Monthly Archives: September 2015

23Sep/15

The Decriminalization of Marijuana

Over the last few years, I’ve written about the marijuana situation in Colorado and the problems of edibles, the first marijuana vending machine, and public health campaigns about the dangers of marijuana. I took the New York Times to task for their pro-legalization stance, spread the news when NYC decriminalized marijuana, and reacted when Nathan Edelman (the head of the Drug Policy Alliance and staunch pro-legalization advocate) spoke about his newfound concern regarding the mass marketing dangers posed by the new marijuana industry.  I give about a half dozen presentations on “The History of Marijuana Policy” each year. A free webinar version of it is available from the National Association of Addiction Professionals (NAADAC) here.

A close friend of mine told me recently that he thought that my work on reforming the criminal justice system in America does not align well with my position on marijuana. I asked him what he thought my position on marijuana was, and he told me that I was for keeping it criminalized. I’m writing this post to inform people about the difference between legalization, criminalization, medicalization, and decriminalization. I am firmly ensconced in the decriminalization camp.

Criminalization – It is illegal to buy, sell, possess or use marijuana. This is the current policy in a majority of states. One can be arrested and charged. One can be sent to jail or prison for using or possessing marijuana. These laws disproportionately effect minorities and people from lower-income households. Having a criminal record makes it very difficult to get a job, a loan, or an apartment. It can also make pursuing higher education problematic as well. For many people, an arrest for marijuana use at 19 can be an albatross for the rest of their lives. Of all the policies here, this is, by far, the worst option.

Legalization – The possession and consumption of marijuana is legal for people 21 years and older. It usually allows for the personal possession of up to 1 ounce. It is regulated by the state government, requires a license to sell it, and is a source of tax revenue. Colorado, Washington, Colorado, Alaska and the D.C. have all legalized marijuana for recreational use. My chief concern about the legalization of marijuana is that it will encourage more people to use it (think about the rampant use of prescription drugs and how the legality of them helped lead to a surge in their use – it is important that I go on record that I believe that the abuse of RX stimulants, depressants and opiates is worse than marijuana abuse). The tax revenue is a major selling point for states with severe budget problems (almost every state). Another worry of mine is: will the widespread use of marijuana lead to more costs (will it lead to more health problems, thus offsetting the revenues brought in by selling it)? That will be difficult to measure (there is a precedent here though – it is widely agreed that for every dollar that tobacco taxes bring it, it leads to $10 in social and healthcare costs). All that said, if the tax revenues are large, this discussion will be a moot point and more and more states will chase those new dollars.

Medicalization – In 1996, the first medical marijuana law passed in Oakland, CA. It created a co-op that allowed members to grow and use marijuana if they suffered from HIV, cancer, glaucoma and a few other severe conditions. After a few years, that law was overturned for a short time but the rubicon had been crossed and California eventually allowed for the use of medical marijuana with a doctor’s note (not prescription). Currently, 20 states have medical marijuana programs, including most of the Northeast and California. Originally pushed for helping people with a half dozen of severe and/or chronic conditions, you can now get medical marijuana for over 200 conditions in a number of states. Medical marijuana is taxed lower than recreational marijuana, so there is an incentive for consumers to try to get medical marijuana. Most research on the medical benefits of marijuana are shoddy, but that is partly the result of the government’s listing marijuana as a schedule I drug. I believe that marijuana should be downgraded to schedule II so that research can be conducted and we can be sure of whether or not there are actual medical benefits.

Decriminalization – (I’ve taken the following definition from NORML)  “Typically, decriminalization means no arrest, prison time, or criminal record for the first-time possession of a small amount of marijuana for personal consumption. In most decriminalized states, these offenses are treated like a minor traffic violation.” Nine states have effectively decriminalized marijuana and two more have laws that will soon be enacted (Delaware in late 2015 and Missouri (!) in 2017). I believe in this path because I think legalization encourages more people to use and I think that marijuana, like tobacco and alcohol, may be revenue negative (the taxes brought in won’t cover the healthcare, social, workplace and legal (underage arrests, high driving) costs).

