Posted on by Nathan Riley

Drug Use Has Comparable Risks To Drinking A High-Ball

Freedom is tied to the discovery of new ideas, what we often call “truth.”

Freedom in the United States is a constant struggle. The most famous and obvious is slavery. Slavery was practiced all over the world, long before it was used to make sugar or grow tobacco. Slaves are a constant backdrop in the Bible. Between 20 to 40% of the Roman population was slaves. Supporters of slavery insisted that once freed blacks would do no work and rape white women. Slavery, we were told, was a pillar of civilization.

As freedom became accepted, slavery conflicted with changing moral standards. Making drugs legal is no greater a change in moral standards than when the United States abandoned slavery or allowed women to vote.

Appeals to freedom, frequently meant changing minds; what was considered “right” became “bad.” Conventional morality opposed a new freedom and then became accustomed to it, even insisting on it.

Freedom permits us to challenge existing ideas; slavery stopped being a “good” and became an appalling evil to many Americans. Freedom allowed reformers to challenge existing ideas and insist on a better reality. Today it is harder to accept that drug use is criminal behavior that good people should stop, an evil that harms us. It is simply untrue that poverty is caused by drug use, multiple reasons are tied to poverty: more people than there are jobs, education that doesn’t instruct many young people, and few programs that help people learn after they are 18 and start to recognize the importance of schooling.

Arguing that drugs are an evil is being challenged. If gambling, overeating and alcohol are addictive it becomes difficult to claim heroin has some special evil factor making it more addictive than other activities. Moreover, drinking, eating, and gambling are legal and most people do not become addicted to these pastimes. People get high at reasonable times in reasonable ways. They do it for the same reason people eat and drink to be merry and have fun. Users feel convivial, have better sex and more fun high.

It’s a pleasure that adults should have the right to enjoy. More and more scientists agree controlled use is possible. Much of the argument gets enmeshed in medical jargon about receptor cells and the way the brain works. However difficult the arguments, these scientific disputes are earth-shattering in their conclusions.

With the same caution that we practice with alcohol, being cautious about how much we consume and when we drink, scientists are telling us that the illegal drugs may foster fun and are just as safe as drinking, which has been legal for nearly 100 years. Many scientists, like Carl Hart in his indispensable book Drug-use for Grown-ups, are saying the public has the facts wrong. Heroin, methamphetamine, marijuana, cocaine, psychedelics, etc. can be used safely, and it’s possible to clearly explain this safe use to the public. In short, there is no scientific basic for making the drugs illegal. The law has got its facts wrong and is impinging on our right to pursue happiness. Freedom Democrats can help persuade the nation to support this reasonable policy. Drug legalization offers freedom to drug users and their suppliers. It is a good thing. It makes sense to weigh the opinion of the scientists; after all, their claim is a breakthrough.

A big mistake is assuming that an illegal drug has the power to control your life. Those of us who live happily with drug users know that people can get high on Friday and be energized for work on Monday. We see this with our naked eyes but public hostility leads us to remain silent. We protect users from the law by keeping them in the closet. This strategy has a bad effect, it prevents the public from seeing the truth. Drug users know that the risk of a highball and a snort are comparable. If drug users left the closet, the public would know that drug users should have the freedom to choose their highs.

A major implication of the scientists’ conclusions is that we overemphasize the dangers of drug use. Focusing on danger moves our thoughts into anxiety, making it easier to accept the false conclusion that this is a high risk activity. A major reason that people use drugs is happiness, a right protected by the Declaration of Independence. Not just protected but one of the three core values in our democracy, “the right to Life, Liberty, and the pursuit of Happiness.”

Making drugs legal is a simple act of respect, recognizing that the millions of Americans who get high know when they are having fun, and wish to have that feeling again and again. Drinkers know the pleasure of that first drink after work. A decent respect for opinion should make it clear that if drug users say it’s fun they know what they are talking about. The argument for drug legalization is just that simple. Don’t believe it when they tell you drugs destroy your lives. It only happens occasionally and is usually not permanent but just a stage in life. It makes more sense to say, “You should be careful, and learn how to use the drugs safely.”

In turn, it is our obligation to recognize that allowing drug users to pursue their habits is an act of respect. Users should be able to buy drugs conforming to strict government standards. A pill taken to get high should be as safe as a pill prescribed by a doctor. Obviously, there would be restrictions. You wouldn’t want pills that look like candy, you don’t want your children to eat a whole box full. The pills should be child-safe. When it says 60mg of whatever drug, it damn well had better be 60mg. At the same time, the legal drug industry should have the right to recognize that their products are used for pleasure. They should have permission to advertise that people enjoy their products, just as alcohol is advertised with people enjoying themselves.

