from two sources. First, these laws are structured as exemptions from the criminal law. Second, marijuana remains outside of the normal systems of oversight and regulation.

The laws against marijuana encompass much more than mere possession. Excusing medical users from the criminal sanctions still leaves them subject to many restrictions. Three examples illustrate this issue.

Medical marijuana users are subject to dismissal from jobs even if they do not use it while working or under conditions in which it could affect their job performance. For instance, all employers with federal contracts are required to test their employees for illegal drugs, including marijuana, and either fire those who fail those tests or force them into rehabilitation programs. Likewise, no exceptions are made for probationers or parolees so that testing positive for marijuana, even with a state medical marijuana card, will result in a revocation and a trip to prison.

Most colleges and universities have federal contracts or receive federal grants that require them to remove anyone possessing marijuana from student housing. Inability to live in dormitories places some students using medical marijuana at a disadvantage compared to those who may be using amphetamines for Attention Spectrum disorders or strong opioids for pain. While the student using medical marijuana may be barred, one receiving methadone maintenance for a heroin addiction is allowed in the dorm.

Local governments in California and Colorado have used the general illegality of marijuana as an excuse for using zoning or land use ordinances to deny permits or business licenses to marijuana distributors otherwise in conformity with state law. Local police have also used that excuse to conduct excessive surveillance of dispensaries or for stopping and searching medical users.

* * *

Medical marijuana users’ major problems arise because the plant, as illegal contraband, is excluded from normal oversight and regulation. Marijuana’s illegality shields it from most of the controls that govern the marketing of legal products.

First, those purchasing marijuana must deal with professional criminals somewhere in the distribution chain. The obvious dangers are that dealing with outlaws exposes the customer to violence and to enviromental harms from unregulated production methods. The other problems are less obvious.

Price is probably the greatest problem. Generally, contraband items sell for about one hundred times what the same product would bring legally. Good quality marijuana now sells for around $400 an ounce, while the legal price for it would be a few dollars at most. Even the quasi-legalization of medical marijuana in California has lowered prices by over twenty percent.

The purchaser of contraband never knows what he is buying. Legal consumables like food and medicines are required to have labels listing all of the contents. These goods are also tested to insure that they do not contain contaminants, including pesticides, bacteria, and fungi. While some dispensaries are labeling wares with THC content and varietal names, this practice is not uniform and is not regulated or supervised.

In licit markets consumers rely on brand names as assurance of effectiveness and quality. Manufacturers devote major efforts to building and maintaining brands and trademarks. In illicit markets manufacturers are fly-by-night and consumers have nothing to rely on. Even if they are able to build a trusting relationship with their immediate supplier, neither they nor that supplier can trust the source of his goods. The old maxim of caveat emptor applies with a vengeance, but the buyer has no reliable way to exercise that wariness.

The major defect of an illegal market for medical marijuana is its divorce from science. When the AMA’s representative testified to Congress in opposition to the 1937 Marihuana Tax Act, his major objection was that the law would hamper, if not totally preclude, further medical research on cannabis. The areas he suggested were those in which use of marijuana has become prominent: pain relief, control of spasms, and nausea control.

The seventy years since the passage of that act has been the golden age of pharmacology. The first two modern drugs, sulfas and amphetamines, had just appeared on the market and the first antibiotic was still a few years in the future. Medical drugs for management of psychological disorders were still fifteen years in the future. Several hundred research papers on marijuana have now been published and its basic medical value is no longer in question. One can only wonder what the situation would be if the pharmaceutical companies and medical schools had been able to attack the issue as aggressively as they did other drugs and botanicals in the 1950s.

State medical marijuana programs are a step forward, but they are only partial solutions. Legality at the federal level is the only way in which those relying on marijuana’s benefits can receive the best medical care and be assured that they will be protected in their homes, work, and lives.

Friday, April 23, 2010

Why Drug Testing?

Why Drug Testing?

In large segments of American business one must pass a drug test before being employed and may be subject to random drug testing during the entire term of employment. Hundreds of local school districts require high school students to subject themselves to random drug tests. Thousands are serving multi-year prison sentences only because they flunked one drug test while on probation or parole. The only people exempt from these tests are elected officials, candidates for office, and police. What’s going on here?

Drug testing was instituted under the Reagan administration as part of the enhanced War on Drugs. Just like Nixon, Reagan had trouble being Tough on Crime because most street crimes are the states’ responsibility. Drug-dealing is almost the only common offense toward which the federal government can take action. His political problems were two-fold: first to build public concern about the drug “problem” and second to show the public that he was doing something about it.

Nancy’s “Just say ‘No’” program took care of the first part, especially with its stress on drug use by children. The army had found an answer to the second one.

