The Drug Policy Digest

Thursday, January 30, 2003
Does Drug War "Prohibition" Cause Violence?

An article on Reason magazine's website takes on the big question of whether drugs cause violence. The alternative, the drug prohibition causes most if not all of the drug-associated violence we see in the newspapaers, seems to be Reaon author Ronald Bailey's position. Read the article here and give the matter some thought. I doubt that it is as clear as either side of the drug war debate claims, but the federal government's drug policies are having broad effects in many communities.

Friday, January 24, 2003
Canada Slow to Accept U.S. "Reefer Madness" View

This article from the National Post (Canadian) is worth a look for an outsider's view of American cannabis policies. The photos alone ("Marijuana Girl") are a story.

England's New Drug Strategy Expands Use of Prescription Heroin Use

The British Home Office has recommended that heroin users should, in certain circumstances, be able to get the drug on prescription from their general practitioners.

A few weeks ago, the British Government unveiled its National Drug Strategy which, on the surface, seems remarkably like that of the United States. The plan, entitled Updated Drug Strategy 2002, cites the following main elements:

– Primary Prevention - preventing today's young people from becoming tomorrow's problematic drug users;

– Reducing Supply - reducing the supply of illegal drugs;

– Communities - reducing drug-related crime and its impact on communities;

– Treatment and harm minimisation - reducing drug use and drug-related offending through treatment and support. Also, reducing drug-related death through harm minimisation (British spelling here and there).

Of course, the section that will get the most attention here is the plainly stated: "Treatment and support need to be accessible to those who need them regardless of ethnic origin, gender, sexual orientation or source of referral. Although waiting times are getting shorter, in some areas and some services they are still too long. There are also gaps in service provision: in particular, treatment for crack users is not available for all who need it. There also needs to be greater consistency across the country in provision of services such as heroin perscribing. More needs to be done, and will be done, to ensure that people living in deprived areas have access to treatment, as part of the wider process of neighbourhood renewal." (my emphasis)

In the context of what they are now doing in the United Kingdom, this is nothing dramatic and the prescribing of injectable heroin is now most often done as a transition to the use of methadone (although doctors in the U.K. often prescribe injectible methadone to maintenance patients, a practice forbidden in the United States).

Still, for those of us in "The Colonies," it is a bit of an eye-opener. Between this and Canada's marijuana decriminalization proposal, I suspect that my friends in the ONDCP (the Office of the "Drug Czar") are not amused.

Thursday, January 23, 2003
FDA Issues Unusually Harsh Warning to Purdue Over OxyContin

In an interesting development, the FDA, has issued an unusually harsh letter warning Purdue Pharma, Ltd. about advertising placed in medical journals for the drug OxyContin. OxyContin is a timed-release oral form of the narcotic painkiller oxycodone hydrochloride (HCl) -- the same active ingredient in the drugs Percodan and Percocet. Unlike these other pharmaceuticals, OxyContin is manufactured without aspirin or acetaminophen (Tylenol) and can contain anywhere from 10 milligrams of oxycodone HCl to 160 milligrams of this active ingredient. By contrast, the original dosage of Percocet contained just 5 mg. of the same ingredient, although Endo Pharmaceuticals, Inc. has been offering dosage forms of up to 10 mg. for about two years. OxyContin, when prescribed at the 160 mg. dose, contains the amount of narcotic painkiller equivelant to 32 tablets of Percocet at the original dose.

In fairness to Purdue Pharmaceuticals (and patients who must receive narcotic analgesics for legitimate purposes), it should be noted that they advise physicians that both the 80 mg. and 160 mg. dosage forms should be reserved for patients who are already "opioid-tolerant." This is often the case in patients suffering chronic pain due to cancer or certain other disease processes. Studies cited by Endo in their release of new forms of Percocet noted that 75 percent of patients receiving prescriptions for Percocet were getting more than the original dosage form would ordinarily permit (1 tablet every 6 hours). Untreated or under-treated pain may be as large a problem in society as addiction itself, according to some observers.