A debate surrounding the legal sale of drugs that get you high and happy should help protect the users and minimize harms. Legalizing drugs means putting to bed the nightmares that surround the myth of addiction. If gambling and overeating can be an addiction, then it is improbable that there is something especially malevolent in a psychedelic or heroin. Sometimes addiction happens; usually it does not.

Freedom would stop the police from interfering with users’ habits. A decent respect for drug users should recognize their heartfelt plea for civility. We will not harm your children, but we will save the young from the harms of harsh criminal penalties. Instead of threats, we insist on respect and recognition, telling the public, “We will listen to you if you will listen to us.”

{If you think ideas like these can become important by showing how many people think this way, then please contact me. I am 82 and nearly blind and looking for an enterprising person to launch Freedom Democrats.}

Posted on by Nathan Riley

Drug Use Is No More Addictive Than Overeating

Since World War II, caring people have rejected stigma, recognizing its cruelty.

Freedom Democrats enthusiastically join in the fight against stigma. The latest group to hold its head high and say, “We are doing nothing wrong,” is drug users. It has become increasingly difficult to accept the stigma that using hard and psychedelic drugs is always harmful and should be illegal. More and more drug users reject the hostile conclusion that getting high must be destructive behavior. Some people have problems with drugs, just as some people have problems with overeating, but the growing body of evidence makes it clear that many people use drugs and have fulfilling lives. It is mean to look down on drug users.

In the United States black people were stigmatized before and after slavery. Black workers were stigmatized as lazy and stupid. Whites were often surprised by blacks’ intelligence and shrewdness. Written before the Civil War, Frederick Douglass’s autobiography was greeted with skepticism. No black, the stigmatizers said, could write that well; a white person must have been the actual author.

When it comes to stigma, the unfair treatment of blacks has lasted an extraordinarily long time, but other stigmatized groups have shed their negative labels since World War II. Historically homosexuals were mocked, occasionally locked up, until the nation went crazy. Immediately after World War II, gays became a national threat. They were considered security risks. Homosexuals could stay in the closet, but if their loves became public, they lost their jobs. It became illegal for Uncle Sam to provide employment to LG persons.

During this gruesome period, supporters of homosexuals helped lesbians and gays stay in the closet. These heterosexuals, like my parents, thought it was helpful to call lesbians and gays “sick.” Sick people deserved compassion and treatment. Psychiatrists thought that gays could become heterosexual with treatment. In other words, lesbian and gay people could become “healthy” by just being like straights. Men chasing women was considered “normal.” “Sick” had turned into a stigma.

During this same period, women fought stigmas that labeled them overly emotional flibbertigibbets who created confusion until men straightened out the problems. Men were the smart, rational backbone of government and society. Women took care of the home. This prejudice was stupid. Virtually every open-minded person understood that some women were smarter than some men and that women often had better solutions to problems. Feminism blossomed and so did the view that women are equal to men.

By the 1960’s, a growing population across the globe realized that labeling groups as “inferior” was wrong. Stigmatization demeaned same sex love, women, blacks, Spanish speaking, and in the northern United States southern whites were stigmatized. It took George Wallace running for President to demonstrate that some whites in the North were just as racist as some whites in the South.

The battle against stigma was widespread in the United States after the upheavals of the 1960’s. As the times changed even the military, long considered a deeply conservative institution, adopted anti-stigmatization policies. Gay and lesbian soldiers opened doors that allowed the transgendered to work in the military. Women, blacks, and Spanish speaking people became senior officers whose rank required them to command white men. Stigma didn’t disappear, but it became dubious and presumptively illegal in the eyes of the law.

This social change is attacked by the Donald Trump administration. Diversity is damned, and employees are dismissed for supporting it. It will be a hot-button issue as long as Trump is president.

Nonetheless, the battle against stigma is being fought on a new front. The latest group fighting stigma is drug users. Slowly but surely, it is being recognized that drug users are not sick nor demented.

In fact, much if not most of drug users’ pain is caused by stigmatizing drug use. Change has been painfully slow. In the 1960’s, using marijuana was considered dangerous. It led to laziness, opened the door to stronger drugs like heroin, and demonstrated a contempt for law. This argument failed. Marijuana use became widespread, and its users did not become drug addicts. Stigmatizing people is dangerous, wrong, and causes harm.

World War II and the German Holocaust had exposed the dangers of racial categories. Their acceptance could justify horrific acts. As the lesson of World War II became clear, segregation in the army and the classroom became illegal. The battle to give blacks the right to vote and end Jim Crow practices created interracial friendships. Smoking pot was not only fun, it was a form of solidarity with the victims of racism.

Pot use skyrocketed and by high school teenagers had been to parties where some people got stoned. It became impossible to claim pot was dangerous. The menace of drug use had been disproved. Zero tolerance, or the goal of making America drug free, became absurd extremism.