In the early 1970s the army was shocked to find that many (some sources say as many as 25 per cent) of the troops in Viet Nam were using marijuana or heroin. The Defense Department instituted drug testing and required a clean test before anyone would be allowed to return to the States. To the surprise of almost everyone, virtually all of the personnel returning to America remained heroin free. The military then began requiring routine testing for all personnel.

Reagan used this model as a way to publically demonstrate his desire to eliminate drugs. He required testing on all employees in safety-related positions over which he had authority, both federal employees like air-traffic controllers and postal truck drivers and those in private industry over whom the government had regulatory authority. This group included airline pilots, railroad engineers, and interstate truckers and bus drivers.

However, the federal jurisdiction did not extend to most employees in the country, who were outside the reach of the interstate commerce powers. Congress stepped in and required insurance companies, which were subject to their regulation, to give discounts on workers’ compensation premiums to employers who tested their job applicants and employees. These discounts were substantial enough for employers to save money by testing.

The Department of Education got into the act by making grants to local school districts to pay for student drug testing. The Supreme Court held that this testing was constitutional if the school board found an existing significant problem of drug abuse and the testing was limited to students voluntarily participating in extracurricular activities like sports teams.

Further expansion of drug testing ran into legal problems. Most cities were precluded from testing members of police forces and fire departments by collective bargaining agreements. Public service unions have refused to renegotiate those provisions.

Louisiana tried to impose drug testing on candidates for public office. When one candidate challenged that law, the Supreme Court held that no relationship existed between the testing and qualification for office and held those tests to be an unconstitutional invasion of privacy.

Except for politicians, police officers, and firefighters, drug tests have become almost universal. What good have they done?

The answer is somewhere between minimal and none.

School drug testing has been examined thoroughly. Across the nation only about 1% of the tests are positive for drugs. Proponents argue that the low rate of positive results shows that the tests are convincing (or frightening) students not to do drugs. However, repeated surveys comparing testing school with non-testing schools show no measurable difference in drug use.

Employment testing is even more marginal. Only about 0.5% are positive. No adequate studies show the extent, if any, to which drug users are deterred from applying for jobs. The problem is that failing a drug test for anything other than marijuana is easy to avoid. Twenty-four hour abstinence before the test is usually sufficient. Opioids and stimulants (cocaine, amphetamines, Ritalin, etc.) are purged from the body in less than 48 hours, and alcohol is cleared in even less time. A Saturday night binge will be undetected by a Monday morning test.

No studies have been publicized showing that employers that test have safer work places than those that do not. On the other hand, early studies showed that productivity was lower in companies that tested than in comparable companies in the same industry that did not.

A major problem is that drug testing is not comprehensive. Alcohol is the only drug that has clearly been shown to adversely affect work place safety, but drug tests do not test for alcohol. Even airline pilots, who are barred by regulation from drinking for twelve hours before flying, are not tested for alcohol. Many people take legal drugs that are required to carry warning labels against driving or operating heavy equipment. These range from over-the-counter preparations like Benadryl to strong opiates like OxyCotin. Many of these drugs are not tested for. For others, including opioids and amphetamines, prescription users are exempt from testing.

Many of the strongest degraders of work place safety and efficiency are non-pharmaceutical. Talking on a cell phone while driving has been shown to have the same effect on driving ability as drinking four beers, and texting while driving is the equivalent of being legally drunk. Insomnia, strained domestic relations, financial worries, and other similar personal problems also measurably degrade performance.

An employer interested in improving work place safety or productivity would not use drug testing. Performance degradation tests, easily administrable in less than a minute at the beginning of a shift, would show actual decreases in ability and would cost much less to use. Some of these are descendents of the old pursuit-rotor tests and may be administered with a small computer or keypad. Of course, this solution presents the problem of what a bus company would do if a substantial percentage of its drivers were incapacitated because of fights with their spouses or aching teeth.

In short, employment and school drug testing is an expensive feel-good propaganda effort with no beneficial effects. They should be stopped and replaced by ability testing in those positions in which safe performance is critical.

Saturday, April 17, 2010

Notes from The Broccoli File

Notes from the Broccoli File

I have been interested in the question of what legal drugs should cost for a long time (see “Legalizing Marijuana II: The price of Drugs”, Aug. 11, 2009). The question is hard because no legal market has existed during the lifetime of any living person.

My starting point was to compare marijuana to other, legal plant-derived psychoactive compounds: coffee, tea, and tobacco. My conclusion was that $1.00 an ounce would be a reasonable price for legal marijuana. A recent PBS cooking show highlighted broccoli hand-grown on small organic plots for specialty restaurants in San Francisco. That broccoli sold for $3.50 a pound (about $0.20 an ounce).