I have argued for keeping the status quo for the next few years to see the differences in addiction rates, arrests, tax revenues, crashes, and health benefits in the states that have different policies. In three to five years, we will have some excellent data so that we can determine what is the best policy path. If the data shows that I am wrong, I will admit it (rather than do like many who double down on their beliefs despite the presence of solid data).

 

21Sep/15

Paxil is Now Considered Unsafe for Teenagers

From the 9/17/15 New York Times:

Fourteen years ago, a leading drug maker published a study showing that the antidepressant Paxil was safe and effective for teenagers. On Wednesday, a major medical journal posted a new analysis of the same data concluding that the opposite is true.

This is the shit that that makes me wild. Back in 2001, a study was released that Paxil was safe for teenagers and young adults. Now a study comes out saying that it’s not safe. Let’s think about this for a moment.

It’s 2002, and your 15 year old daughter’s behavior has been a big concern for several months. She doesn’t talk much and she responds to questions with one or two words. She rarely makes eye contact, eats sparingly and isolates in her room. She sleeps over 10 hours per day. Her friends have changed and her grades are not what they used to be. You’ve talked to your friends and parents about it and taken her to a number of different therapists. Nothing seems to work, and you are getting terribly worried about your daughter and feeling like a failure as a parent. You think about your daughter at work, and it saps your production and energy. You and your spouse sometimes argue about what to do (and whose genes are responsible for it). You feel desperate. You hear about a new drug called Paxil, but you are nervous about its effects. You see this ad on TV. A doctor tells you that a recent study says that it is safe and often effective for treating teenage depression. The choice between a depressed, isolating daughter whom you don’t recognize and a chance to see your sweet girl’s pleasant disposition return, you convince your daughter to take Paxil, because you trust the government and your doctor.

And now we learn that they were wrong. What kind of damage did Paxil do to your daughter in the meantime?

The drug companies don’t always have the consumers best interests in mind (I’m being diplomatic here). This article from MotherJones entited “Disorders Made to Order” is harrowing in how it breaks down how Big Pharma creates a market in order to push their chemicals on a trusting public:

GlaxoSmithKline’s modus operandi-marketing a disease rather than selling a drug is typical of the post-Prozac era. “The strategy [companies] use – it’s almost mechanized by now,” says Dr. Loren Mosher, a San Diego psychiatrist and former official at the National Institute of Mental Health. Typically, a corporate-sponsored “disease awareness” campaign focuses on a mild psychiatric condition with a large pool of potential sufferers. Companies fund studies that prove the drug’s efficacy in treating the affliction, a necessary step in obtaining FDA approval for a new use, or “indication.” Prominent doctors are enlisted to publicly affirm the malady’s ubiquity. Public-relations firms launch campaigns to promote the new disease, using dramatic statistics from corporate-sponsored studies. Finally, patient groups are recruited to serve as the “public face” for the condition, supplying quotes and compelling human stories for the media; many of the groups are heavily subsidized by drugmakers, and some operate directly out of the offices of drug companies’ P.R. firms.

The FDA and the federal government seem to be constantly fighting rearguard battles. In August of 2002, a federal judge ordered GlaxoKlineSmith (the makers of Paxil) to stop running ads that say it isn’t habit forming. This USA Today article states that 35 patients experienced severe withdrawals when they stopped taking Paxil. It’s very hard to know who and what to trust.

If the new study is correct and Paxil is harmful to young people, than I hope that a class action lawsuit will bring GlaxoKlineSmith to its knees. To read the full New York Times article, click here.