In city after city, all over the world, it became recognized that some people did drugs, always had and always will. Policy makers were forced to answer the question, what is the harm? If it was the spread of disease from needle-sharing, then it became obvious that drug users should have a steady supply of sterile needles. Though by no means universal, harm reduction became a public health objective. Cities like San Francisco boasted of their accomplishments in reducing drug related harm. Other cities kept their policies lowkey and faced attacks if their harm reduction programs became public knowledge.

Harm reduction is a major step forward, but like supporting homosexuals because they are “sick” it doesn’t dispute the belief that drug use is dangerous and inferior behavior.

A growing chorus of thinkers now argue that drug users are not sick and those who have problems deserve help. It is generally understood that gambling can become addictive and lead to financial disaster. In fact, most gamblers watch their pocketbook and stay within a budget. Gambling is fun, and that is why people like it. Drug users are just as sensible.

The argument that heroin is dangerous because it is addictive has become suspect. Gambling can be addictive for some but not for others, the same is true for heroin. Bankers, plumbers, and college professors use heroin without harming their careers. A Columbia University professor came out of the closet about his drug use. Carl Hart makes this argument in his book Drug Use for Grown-Ups. Consider this observation: lock-ups in cities all over the United States don’t help heroin users going through withdrawal. For some, it is horrible agony, but for many it’s just a challenge and they “tough it out.” Don’t think you know about heroin’s effects because you read newspaper stories or saw antidrug movies. The effects are individual, and they vary with the individual, just like gambling and drinking. Some people get great pleasure from eating and preparing food; other people overeat. You can’t generalize about drug use anymore than you can generalize about eating.

Addiction is a troublesome concept. Using heroin, methamphetamine, is a problem for some but not everyone. That is the lesson that Freedom Democrats are learning and disseminating.

In a free country, no judge should be allowed to tell a person you must go into treatment. It should be up to the person to decide if they want help. Nobody should be allowed to shout “Don’t do this! You will go to jail!” That is not freedom; it is stigmatizing and ignores the right of persons to make their own decisions about how they live their lives.

Posted on by Nathan Riley

Addiction, Everybody Does It

One of the strangest promises Donald Trump has made is stopping fentanyl. The notion that being mean will stop drugs has never worked.

Freedom Democrats would be familiar with the iron law of prohibition: a more aggressive enforcement brings even more dangerous drugs to the market. When oxycodone was widely available, its safety had been demonstrated to the satisfaction of the Food and Drug Administration (FDA). That many users would experience withdrawal was an unfortunate side effect. That the drug was widely available also meant many persons used it who had received no prescription.

Freedom Democrats believe that the relationship between doctors and patients should be respected, especially by politicians. They have no expertise, and the doctor and the patient should develop their own course of treatment. No drug enforcement agency. No rules about dosage or where the drug’s may be used. That is up to doctors, their patients, and agreements about best medical practices.

Freedom Democrats, had they been in charge, would not have blood on their hands. The politicians who played the blame game are responsible for hundreds of thousands of deaths. Lawmakers blamed the pharmaceutical companies for trying to expand their market. In this one sided view, the users had no responsibility; they were simply victims of addiction, had no intelligence, and no will power.

Elected officials accepted the discredited idea that drug users aren’t citizens, have no rights, and are trapped. A nefarious evil captures the user’s soul and deprives them of choice. It’s malarkey; similar ideas have existed for centuries. Witches after all were supposed to exercise control over their victims. Back then, the witches were killed.

Centuries later Democratic and Republican politicians adopted policies that killed the users. They were denied any moral culpability; the drug users were trapped by their “habit.” The politicians dismissed the possibility that drug users were rational and able to control their lives. The way they handled their habit was comparable to the way millions respond to alcohol, food, and caffeine.

The only difference is this group isn’t stigmatized and dehumanized. The effort they put into controlling their habits receives positive reinforcement and often drug treatments.

But the closed-minded lawmakers offered oxycodone users no support; in fact, their one-sided view simply killed hundreds of thousands of users. It should take no brains at all to realize that if a person regularly uses oxycodone you don’t simply say, “You can’t have it. The law says stop.” The law offered habitual users no comfort and legal ways for changing their habits at their own pace. All too often, judges thought it reasonable to tell users you must stop now, a decision that should be made by doctors and their patients.

To nobody’s surprise, Stop Now was a gift to cartels and ingenious people who created alternative illegal supplies. History had repeated itself. Banning marijuana, cocaine, and amphetamines had produced illegal markets. In fact, they offered economic stimulus to criminals, and more work for the police. The criminal justice system will thrive.

