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.

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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 · 2 Comments

Don’t Be Fooled: Marjiuana Isn’t Always Fun. For Some It Carries Serious Risks

Legalization is no panacea. Simply lifting the criminal penalties creates new problems, not insurmountable but which require community attention.

Nobody knows this better than Portland, Oregon, where the decriminalization of all drugs became a major source of public dissatisfaction. As might be expected, Covid added to the city’s problems, but national attention focused on the open-air use of drugs, making it a political issue. So widespread was the discontent that the City abandoned its governmental structure. Among the changes, City council districts replaced at-large elections.

A spectacular and thoughtful article has brought similar attention to the problems tied to the sharp rise in marijuana use. About 4.5 million people aged 18 and over use marijuana daily or near daily. In 2002, approximately 1.5% of adults 26 and over were daily users. Today, it has skyrocketed to an estimated 7%.

In a major piece of enterprise journalism, the Times spoke to close to 600 users and discovered frequent illnesses in states across the nation. The journalists described widespread use even among users experiencing negative reactions, who often didn’t connect their symptoms to marijuana use. Although alarmed, many experts the Times consulted remained supporters of legalization. However, every one of them wanted wider recognition of the medical problems, which are often unknown to doctors and emergency rooms.

The newly legal businesses frequently offer products whose potency would give most stoners concern. New users without marijuana experience were vaping with products that had a 90% THC concentration. Anybody who’s hung out with drug users has met some people with a compulsion to persistently seek stronger drugs in the hopes of experiencing better highs.

Current legalization policies not only give such adventurers a free hand to try more potent versions of pot but also permit the marketing of these products to persons with limited experience who are unable to recognize ill effects, even dangers. Legal weed dispensaries don’t only sell grass that is recently harvested; they also sell hybrid products that provide an ever-increasing kick. In short, the Times team described a laissez-faire market lacking regulation.

Think about what would happen if liquor stores had no idea whether their whiskey was 80 proof, 100 proof, or 120 proof. Liquor products are standardized to protect buyers. They know what to expect because government rules mandated be presented to the consumer.

Pot is sold in a variety of products, sometimes from pot plants, other times from hemp, and undoubtedly many products in a pot store are cooked and unnatural.

As people grow older, they select their attitudes towards beer, wine, and liquor. A growing number of young adults simply don’t drink. Bar or restaurant patrons frequently encounter servers who don’t use alcoholic drinks.

What is surprising is the extent to which users experience problems that are often associated with booze: vomiting, mental confusion, and even cause psychosis. But all too often the public believes pot is harmless, which is often true but not always.

A more serious illness tied to marijuana is cannabinoid hyperemesis syndrome (CHS). A wide range of symptoms mark the syndrome:  “nausea, vomiting and pain… extreme dehydration, seizures, kidney failure.” Even cases of cardiac arrest are reported. According to the three reporters on the Times team, doctors and users are unfamiliar with the connection between these symptoms and marijuana use.

Legalization properly done will inform the makers of marijuana products, the medical community, and consumers about the risks. The bottom line is that pot and other psychotropic drugs should be treated with respect, and many should stay away.

The outlook is cloudy. Congress can’t even agree on legislation that gives sellers and growers full access to banking facilities. Many people still attribute magic powers to pot and see it as a life-destroying force. The great merit of the Times article is the clarity with which it recognizes the pleasures experienced by potheads while offering specific and detailed information about how things can go wrong. The impact of the Times story, presumably the first of many, on the legalization community is uncertain. Many, including this writer, will think it’s an argument to make pot use a crime. It took me three readings to realize that Megan Twohey, Danielle Ivory, and Carson Kessler had fairly weighed the contentious arguments and found problems that any fair-minded person would want to address.

Posted on by Nathan Riley

Sex Work Isn’t the End of the World

The last place you’d expect to find a thoughtful discussion of teenage prostitution is a four-dollar Amazon gay romance.

Dark Angel is Corbin’s tale of trading sex for money. A key reason this novella deserves serious consideration is his family’s circumstances. His mom’s job doesn’t cover living expenses, a predicament tens of thousands of families face every week.

It isn’t a sociological study; it’s a dramatic story. Corbin shouts at his fourteen-year-old brother “Shut up!  Someone has to support this family…” “Don’t be naïve.  You think Mom can magically support us now that she found a crappy ass job that likely pays next to nothing? Don’t you understand, Charles?  Financially, we’re fucked.”