Since then my motto has been: “Marijuana is Broccoli” and I call my collection of drug price information the “Broccoli File”. Here is a sample of Broccoli file entries, both current and historical. These are just raw data: I have attempted no analysis. I hope someone among the readers with more skills in economics and historical economics than I have (a frighteningly low level to meet) will attempt to give some meaning to them. The usual method for comparing historical prices is to use a ratio based on the daily or yearly earnings of an average worker, but that method is tricky when comparing the two ends of the twentieth century. The changes in productivity caused by advances in technology and automation have dramatically changed the structure of the work force, and those same technological changes have caused greatly different comparative changes in the cost of producing goods based upon the technologies used.

First are some gleanings from recent news stories:

-- Street prices for marijuana in Los Angeles dropped over 20% when the medical marijuana dispensaries opened and some dealers started offering home delivery.

-- Public meetings in Humboldt County, California (heart of the “Green Zone”) express concerns that state legalization will lower marijuana prices at least 50%.

-- Street quality dried and trimmed marijuana may be purchased in one-pound, plastic-sealed packages for $25 at the farms in the Mexican interior.

-- A story about the war in Afghanistan mentioned in passing that American troops in that country were buying hashish for $1.50 an ounce.

I have also gone back and mined some of the standard histories (primarily Musto, “The American Disease” (Expanded edition), Acker, “Creating the American Junkie”, and Tracy and Acker (eds.), “Altering American Consciousness”) for information about drug prices, both legal and illegal, in the 1900 – 1940 period:

--When the import of smoking opium became illegal with the Opium Exclusion Act of 1909, the price of a can of opium jumped from $4.50 to over $9.00. Two factors probably prevented from price from increasing more. First, smoking opium is very dilute, being only 5 -8% morphine while normal opium latex is about 10%, and second, opium, morphine, and heroin were all still available for open purchase. Heroin sniffing became much more popular after smoking opium was banned.

-- Bayer introduced heroin in 1898 and sold both heroin and aspirin at the same price during the period when heroin could be sold legally.

--An addict in 1919, when enforcement of the Harrison Act became rigorous, complained that a dose of 5 gr. of morphine that he used to buy from the drug store for 25¢ now cost $5 from the dealer. (For those as illiterate as I was in apothecary weights, 1 grain = 60 mg.)

--By 1921, when alcohol prohibition had been in effect for a year, a shot of whiskey that had cost 25¢ or 50¢ in a legal saloon had been replaced by a cocktail selling for $3.50 – 5.00 in a speakeasy.

--Dr. Charles Terry, director of the Jacksonville, Florida municipal narcotics clinic, mentions giving prescription for a “dose” of cocaine (probably an ounce) that could be filled for 50¢.

--The New Haven, Connecticut, clinic between 1919 and 1921, was showing a substantial profit dispensing heroin at 4¢ a grain.

-- Pennsylvania still had over 17,000 opiate addicts being maintained on compassionate exemptions to the Harrison Act in 1930. They received about 10 grains a day at a cost of under $4.

Let me end with one last modern case. I recently filled a prescription for a generic equivalent of Vicodin (hydrocodone with acetaminophen). I received twenty 5 mg. tablets for the chain pharmacy’s standard price of $4 for a generic prescription. Therefore, I received 100 mg. of hydrocodone – or 1 tenth of a gram – for $4. This amount is the equivalent of about 1.7 grains for comparison to the earlier prices.

A lot more examples of prices from this crucial 1900 – 1930 period are available for someone willing to do the digging. I hope someone will follow up on these clues and tell us more about the effects of the Harrison Act and the Volstead Act on prohibited substances.

Saturday, April 3, 2010

Ain't No Such Thing as Dangerous drugs

Ain’t No Such Things as Dangerous Drugs

For almost a century Americans have been warned against “dangerous drugs”. In this context, the term is usually synonymous with “illegal drugs”. However, this term as used is totally without meaning. It is strictly a propaganda tool. Even worse, this misleading concept has led to counterproductive, expensive, and dangerous public policies.

The problem with the misidentification of illegal drugs with dangerous drugs is that it leads to misconceptions in the formation of policy. These misconceptions arise mainly in three areas: that illegal drugs are a separate category, medically distinguishable from legal ones; that illegal drugs are a distinct category, related to each other physically and biologically; and that the dangerousness of drugs can be measured on some kind of absolute scale.

However, the only distinction between legal and “dangerous” drugs is the arbitrary delimitation drawn by Congress in a rather zigzag fashion. Two of the scariest dangerous drugs are cocaine and methamphetamine, but each of these is also a legal drug that can be prescribed by a doctor. Cocaine is used by doctors as a local anesthetic in some nose and throat procedures for which the synthetics are not as effective. Methamphetamine, under the trade name Desoxyn, is prescribed for children with affective spectrum disorders and as a diet pill for some cases of extreme obesity. For most people methamphetamine and amphetamine, also used for ADHD either directly or in a time-release form as Adderal, can be used interchangeably.