Not so the drug users. They were too often conned into believing that a pill was oxycodone when in fact it contained a strong dose of fentanyl. The number of victims of the politician’s callousness soared to over 100,000 a year dead from overdoses. More people died in one year than died in the Vietnam War. Freedom Democrats would damn lawmakers for their callousness and cruelty.

This time the witches didn’t die; it was their victims.

Trump displaying the ignorance that is a trademark simply argued that drugs were reaching America because we weren’t really trying. He slammed tariffs on Mexico.

The iron law of prohibition suggests that fentanyl will be replaced by even more dangerous drugs that kill quickly. That drug has already surfaced—nitazenes. Being mean kills drug users.

The very idea that a societal habit like ribald humor can be banned is a joke. For one thing, and Freedom Democrats are an example of this, there is no agreement that drug use is criminal. Another problem is people make money selling banned substances. Banning alcohol in the 1920’s made many fortunes.

Trump’s effort to try harder in the silly hope that the drug will stop reaching the U.S. doesn’t recognize that law enforcement and drug smugglers all too often find ways to share the wealth. Mexico is famous for its ties between law enforcers and drug cartels. Nothing Trump does will change this reality, but we do know that a new drug is here—nitazene.

Democrats of course join Republicans in chasing the impossible goal of stifling the drug trade.

We are still looking for the charismatic and verbally fluent political leader who will support doctors being able to treat drug users without strangers violating their privacy and setting rules that harm a successful treatment.

Obesity is universally recognized as a major U.S. health problem. Doctors understand that many people eat for pleasure; in other words food acts like a drug. It was my habit and mastering it made my weight drop from 270 to 195 and brought a happier life. Dr. Peter Grinspoon’s book Up in Smoke and website makes sensible arguments for allowing doctors to treat patients who use drugs without outside interference.

He makes the point that using drugs is normal. We refuse to recognize that gambling, eating, and caffeine also have addictive impacts. In my case, my addiction to food started in elementary school. I fit Dr. Grinspoon’s theory that “suffering, often alone, feeling bad about myself, in the shadows” drove my eating and explained why diets did not work.

When I was grossly fat, I used to tell people I was addicted, and it was completely visible. Only a few people recognized that I was speaking about my eating habits. People didn’t associate eating with addiction. Addiction is the all-too-common habit of confronting other problems by repetitive behavior that brings no real relief.

Freedom Democrats recognize that drug use and overeating are sister phenomenon. This humane response is alien to Trump’s angry “stomp it out” mentality. It is one reason why Trump is malicious and cruel.

Posted on by Nathan Riley

The Mistruths About Pot

The mistruths about pot

Dr Peter Grinspoon who writes for Substack (8/mo$80/yr) is on staff at Massachusetts General Hospital and Harvard Medical School. He comes from a family that has resisted stigmatizing persons who use drugs.  He and his father, Lester, criticize misleading propaganda exaggerating the dangers of drug use. He is a voice of calm who says that drug use is manageable for society and gives confidence to users that they can deal with their problems.

In this article, Dr. Grinspoon criticizes current definitions of Cannabis Use Disorder which formed the basis of a NY Times article warning of increased dangers from pot.

*

There is absolutely no question that cannabis can be addictive, but it is fiercely debated how addictive it truly is. According to the field of addiction psychiatry, a group of specialists who have generally been anti-cannabis for half a century and who have promoted many of the U.S. Government’s mistruths about cannabis in the past, “cannabis use disorder”, (CUD), a term used synonymously with cannabis addiction, is diagnosed objectively when patients fulfill a certain number of criteria over time that have been carefully validated (see below) — just as is done for addiction to opioids or alcohol.

Some of these symptoms that contribute to a diagnosis of cannabis addiction include tolerance, withdrawal, cravings, inability to control use, use in hazardous circumstances, and continued use despite negative consequences. This is not very different from how we diagnose other use disorders except that there are no provisions for medical cannabis patients who are getting needlessly saddled with a diagnosis of “cannabis addiction” merely because they have ‘tolerance’ and ‘withdrawal’. We all have tolerance and withdrawal to many of our prescribed medications – no one says you are addicted to your SSRI, or your coffee for that matter. When diagnosing opioid use disorder, these two qualifiers – tolerance and withdrawal – don’t count if the opioids are medically prescribed, because all patients would have tolerance and withdrawal but not all of them are addicted. So why wouldn’t the same be true for diagnosing cannabis addiction, for the millions of medical cannabis patient? In short, this is how the addiction specialists, operating under the hangover of the War on Drugs, have been (in my opinion) vastly overestimating the number of people with cannabis addiction, to the detriment of all involved.