 

16Sep/15

Rutgers Football Players’ Reign of Campus Terror

Rutgers Football Captain Leonte Carroo was arrested on Sunday morning for  assaulting “a woman he was romantically involved with by picking her up and slamming her down on a concrete surface.”  This came on the heels of the news from 10 days earlier that 5 Rutgers players (eventually more would be charged) were arrested for a series of home invasions, armed robbery and assault. A few of these football players must be experienced in those crimes, as it’s hard to imagine all of them breaking the law for the first time together (it’s not often that someone is caught the initial time they engage in criminal behavior). A couple of days before those arrests became public, it was announced that Rutgers Football coach Kyle Flood was under investigation for breaking university rules by contacting a professor on behalf of one of his players who failed a course (and to make matters even worse, that player was one of those charged with the aforementioned campus terror crimes). Let’s not forget that Rutgers also produced a player who engaged in one of the most notorious acts of domestic violence in modern American history.

One can sardonically state that Rutgers Football has finally made the big time, because a lot of top football schools also are chock full of perps who terrorize the campuses that houses, feeds and educates them for free. This is nothing new: Sports Illustrated published a story in 2011 about the out-of-control crime committed by college football and basketball players. Back in 1989, national media outlets published stories about the Oklahoma Sooners Football Team’s reign of terror on their campus, but it actually pales to what has happened at Rutgers during 2015.

Not only does the Rutgers Football team consist of numerous violent individuals with a disregard (disdain?) for paying students, but it is a program that requires subsidies by the very students that they are assaulting in order to operate. During the 2012-13 school year, the Rutgers Athletic department took $47 million dollars from other parts of Rutgers. It’s the most revenue negative athletic program in the nation. For people that argue that joining the Big-Ten will help with the revenue stream, they are only partially correct. Because in order to play in the Big-Ten, a school also has to spend more. Dr. Thomas Prusa summed it up in Daily Targum last spring:

“When compared to other universities in the United States, Rutgers’ academic program bears the highest cost to the rest of the University for an intercollegiate athletic program”, said Thomas Prusa, chair of the Department of Economics. “To try to do any sugarcoating of the magnitude of (this) financial loss is just not being honest,” he said. “We’re No. 1 in financial losses … by a mile, we lose more money than any other university on athletics”.

“Rutgers Athletics is engaging in a financial arms race against other Big Ten schools, making important decisions with the assumption that spending more money translates to winning more games”, Prusa said. To say the University is operating at a net loss would be an understatement. “The only spillover benefit from the University’s athletic spending would be a perceived sense of pride in going to Rutgers because of the wins made by revenue-generating teams,” Prusa said.

“There’s a direct cost imposed on students, that students don’t understand is (there),” he said. “We’re now in this better conference, and the reality is, we’re in a set of schools that have so much of a giant financial advantage (over Rutgers). It’s just a financial spending race.”

In 2007, Rutgers English Professor William Dowling’s Confessions of a Spoilsport was published, and it detailed the history of Rutgers athletics up to that point. Dowling described a number of scandals that rocked colleges and universities over the previous 30 years. He explained that there is a common pattern in the way they are usually handled:


1) college officials express shock
2) an investigative committee is established
3) a version of the following statement is issued: “the scandal does not truly represent this esteemed university”
4) there is an announcement that “nothing like this will ever happen again”

I expect Rutgers will follow this playbook this fall. And in a few years from now, we’ll probably go through this again. Rinse. Wash. Repeat.

 

14Sep/15

A Huge Roadblock to Criminal Justice Reform

I hike in the Adirondacks a few times a year. The region is huge, as it has over 6.1 million acres. There are 46 peaks, with the highest one being Mt. Marcy (5,343). Over 132,000 people live in the region year round, scattered through over 100 towns and villages. Over the years, the major sources of industry have included farming, mining, milling, and in more recent times, tourism and recreation. The Winter Olympics have been held there twice – in 1932 and in 1980 (the arena where the USA Hockey Team’s “Miracle on Ice” victory over the USSR is still in use in the center of Lake Placid).

Last February, a friend and I took a winter mountaineering class in Lake Placid, NY. I remarked to our instructor how far from a major city center the region is, and I asked her if tourism was the number one source of income for people that lived there. “No,” she replied, “it’s the prison industry.”