Mark Roeder has an ear for dialogue; whether it is a bunch of jocks ribbing each other or a teacher talking to a student, you immediately recognize that this is the way people talk to each other all over the United States. For years, followers of his work have recognized this as a strength of his writing. But Dark Angel turns a new page with its sympathetic portrayal of the pressures young Corbin faces in high school. Roeder, who often writes fantasy novels, becomes realistic without losing his charm.

Corbin’s predicament is powerful but also so common that it deserves serious consideration in discussions of legalizing sex work.

The family is already living on the edge when the father walks out. Corbin and his older brother kick in cash to help their desperate mom and keep the family together. It’s money earned from older guys paying for sex. It’s shady money. Both Corbin and his older brother, Marc, move easily into other scams that pay. Corbin believes there is little difference between prostitution, stealing, and drug dealing. Corbin is convinced they are equally bad, and he is scarred for life by his participation in the underworld. But the reader is unconvinced. His devotion to his mom and family leads him to use the money to pay for the electric bill and groceries.

How Corbin breaks out of this cycle forms the book’s dramatic tension.

His mom doesn’t get rich but does find a good man. The book never wavers from its depiction of low-wage work and the harsh effects it has on family life.

The father’s cruelty works its harshest effects on the oldest child, Marc, who had the strongest ties to his dad. A subplot depicts the horrid results.

Set in 1972, in small-town America, the book makes it clear that teenagers will find ways to meet men with money. Corbin is introduced to sex work by his older brother. Other characters in the book seek money for college or every day expenses. There is nothing in the predicament faced by these teenagers that can be solved easily. People looking for policies that will end these practices that have existed for centuries will find little encouragement. Teenage sex workers exist all over the world.

But Corbin is lucky and, of course, a teenage romance has a happy ending. Once his secret is discovered by his teacher, who is also his mom’s new boyfriend, Corbin goes into therapy.

There he learns that his brother and the Johns didn’t “make him gay.”  But advocates of legalization recognize that this confusion causes great pain and often leads to deep-seated hatred of gay men. Legalization ends the myth that behavior like sex work or gambling are soul-destroying activities. It enables people mixed up in these activities to see that they are good people.

Corbin escapes when a good man ends the family’s desperate struggle to make ends meet. Sex worker after sex worker have long insisted that they must have good jobs if they are to start new lives.

It’s a measure of the wisdom of Dark Angels that Mark Roeder recognizes this gut economic reality. The pleasure of reading this work comes from meeting the family, and one presumes there will be a sequel.

Posted on by Nathan Riley

Protect Women Make Sex Work Legal

In San Francisco, decades ago heroes of the legalization movement—like the scarlet harlot Carol Leigh—popularized the ingenious phrase “sex work.” She and her fellow radicals curbed the disgust conveyed by taunts like “whore” and “hooker.”

The new phrase replaced contemptuous words directed at the women but sheltered the men buying sexual favors.  Such language stigmatized relationships without evidence. Carol Leigh’s punchy slogan, “Sex work is work” took the mystery out of these sexual contacts by reminding us that buying and  renting are mundane daily activities.

This approach developed during the sexual revolution, when women’s right to their bodies and sexual pleasure became socially acceptable. This social change brought many positive benefits, including making same sex attractions legal and granting freedom of speech to pornography. It was an imperfect solution that It led to an increase in STDs and fostered the spread of AIDS.  Proving no good deed goes unpunished.

When it was illegal, pornography had been labeled prostitution. After all, the performers were paid to have sex. The sexual revolution increased the public’s recognition of the variety of sexual behaviors.

One obvious result: a worldwide multibillion-dollar industry centered around pornography.  It became a big business with local economic impacts and jobs. It offered vicarious sexual pleasures to the elderly, the timid, and the obese.  Of equal importance, in the United States it offered employment to drug users and people released from prison. There is testing for contagious diseases. These jobs are open to anyone. High school diplomas are not required. There is no drug testing.  No check of criminal records.  It is a unique job opportunity open to everyone, unlike most work in the U.S.