According to the addiction psychiatrists, the consequences of having CUD can be quite severe (this is true), especially in teens and young adults who are particularly susceptible (this is true). CUD is associated with lower happiness, an unsatisfying social life, lack of career success, lower socioeconomic status, car crashes, emergency room visits, cognitive decline, problems with other drugs, other psychiatric diagnoses, suicide, and low motivation (though, these are misleading; the concept of “associated” is a big problem – it is not causation; other issues, such as poverty, can be an alternative explanation). According to many addiction specialists, use of cannabis should generally be discouraged, except, perhaps if the use is “medical” which they have been skeptical about (less and less so). They believe all drug use is bad (except, perhaps, the social use of alcohol, which caused 172,000 deaths last year).

Many addiction psychiatrists believe that CUD is extremely common and cite studies that show that CUD afflicts up to a quarter to a third of adult cannabis users (which is untrue). According to the American Society of Addiction Medicine (ASAM), “between 9.3% and 30.6% of American adults who use cannabis have CUD.” The fact that this range is gigantic—more than a factor of three begs the question of whether the criteria are somewhat, or possibly vastly, overinclusive and whether they are sensibly applicable to medical cannabis patients (they aren’t). Many are concerned that the legalization of cannabis will result in more cannabis users (this is true) and, consequently, more people that succumb to cannabis addiction (likely true – a proportion of people using any intoxicant get addicted). Regular cannabis users can get withdrawal symptoms which can make it harder to quit.

Many people in the cannabis community don’t believe that cannabis is addictive at all—they think it is just another bogus U.S. government propaganda point. Of note, it was a propaganda point, but that doesn’t mean it isn’t true. A common story is, “I used it for twenty years and then I was able to stop on a dime without any problems. How can it be addictive?” Others think it can be mildly or infrequently addicting, with an occasional person who goes off the rails. Cannabis proponents point out that the majority of studies of its addictiveness have been funded and conducted under the auspices of the War on Drugs, where there was, and still is, massive institutional pressure to demonstrate harm over benefits. (This is true).

How do we disentangle all of this?

What is the definition of cannabis addiction?

There are eleven criteria for CUD. A patient needs to have two out of the eleven of these criteria for at least a year to qualify as “addicted” to cannabis, accompanied by “significant impairment of functioning and distress.” Keep in mind that if you meet two or three criteria you have mild CUD, if you meet four or five you have moderate CUD, and six or more means severe CUD.

The 11 criteria are:

1. Use of cannabis for at least a one-year period, with the presence of at least two of the following symptoms, accompanied by significant impairment of functioning and distress.

2. Difficulty containing use of cannabis—the drug is used in larger amounts and over a longer period than intended.

3. Repeated failed efforts to discontinue or reduce the amount of cannabis that is used.

4. An inordinate amount of time is occupied acquiring, using, or recovering from the effects of cannabis.

5. Cravings or desires to use cannabis. This can include intrusive thoughts and images, and dreams about cannabis, or olfactory perceptions of the smell of cannabis, due to preoccupation with cannabis.

6. Continued use of cannabis despite adverse consequences from its use, such as criminal charges, ultimatums of abandonment from spouse/partner/friends, and poor productivity.

7. Other important activities in life, such as work, school, hygiene, and responsibility to family and friends, are superseded by the desire to use cannabis.

8. Cannabis is used in contexts that are potentially dangerous, such as operating a motor vehicle.

9. Use of cannabis continues despite awareness of physical or psychological problems attributed to use—e.g., anergia, amotivation, chronic cough.

10. Tolerance to cannabis, as defined by progressively larger amounts of cannabis needed to obtain the psychoactive effect experienced when use first commenced, or noticeably reduced effect of use of the same amount of cannabis.

11. Withdrawal, defined as the typical withdrawal syndrome associated with cannabis, or cannabis or a similar substance is used to prevent withdrawal symptoms.

What’s wrong with this?

This is a nuanced discussion which I go over it in granular detail in my recent book, “Seeing Through the Smoke.” The gist of it is:

There are many reasons why our definition of cannabis addiction is not only broken but has been harmful to people.  It is overly inclusive, which I will discuss below. When you give someone a definition of “addiction” (to anything…) when they aren’t addicted, it harms them. They are treated with stigma and judgment by their healthcare providers and are discriminated against by insurance companies. This can result in tangible harms. For example, it has been demonstrated that people who are labeled with any addiction are prescribed fewer pain medications by their doctors and are not treated with as much compassion. Doctors unfortunately share the same stigma against addiction that most other people do.

Dr. Staci Gruber is a brilliant researcher at Harvard Medical School and is the director of the Marijuana Investigations for Neuroscientific Discovery (MIND) program. As she puts it,

As in the case of opioid use disorder, for example, tolerance and withdrawal criteria are not considered for individuals who are using opioids under appropriate medical supervision. With regard to cannabis, similar exclusions from DSM-5 criteria may need to be applied.