I’ve spent a little bit of time researching this, and I’ve determined that it’s extremely hard to determine what is the top industry in the Adirondacks. The list of prisons in New York State is so long that it is shocking. This map shows that a vast majority of them are located in rural areas. One researcher has been writing about the increase in the number of rural prisons for over two decade: a chilling 2002 paper can be read here. Whether it is the number one, three or five industry, it is obvious that the department of corrections is of vital importance to the economy of Northern New York.

Over a decade ago, the then-commissioner of the Connecticut Corrections System engaged in some major prison reform initiatives because it was too prohibitively costly not to. Her major push was for the early release of prisoners – in doing so, she saved her state tens of millions of dollars. With the economic collapse of 2007-08 and the subsequent further collapse of state revenues throughout the nation, both Republicans and Democrats are acknowledging the need for criminal justice and prison reform (here is an excellent article about it from the New Yorker this summer). You can read about the different stances that the various 2016 Presidential Candidates have taken here – regardless of their views, it is clear that criminal justice reform has become too expensive not to address.

Throughout the United States, state prisons cost over $50 billion dollars a year to run. This does not include capital costs (construction), nor does it include employee benefits and pensions (this falls under a different department); therefore, the yearly costs for maintaining state prisons is much higher than the advertised $50 billion.

It’s a big industry that employs a lot of people. A lot of these prisons are located in rural areas, and are major employers in those regions. Any discussion about cutting the size of prisons or closing some down are surely to be met with a rabid response from the people that work there. Prison employees are so numerous in some areas that they have real political power, as is illustrated in this 2013 article about the closing of two prisons in Pennsylvania:

But closing prisons is no easy feat. As a Texas legislator pointedly explained, prisons – often large employers in sparcely populated rural areas – develop their own political constituencies. Sen. John Whitmire, the longest-serving senator in the Texas Legislature, told the Patriot-News, “There are so damned many prisons in so many legislators’ districts, they’ve got a built-in lobby.

Democratic Sen. John Wozniak, who represents Cambria County, told the Johnstown Tribune-Democrat he was concerned about the employees and contractors who rely on the prison at Cresson for their livelihood.

The Tribune-Democrat noted the prison is important to the economy of the region, quoting Linda Thomson, president of Johnstown Area Regional Industries, who said “First of all, they’re recession-proof, or likely to be there, and these jobs are highly sought after. They’re family-sustaining jobs, so good for the economy.”

Reforming drug policy, eliminating mandatory minimum sentences and three-strike laws, and providing counseling and job training to prisoners and ex-offenders are all difficult goals to accomplish. They are that much harder when opposed by people who are fighting to keep prisons open and full in order to save their jobs (and provide for their families). Part of the discussion of prison reform must also include a plan to address what will happen to the people that work in prisons. Without it, meaningful reform will be even harder to attain.

10Sep/15

What is Vivitrol and How Can It Treat Heroin Addiction?

Over the last few months, I’ve received a number of calls, texts and emails asking me about Medication Assisted Treatments (MAT’s). Putting someone on MAT’s should not be part of an initial treatment plan during a patient’s first time in treatment. MAT’s should be considered after previous attempts at treatment have failed. I often refer people to an article I wrote about MAT’s last summer:

Vivitrol is injectable naltrexone. Because there isn’t any opiate or synthetic opiate in it, it is not a controlled substance. Any doctor can prescribe it. Patients get a shot 1x a month. Vivitrol helps reduce cravings and it mostly blocks the euphoric effects of opiates.

It is effective for both opiates (heroin, oxycotin, hydrocodone, etc…) and alcohol. Vivitrol is not a controlled substance, so it doesn’t take a special prescriber’s license or training to issue it. It is neither addictive nor abusable in any way. All that said, there is an American line of thought that says “take a pill, get better.” That tactic angers me for almost any illness. When it comes to getting clean and staying off of opiates or alcohol, Vivitrol (or other MAT’s such as suboxone) is not particularly effective without regular therapy and urine drug testing. The law does not require therapy or drug testing, but clearly the best practice is to do so. I tend to recommend Vivitrol for a period of 6 to 12 months. This allows the client enough time to stabilize, reduce cravings, get proper therapy, develop a support network and plan for the next phase of their life (education, work, service).