The prescribing directions for the product clearly indicate that OxyContin is not for "prn" (take as needed) use, but should be reserved for patients requiring "around the clock" narcotic pain relief "for an extended period of time." In addition, the drug should be prescribed only for "moderate to severe pain." This is not the kind of medication that one should take for a simple headache or for muscle strain (although I have no doubt that it would work well in either case). Less potent medications (including some narcotic combination drugs) would be just as effective and not nearly as potentially hazardous.

Those abusing OxyContin often defeat the timed-release feature of the drug by crushing the tablet and either "snorting" (the correct term is "insuflation") the powder or mixing it with water and injecting it. As biting down on the tablet is strongly discouraged (it can cause an immediate release of the entire "load" and result in an overdose), these practices have lead to fatalities in some who abuse this medication.

The FDA's letter states that Purdue "grossly misrepresent(s)" the safety profile of their product in ads published in JAMA in October and November of 2002. The manufacturer, according to the FDA had failed to properly disclose the "fatal risks" and abuse liability of their product. In addition, the letter claims that Purdue tacitly encouraged the prescribing of OxyContin for painful conditions that are neither chronic (requiring around the clock dosing for extended periods) or sufficiently severe ("moderate to severe pain") in violation of their own prescribing information.

Too bad. OxyContin is an excellent medication for moderate or severe pain. The FDA letter reads more like a cease and desist order (including threats of product seizures) than a regulatory advisory. Purdue better come out with the "abuse resistant" form of this medication quickly. Supposedly they haven't been too happy with the addition of naloxone (Narcan, another product of Endo Pharmaceuticals) or other antagonists -- a tactic that worked well in controlling Talwin abuse almost 20 years ago. Click here for more detail on the OxyContin controversy.

They might want to do something, or several things, soon.

Tuesday, January 21, 2003
New JAMA Report Resurrects the Marijuana "Gateway" Theory

A new study published in today's issue of the Journal of the American Medical Association has revisited the marijuana "gateway" argument. JAMA is normally not available to non-subscribers, but the editors have made this article available to those who want to read it.

The study, by a group of Australian researchers, examined 311 sets of same-sex twins in which only one twin had smoked marijuana before age 17. Early marijuana smokers were found to be up to five times more likely than their twins to move on to harder drugs.

If you've heard this (or something like it) before, you might want to skip to the authors' conclusions and discussion:

"The results of our co-twin control analyses indicated that early initiation of cannabis use was associated with significantly increased risks for other drug use and abuse/dependence and were consistent with early cannabis use having a causal role as a risk factor for other drug use and for any drug abuse or dependence." After pointing out that causation is difficult to prove in these types of studies, the team notes that "Regardless of the mechanisms underlying these associations, it is apparent that young people who initiate cannabis use at an early age are at heightened risk for progressing to other drug use and drug abuse/dependence."

Tempering these findings are the authors' warning that "While the findings of this study indicate that early cannabis use is associated with increased risks of progression to other illicit drug use and drug abuse/dependence, it is not possible to draw strong causal conclusions solely on the basis of the associations shown in this study."

An accompanying editorial by Columbia University's Denise Kandel, who has published studies on this question for over 20 years, reminds us that other recently published studies, including one by RAND's Dr. Andrew Morral, have shown alternative explanations for the association between marijuana and other drugs. A curious note in the JAMA piece is the statement that "In addition to cannabis dependence, the health risks associated with chronic cannabis use may include chronic bronchitis, impaired lung function, and increased risks of cancers of the aerodigestive tract." It seems to me that attempts to support the "gateway" theory run the risk of implicitly conceding the point that marijuana use per se is not hazardous but leads to the use of other hazardous drugs. I'm not certain that the drug warriors are ready to concede this fact and therefore, they might want to avoid the "gateway" idea all together. But, that's just my opinion. Read the study yourself and draw your own conclusions.

Can PCP be Held Guilty of Homicide?