I’d get rid of the “may” part. In fact, in a 2013 paper, “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale,” author Deborah Hasin, who has authored several of these studies implicating 30 percent of adult cannabis users as addicted, argues,

An important exception to making a diagnosis of DSM-5 substance use disorder with two criteria pertains to the supervised use of psychoactive substances for medical purposes, including stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic/anxiolytic drugs, and cannabis in some jurisdictions. These substances can produce tolerance and withdrawal as normal physiological adaptations when used appropriately for supervised medical purposes. With a threshold of two or more criteria, these criteria could lead to invalid substance use disorder diagnoses even with no other criteria met. Under these conditions, tolerance and withdrawal in the absence of other criteria do not indicate substance use disorders and should not be diagnosed as such. (emphasis added) If the patient is using benzodiazepines, opioids, or cannabis for legitimate medical purposes, we ought to completely ditch the criteria of tolerance or withdrawal, as these are intrinsic parts of many medicines that we routinely use.

Even the person giving us studies that demonstrate a 30% addiction rate among adult users of cannabis thinks the definitions are broken. (And what does “in some jurisdictions” have to do with anything? Either cannabis is or isn’t a medicine—it’s a pharmacological thing, not something decided by the legislature or voters in Mississippi or Vermont. If a policeman is chasing me and I make it over the border from Idaho into Oregon, are my tolerance and withdrawal suddenly valid and noncontributory to a diagnosis of addiction?)

For all the reasons cited above, Dr. Gruber concludes,

CUD is likely a unique construct among those using cannabis medically, and existing tools developed for use in recreational consumers do not appear to be reliable, valid measures for assessing CUD in medical cannabis patients.

I believe that estimates of CUD have been wildly inflated by roping in millions who use cannabis medically (often with great benefit). I would abandon the concept of CUD altogether and start from scratch. We need to create an untainted measure of cannabis addiction that accommodates the current realities of the drug to better target (and not mistarget) treatment.

How I would fix the definition of cannabis addiction

Given that no one is going to ditch this definition, and that some people clearly do get into trouble with cannabis, how can we adjust the sensitivity of the definition of CUD so it better reflects reality?

I would start by eliminating the categories of withdrawal and tolerance. This makes sense given how many useful and commonplace medications have tolerance and withdrawal as common features of their use, such as opioids, benzodiazepines, and antidepressants. This change would help avoid ensnaring the many patients who are using cannabis for medical reasons, or for reasons of wellness and enhancement, into an unhelpful category of “addicted.”

Next, I would go back to the widely accepted tradition that addiction is a clinically diagnosed disease. We should get rid of this habit of diagnosing millions of people by computer-assisted telephone interviews which, with cannabis, just appears to create this hypothetically addicted body of people who don’t seem to materially exist.

Next, I would increase the number of criteria one needs to qualify for CUD. There is evidence to suggest that a higher number of criteria results in a more accurate diagnosis. The more criteria you require, the more cases you might miss, but the more diagnostic certainty you have for the cases you have diagnosed. Given that we appear to be over-diagnosing cannabis addiction, this seems like a good trade-off, as it would help us to be more certain about the cases we diagnose. It would also help the patients take the diagnosis seriously. If we get rid of tolerance and withdrawal (so there are now nine not eleven criteria) and made it so that you needed four out of nine to qualify (instead of the current two out of eleven), this would be much more accurate. If we did this, a more reasonable number of people given a diagnosis of CUD would actually have a clinically meaningful CUD.

In fact, some recent studies have shown that it is almost entirely “severe CUD,” meaning six or more criteria met (of the eleven), that is associated with psychosocial problems. In my schema (without withdrawal or tolerance), that would equate to needing to meet four out of nine criteria. The main difference is that if we tightened this up, we wouldn’t needlessly be diagnosing, pathologizing, stigmatizing, and, as a consequence, harming so many people who are using cannabis without problems and with benefit.

Further, I would search for a way to incorporate the positives of cannabis use into our diagnostic considerations, to get a more nuanced view of why someone is using cannabis. I understand that this isn’t a common feature of diagnosing an addiction, but it is the only way to make our approach to cannabis—which is a medicine as well as a drug of potential misuse, and which can have positives and negatives at the same time—remotely coherent. There was a recent, excellent article about this, “Harm reduction isn’t enough: Introducing the concept of Mindful Consumption and Benefit Maximization (MCBM)’.

My personal opinion is that cannabis is about as addicting as caffeine. People get extremely dependent on caffeine, yet still manage to enjoy fulfilling lives, not unlike the use of cannabis for many people. Caffeine usually isn’t particularly disruptive, unless you develop palpitations, heartburn, anxiety, or insomnia. Heavy, regular users of either cannabis or caffeine are susceptible to symptoms of cravings, tolerance, and withdrawal symptoms. The use of neither should be stigmatized or criminalized.