One of the key concerns about Vivitrol is that it is very expensive. Even with insurance, it can cost a few hundred to upwards of a thousand dollars a month. This means that it is really only accessible to the upper middle class and above. I’m hoping that will change. This summer, Senator Joe Vitale, introduced legislation that was ultimately passed by the NJ legislature and signed into law by Governor Christie that would allow people on Drug Court* to graduate from that program while still on MAT’s. It seems a bit wild that we need to have a bill that allows for this, but then criminal justice reform and the improvement of treatment & aftercare are often tough, uphill slogs (but there is improvement all the time…it is not a sisyphean task).

I have never taken money from any pharmaceutical company in any way, shape or form. I never intend to. I think that once one takes money from a pharmaceutical company, it compromises both your viewpoint and the appearance of your viewpoint. I prefer to remain a neutral, well-informed outsider that others can trust.

Finally, I’m a bit appalled by the comments on articles that I’ve read over the years about MAT’s and how they can help people get and stay clean. The comments usually follow one of three themes:

(1) I got sober through God and AA. That’s the only way. Everything else is BS.

(2) I hope this author dies a fiery, painful death.

(3) Another shill for Big Pharma. I hope you die.

All this really proves is that one probably shouldn’t read the comments at the end of articles, but for the fact that it shows us where a percentage of the interested population are currently at. Educate, educate, educate. The data is there (though usually people with ideas that entrenched will double down on their beliefs, even in the face of data).

* Drug Courts cost about 20% of jail, while offering a better return on the public dollar. Less of them relapse and return to crime compared with their brethren that are stuck in jail or prison without treatment, education or job training.

04Sep/15

The Army’s Alcohol Problem

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I love the US Army; I  have joined it twice in my life. I enlisted in 1996, was honorably discharged in 2004 and then was directly commissioned in 2014. That does not mean that I like or approve of everything that it does or how it always goes about its business. My feelings for the Army are akin to the love one has for a family member but hopes that they make better choices (or how one can love a university but wish that their athletic program would just disappear into a black hole, never to return). All of that is preface to this: the Army has an alcohol problem and that problem has massive ramifications.

This summer, I reported for a month of medical officer training at Ft. Sam Houston in San Antonio, Texas. There were 365 people in my class. There were about 40 prior service people (including some enormously impressive individuals), a ton of recent ROTC grads, several green-to-golds, a few West Pointers and a bunch of directly commissioned medical professionals. We were divided into six platoons; I was part of 3rd Platoon. While I got to know a number of my fellow soldiers, most of the people that I had in-depth conversations with were from the 3rd. I have been working in the addiction treatment and recovery support field for a dozen years, and yet I was still moved (not surprised) that more than half of them have a family member that either is in active addiction, is locked up because of their use, is currently in treatment somewhere, or died directly from alcoholism. When I told them what I do and that one of my goals is to help the military institute better policies for mental health and addiction treatment, every one of them said something to the effect of “bless you” or “can we clone you” or “what can I do to help?”

Throughout the training, multiple instructors and cadre would make references to drinking and a few would ask “how many margaritas did you drink this weekend?” to numerous soldiers. They meant well, and were trying to be free and easy and bond with their troops. I thought it improper though and that it sent the wrong message. I conferred with a few psychologists and a number of doctors about their reactions, and they expressed frustration and occasional exasperation about it as well. Here we are, 365 regimental medical officers, being trained in a variety of methods to help “preserve the fighting strength of the Army” and we were continually exposed to a drinking culture. To be clear, I’m not part of a temperance movement – most people can handle alcohol without a problem and have a right to drink. That said, I, along with a number of my highly educated peers, believed that it was improper and sent the wrong message.