Heroin is the classic dangerous drug. Chemically, it is diacetylmorphine, and it is converted to morphine in the body. Experienced addicts cannot tell whether an injection they receive is heroin or morphine; the two drugs are indistinguishable to the user. The other opioids all have the same effects on the body although they may differ in strength, speed of onset, and duration of effect. These include the synthetics like methadone and fentanyl as well as the opiates derived from opium like OxyCotin, Percoset, and Vicodin. Surveys indicate that today the majority of new heroin users developed dependencies on prescription opiates and turned to heroin because it was cheaper and more readily available than the OxyCotin or Vicodin they had been using.

OxyCotin is a time-release formulation of oxycodone, one of the two active ingredients of Vicodin. Ironically, the other ingredient of Vicodin is acetaminophen, a “safe” drug available over the counter under trade names like Tylenol. Acetaminophen is actually the more dangerous of the two drugs, causing severe liver damage and resulting in more deaths each year than all of the opioids combined.

One surprising development of the past decade or so has been that many problems of dependencies and fatalities have involved legal prescription drugs like Valium, Xanax, and Paxil. Many seem confused by the idea that these “safe” legal drugs can cause such problems.

If the line separating legal drugs from illegal ones fades to invisibility when examined, the fence gathering the illegal drugs into one “dangerous” category never existed. When the Harrison Narcotics Tax Act was passed in 1914, it classified both opiates and cocaine as narcotics, and the confusion has worsened ever since. If heroin, cocaine, LSD, and marijuana, are taken as representative of the four major classes of illegal drugs – opioids, stimulants, psychedelics, and euphorants – one would be hard pressed to find any similarity other than legal status among them.

The opioids – along with legal drugs like alcohol, Xanax, and Valium – lead to classical addictions, with reward, tolerance, craving, and withdrawal. They can cause death by overdose, but have no other significant medical or behavioral consequences.

The stimulants, which include cocaine, the amphetamines, Ritalin, and caffeine, can lead to habitual dependency in heavy, frequent users, although this is not a classical addiction. They are frequently involved in binge usage, with paranoid behavior accompanying the binges. Death can result in users with pre-existing heart conditions. Long-term heavy use can result in psychotic episodes.

The psychedelics – which include LSD, psilocybin, and mescaline – are non-addictive and have little or no risk of overdose deaths. They induce visual hallucinations and some time distortions in users but do not interfere with normal intellectual functioning. Many of them have significant evidence of medical effectiveness.

The euphorants are marijuana and MDMA. They are non-addictive, although a small number of marijuana users develop weak habitual cravings. They are non-lethal, although in the early days of MDMA, a few users died of associated heat exhaustion. They elevate the user’s mood and may temporarily decrease muscular coordination and reaction.

The last irony is that no relationship exists between dangerousness and illegality. Danger in this sense includes both short- and long-term risks to the user’s health and risks imposed on surrounding non-users. Dangerousness is not an absolute measure, but is relative to the intended use. After all, a few dozen people die each year from water overdose, and over-the-counter pain relievers kill more each year than all of the illegal drugs combined. Many of the Drugs for cancer chemotherapy are deadly poisons that are used only in carefully controlled hospital settings, but as alternatives to certain impending death, most assume them to be reasonable risks.

By any measure, the most dangerous drugs are alcohol and tobacco. They cause deaths and injuries in numbers many times greater than any other drugs.

Over 400,000 people die each year from deaths medically related to tobacco consumption. Although tobacco is used primarily as a delivery mechanism for nicotine, tobacco is the main problem since most of the diseases come from ingestion of the smoke from burning tobacco, not from the nicotine. Acute overdoses from nicotine are rare. Most direct injuries are caused by fires started by negligent smokers.

Alcohol probably wins the title of most dangerous drug. Although the 150,000 or so deaths from alcohol-related illness are not nearly as many as those caused by tobacco, it presents two other risks. First, overdose deaths from binge drinking are significant. Second, alcohol use imposes severe social costs. Alcohol-related traffic deaths are around 16,000 a year – more than the total deaths from all illegal drugs. Alcohol is the only drug the use of which has been causally related to violent behavior, domestic violence being the prime example.

On the other hand, the risks associated with the illegal drugs are primarily the costs of their illegality. Almost all crime associated with drugs are crimes arising from the black markets in which they are bought and sold. Even the illnesses associated with illegal drugs are actually the illnesses of poverty brought on by the exclusion of users from normal economic activities.

Even the drug risks themselves are law-related. Opioid addicts in legal regimes, like heroin users in Switzerland or the Netherlands or methadone users in the U. S., practically never die of overdose and function normally in work and family.

These three misconceptions have led the country into a failed, expensive, and harmful set of drug laws. The time has come to recognize the failures of these policies and look for a new reality-based approach.