Finally – there a misconception that “all drug use is bad”  under any circumstances (except, of course, alcohol…) which I disagree with, but that is for another day.

Posted on by Nathan Riley

Overdose Deaths Are Proof That the U.S. Fails To Provide Healthcare to Drug Users

With a drug overdose, a person gradually stops breathing and while it is not true for marijuana, opioid use can be dangerous.

Crossing the street is dangerous—vehicles kill. That is why we have traffic lights and look both ways before crossing. For the illegal drugs we also have “traffic lights:” Don’t do drugs alone. Be sure there is someone there who can help if the user becomes helpless and could die. Have naloxone nearby to interrupt an overdose.

In cities all over the world, drug users inject, inhale, and snort in facilities where a healthcare specialist is on duty and able to interrupt the overdose, or some other health crisis that threatens the user’s well-being.

But not in the United States.

Such facilities are rare and subject to legal sanction because U.S. law can’t distinguish between a crackhouse and a healthcare facility. It’s not just stupid; it’s cruel and all too often murderous.

New York City should have dozens of these programs. Almost every needle exchange program would like to become a healthcare facility where drug users ingest drugs while a healthcare specialist oversees, ready to protect the user if things go wrong. Even with severe limitation the two facilities in New York City have interrupted 1,000 overdoses.

Needle exchange programs set up to stop the spread of H.I.V. faced opposition. “This neighborhood already has too many programs.” Or providing sterile needles and stopping the spread of disease, “Encourages drug use. There is only one message, and that is ‘Just say no.’” Drug use is wrong, accepting the conclusion that illegal drugs must be demonized. Thanks to the public health community and ACT UP’s demonstrations that delivered pithy messages supporting them, needle exchange programs can be found in metropolitan areas all over the United States. Safer consumption facilities should also become widespread.

The neighborhoods survived needle exchange, and the lives of the general public stayed the same. By and large, only drug users and local officials paid attention to the programs. Adding Supervised Injection Facilities would also neighborhood health.

Drug users should have a place to inject drugs away from public view. Many members of the public are disgusted when users take their drugs on street corners or under bridges. A city with drug consumption rooms protects the neighborhood and the privacy of drug users.

The arguments in favor of safer injection facilities are overwhelming. All over Europe, cities have adopted these programs for decades. But not here. A federal judge in Philadelphia has actually found that U.S. law prohibits these programs. Laws intended to close drug dens also stopped health programs.

This situation is more than stupid. It’s deadly. In New York City, on the average, there are about eight deaths every day from overdoses. In 2014, the state comptroller’s researchers reported 2,300 deaths. In 2021, 5,841 New Yorkers died.

Unless something positive is done, 58,000 New Yorkers will die every ten years. The number of deaths in the United States is equally startling. In 2021, 106,719 died in the U.S. That’s a million deaths every ten years.

Nothing, it seems, will persuade U.S. officials to give drug users “traffic lights” to improve their safety. During this time, fentanyl use spread and increased the risk of an overdose.

Fentanyl is easier to smuggle because just a little bit provides a powerful high. If, as Freedom Democrats advocate, these drugs were manufactured by drug companies and prescribed by doctors, only rarely would the prescription authorize fentanyl. There would have been few, if any, overdose deaths from fentanyl-laced drugs.

But because the United States gives illegal operators a monopoly, they are able to add fentanyl. But facts are facts; in the United States people were using opioids when George Washington’s troops were fighting the British, when the Union was battling the Confederacy, and when the United States entered World War I. Opioid use has a long history and will not go away. Policy makers must recognize this reality.

Opioid use is here. And if Freedom Democrats get their way, it will be a safe drug to use. Obviously, some users will want the drug every day; that has always been true, but so what.

Anybody who knows drug users knows that there are depressed people who depend on it. Others want their high right after they’ve been released from prison, forcing them to go “cold turkey” didn’t stop the memories. Indeed, one group who suffer overdose deaths are recently released persons.

Some drug users live disorganized lives, but there are others who support positive change.

Recent news reports describe such a person. Cecilia Gentili founded Trans Equity Consulting, served as director of policy at GMHC, and was board co-chair of the New Pride Agenda. The details of her death are silent on whether she was by herself when the overdose occurred, or whether she was only an occasional user and unused to the potency of fentanyl-laced heroin.

She was in the news in late September 2024 because the two dealers who sold the drugs pleaded guilty in federal court. They face prison sentences well in excess of ten years, an outcome that would probably sadden Cecilia Gentili, who spent her life helping sex workers and transgender persons live with pride. She fought laws that punished persons for their life choices.