One Saturday, a group of us went to the AMEDD (Army Medical Deparment) museum. We learned about the history of Army medicine (as a New Jerseyan, I was happy to learn that Dorthea Dix was a Civil War nurse who also helped found early mental asylums) and how it has evolved over the course of time (I will write about this in the near future). It was educational and filled me with pride. Before we left, we stopped by the AMEDD museum store, where to my horror, the above pictured flasks were for sale. I was outraged – they should not be sold there. It’s a terrible message. I was most upset about the “RX Booze” labeled flask.

Alcohol misuse, abuse and dependence are problems within the military. Especially because there is a strong correlation between alcohol misuse and

(a) untreated PTSD

(b) sexual assaults

(c) suicides

These are areas that the Army (and military as a whole) has acknowledged as huge problems and need to be addressed (we were exposed to multiple sexual harassment and assault trainings). They do not happen in a vacuum though, and all three of those problems are exacerbated by alcohol. Getting leadership to talk less about weekend drinking and eliminating the sale of spring-breakish flasks will not fix these problems, but doing so will begin to change the alcohol-soaked culture that permeates throughout much of the Army. It starts at the top. To quote one of the cadre, “make it happen.”

03Sep/15

A Brief Note on Advocacy Work

Last month, I wrote a piece about the upcoming Unite to Face Addiction March in Washington, DC. The purpose of the event is to alert the public and our nation’s leaders about how many people are in recovery and how many more could get there if more (and better) policies were enacted. A number of the principals involved are quite impressive.

Advocacy work has been very effective in recent years regarding gay rights, breast cancer awareness, and veterans’ issues.  Over the last several years, advocacy work in the addiction treatment and recovery field has skyrocketed. Organizations such as Faces and Voices of Recovery were some of the first movers. We need to tread very carefully here though, because if advocacy work is not engaged in properly, it can actually harm the movement rather than help it. Here are a few suggestions:

(1) Most of the people doing advocacy work for addiction treatment and recovery support services tend to be in recovery. It makes sense, because they have experiences to share and a strong sense of purpose. However, I think that there should be a minimum length of sobriety for people that engage in advocacy work. One of the cardinal traits of someone with an active addiction is inconsistency (not always, but almost always). I think that someone who is 90 days or 9 months clean is a poor immediate candidate for this work (think of the times someone who just started working out 5 days ago or changed their diet 3 weeks ago or started using a new product last month gets all evangelical with you about it and tells you how you need to change your life). Two years to me seems to be a good threshold.

(2) Have advocates done or accomplished anything else? Getting clean and staying sober is hard. It’s amazing when someone sticks to it, and you often see entire families transformed. But being effective at changing the opinions of others and influencing public policy requires a bit more experience and gravitas. There are times when advocates will be criticized and attacked – you need to fall back on a some kind of successful, varied foundation. Advocates should be able to point to their family life, education, charitable service, work or some other aspect of their life. It comes down to this: why should someone listen to you? The more you bring to the table, the more you will be able to sway those that originally disagreed with you.

(3) Stay grounded. Too often, advocates use the movement to advance their own personal agenda and they lose sight of what they are doing. I’ve seen far too many addiction treatment and recovery advocates flame out (and/or relapse) because they paid too much attention to their own press and stopped taking care of themselves. When this happens, you do the movement more harm than any good you brought before it.

(4) Powerful advocates include athletes who became addicted to painkillers (Americans, myself included, overly-love sports), military members & veterans, and the parents of young people who have died. These figures are often harder to shout down than traditional people in recovery. Try to include them in your work. That point made, there will still be some obstinate individuals who say horrible things about these people in the comments section on news articles – don’t let them make you hate humanity. Share those reactions sometimes in your advocacy as an exact reason why we need to engage in this work.

(5) Advocacy has many forms. Speaking, writing, training, one-on-one talks, tabling, calling on politicians, letters to the editor, teaching and a host of other ways. It’s important to do big and small work. Sometimes we get to talk to 500 people at once (or 500,000 on TV), and other times we might be at a community event with 20 people. Do the work, don’t despair. We need you.