 Clearly the requirement of sexual availability limits the number of persons willing to do sex work. This activity isn’t for everyone. But it has attractions. The preparation for this work has a pleasant side: what do I wear, what make-up, showering and douching.  The sex worker is a performer. But there are serious differences between those who live a middle-class life and work by appointment, and the poor desperate for money. All over the United States there are unemployed individuals who don’t live paycheck to paycheck, but survive day to day. For a person trapped in this situation sex work is often humiliating. There are threats of violence and encounters with the police whose enforcement efforts target people of color living lives of quiet desperation. For the street walker, one sex act may not provide the money to meet daily expenses; they must find multiple partners.

All too often, they must turn their earnings over to a panderer, who confiscates most of their money. But even this nightmare scenario has complications. An older woman can hire a young man to perform chores including protecting the women they work with from violence. In this arrangement, the woman with experience runs the show. The young man follows the woman’s lead. Figuring out who is the sex trafficker isn’t obvious. The hostile phrase “sex trafficker” is a problem; this is a dangerous criminal activity. This hostile rhetoric ignores the accomplishments of people who rent their bodies. They are graduate students, comedians like Carol Leigh, marathon runners; there is more to their lives than sex work. But these words generate hostile public opinion. It is a right-wing movement trying to ignite hostile reactions.  For example, these groups call queer and trans individuals pedophiles and groomers.

Sexual arrangements are as varied as the capacity for human invention. For those groups hostile to sex work the nightmare scenarios predominate; the sex workers are victims—the exploited poor. They can’t and they don’t argue that the women who spentd time with wealthy men are “victims of sex trafficking.” Their rhetoric would have us believe that sex workers walk the streets living in fear of violent pimps. They favor using existing laws making sex work illegal. Their conclusion that the criminal law will bring positive results is not compelling. They believe this approach will get women off the street, protect children, and curb the social menace of “trafficking.”

They eagerly shut down brothels where women work a set number of hours, servicing the customers who walk through the door. All too often these women spend a workday earning a share of their fees with the brothel owner. Because sex work is illegal, these women can’t complain to the government or seek changes in their working conditions. These complaints would backfire: the women lose their job, the brothel is closed, and rules that will improve relationships between the customer, the sex worker, and the brothel owner are buried when they should flourish. Making brothels illegal, makes reform difficult; the only legal option is shutting the business down.

These establishments charge fees within the reach of working men, often immigrants or travelers who are separated from their families. Discussions of sex work should acknowledge class distinctions. A business charging customer $50 has different problems from the sex worker who earns $1000 in a night. Such acts occur in the privacy of an apartment or hotel room and are seldom investigated by law enforcement. The brothels that charge lower fees and depend on a volume business ask their women to have sexual encounters constantly throughout the working hours. Working conditions in a legal environment could give women more control over the number of customers and curb greedy brothel owners. Ideas for giving women autonomy in these situations receive little publicity and are seldom part of the public dialogue.

In many states, the injustice of arresting women while men avoid prosecution have led district attorneys and legislators to support decriminalization of sex work. This is clearly a positive first step. It combats racism and male chauvinism in law enforcement. Arresting men doesn’t really end the injustices. All too often the men’s needs are simple, and their choice of a transitory sexual encounter is free of criminal intent. The hope that arresting men will control prostitution seems dubious. Sex work for people with little money has always been an underground affair. The most likely outcome is that only a few customers will be arrested while the sex work industry finds ways to avoid prosecution. The legality of paying for sex is a contentious issue. The public will never unite and support one policy. The number of customers and women are greater than the resources of law enforcement, which must focus on other priorities like violent crimes and preserving public order. In short, law enforcement is unlikely to stop this illegal activity. And of perhaps greater importance it is unlikely that the public will give enthusiastic support to a crusade against prostitution. Consequently, only some sex workers and some customers will be ensnared by the legal system. The arrests become discretionary and unfair. Why should a small minority be punished while the majority go scot-free.

Legalization doesn’t mean approval, and it doesn’t mean a loss of social control. Cigarette smoking has been greatly diminished even though it has remained legal. Making alcohol illegal provided criminals with huge amounts of cash and left the police dealing with corruption. But once it became legal, drunk driving enforcement, and reminders that drinking water is healthy reduced alcohol consumption. The legalization of sports betting has diverted profits from criminals to businesses. Sports betting has brought professional basketball money for players’ salaries and the creation of midseason playoffs with big cash awards for winners. Making sex work legal would give women a platform for changes and greater protection. If their work is legal, they can call the cops to stop violence.   Small changes that cumulatively have a big impact will bring positive results with legalization.