We don’t know anything about a person if all we know is that they get high. The U.S. hostility to drug use rests on witchcraft, not science. The United States attributes magic powers to drugs like opioids, but in fact some users have no problems with their drugs, while a smaller group experience fatal consequences.

Freedom Democrats, I believe, should recognize the dangers of many illegal drugs, like heroin and methamphetamine, but society should recognize, with medical care, these drugs are and can be used safely. It makes no more sense to interfere with the doctor patient relationship by prohibiting the medical profession from prescribing drugs that help a person get high than it does to interfere with the doctor-patient relationship surrounding pregnancy.

In fact, the number of deaths from illegal abortions plummeted once government allowed women to consult and work with doctors during the difficult decision about abortion. The same positive results would happen if society allowed doctors the freedom to work with patients who use drugs, leaving it up to the doctor whether the patient will have access to pharmaceutical drugs whose purity has been verified.

It is critical to end the stigma attached to drug use that often forces users to take their drugs secretly and alone. There is no more chance of the United States becoming a nation of drugs users than lifting the stigma attached to homosexuality made everyone gay.

In fact, working with public health specialists it is possible to control drug use and prevent dangerous outcomes. Sixty years ago, on a hot summer day millions of Americans drank beer to quench their thirst. Today they drink water. That is a positive public health result, achieved with a minimum of criminal sanctions. Making drug use a crime causes deadly results. It’s time for us to welcome drug users into society rather than punish them for their habit. The law also ruins the lives of drug sellers with long prison sentences. The only reason they have a market is because the law makes drugs illegal. If drugs were legal, doctors and patients could make their problems manageable.

 Overdoses are proof that society is failing to provide healthcare.

Posted on by Nathan Riley

Fentanyl Doesn’t Kill, Bad Laws Do

Fentanyl keeps cropping up on the edge of the presidential election campaigns. Some Republicans claim Biden’s permissiveness has flooded the nation by allowing immigrants to bring this deadly drug across our borders.

This is nonsense peppered with half-truths. Each year over a hundred thousand drug users die an accidental death from a drug overdose. A major cause of these fatal events is tied to fentanyl. One reason people keep using it is that they don’t drop dead after getting high. This is always true. The deadly drugs that newscasters and politicians use to justify authoritarian laws kill some people while others survive.

The law and law enforcement give users a small choice of drugs. Then, in an extraordinarily vicious act of social ostracism, the drug users get damned for using the drugs. They are dangerous because they are potent, in other words, a little bit goes a long way. When trying to avoid the cops, a drug that gets many people high but is easily hidden becomes advantageous. This is the exact opposite of what doctors and public health officials would want from a drug.  The notion that illegal immigrants supply U.S. drug users would be silly if people weren’t dying. There are thousands and thousands of people who don’t want to get high from alcohol, nicotine, and caffeine and therefore are pushed into the illegal market. Americans were using opium during our revolution. And guess what? They are still using it.

Fentanyl is an extremely potent form of opium that is manufactured, whereas opium and heroin are plant based. As the newspapers have reported, the fentanyl epidemic started when the United States cut off legal supplies of oxycontin.

Drug companies and pharmacies, responding to new laws, vastly reduced the supply of this relatively safe pharmaceutical painkiller. These companies are law abiding, and when the law restricts supply they comply. Their business is legal, and they want to keep it that way.

It will come as no surprise to students of U.S. drug enforcement that no provision was made for the thousands who made oxy part of their lives. Some bit the bullet, obeyed the law, and stopped using. Others, as always happens, went to the illegal market. Evading the law makes potent drugs like fentanyl a good idea.

The notion that illegal immigrants victimized innocent Americans by supplying them with fentanyl is absurd. Drug users were looking for an alternative to oxy. Fentanyl could be purchased by mail from China. Drug syndicates in Latin America avoiding U.S. law enforcement by smuggling fentanyl into the United States. Immigrants crossing the border are no significant suppliers.

Congress and state legislators could have simply accepted the fact that some users didn’t feel able to give up oxy. It would take longer but would put fewer people in jail and drastically reduce the number of overdose deaths if the law showed some patience and worked with users, even those who kept using oxy.

It requires no special act of genius. This is what we do with people who want to give up drinking or become dangerous when they drink. The problems are similar. Drunk driving laws give law enforcement an entry point without authorizing the harsh and intrusive drug laws.

Drinking is controlled. Younger people have developed the habit of drinking water. At parties, they and their friends who do drink can hang out together without a problem. The same thing can happen with drugs that we label dangerous. What makes them dangerous is the bad laws governing their use. The control is exercised voluntarily, which is the way it should be in a democracy that is governed by the consent of the governed.