A recent article by Reason magazine's Jacob Sullum does an excellent job of examining the connection between PCP (and other drugs) and violence. It is worth a look:

"Everything people used to say about marijuana is true of angel dust." So claimed Robert DuPont, director of the National Institute on Drug Abuse, in 1977.

Mr. DuPont's comment is worth revisiting now that Washington, D.C.'s police chief is citing "angel dust" — the veterinary anesthetic phencyclidine (PCP) — as an explanation for his city's rising homicide rate. End-of-the-year figures show that homicides in D.C. jumped 12 percent between 2001 and 2002, and Police Chief Charles Ramsey says increased PCP use is one reason.

"It's really alarming," Chief Ramsey told The Washington Times in December. "We are seeing PCP use on the rise, and when you couple that with the number of weapons on the streets, we are seeing an increased number of homicides."

Robert DuPont's 1977 warning about PCP suggests one reason to be skeptical of this theory: Back in the 1920s and '30s, police spoke just as confidently about a link between marijuana and violence. The Federal Bureau of Narcotics portrayed marijuana as "the killer drug," giving men "the lust to kill, unreasonably and without motive."

One of the first such reports came from a Texas police captain who claimed habitual marijuana users "become very violent, especially when they become angry, and will attack an officer even if a gun is drawn." He added that they "seem to have no fear," are "insensible to pain," and display "abnormal strength," so that "it will take several men to handle one man."

This description is eerily similar to contemporary stories about PCP users, whose rage and superhuman strength are said to resemble those of the Incredible Hulk. Of course, the fact the authorities were wrong about marijuana does not mean they are wrong about PCP. But a careful examination of the evidence provides little support for PCP's reputation as a Dr. Jekyll potion that unleashes the monster within.

In a 1988 review of 350 journal articles on PCP in humans, the psychiatrist Martin Brecher and his colleagues noted that high doses of PCP can produce "severe agitation and hyperactivity," along with "cognitive disorganization, disorientation, hallucinations and paranoia." Combined with the drug's anesthetic effect, which makes users less sensitive to pain and therefore harder to restrain, such acute reactions have contributed to PCP's fearsome image.

Yet in their search of the literature, Dr. Brecher and his coauthors found only three documented cases in which people under the influence of PCP alone had committed acts of violence. They also noted that between 1959 and 1965, when PCP was tested as a human anesthetic, it was given to hundreds of patients, but "not a single case of violence was reported."

Dr. Brecher and his colleagues concluded that "PCP does not live up to its reputation as a violence-inducing drug." That does not mean PCP users are never violent. But when they are, their behavior cannot be understood as a straightforward effect of the drug.

"Research on the nexus between substance use and aggression," notes the criminologist Jeffrey Fagan, "consistently has found a complex relation, mediated by the type of substance and its psychoactive effects, personality factors and the expected effects of substances, situational factors in the immediate settings where substances are used, and sociocultural factors that channel the arousal effects of substances into behaviors that may include aggression." The pharmacologist John P. Morgan and the sociologist Lynn Zimmer put it this way: "No drug directly causes violence simply through its pharmacological action."

This point is obvious when we consider alcohol, the drug that is most strongly associated with violence. The fact that some people get into fights after drinking does not mean alcohol makes them behave that way. Variations in responses to alcohol across individuals, cultures, and situations show drinking does not necessarily lead to bloodshed.

Another complication is that drug prohibition creates a black market in which disputes are resolved through violence. An analysis of New York City homicides committed in 1988 and identified as "crack-related" found 85 percent grew out of black-market disputes. Only 1 homicide out of 118 involved a perpetrator who was high on crack.

Read the entire piece online at The Washington Times

Friday, January 17, 2003
"Drug Strategies" Group Releases Guide to Teen Drug Treatment

Drug Strategies, a Washington-based drug policy group, has released a manual for those interested in finding quality drug treatment programs for adolescents with substance abuse problems. Titled Treating Teens: A Guide to Adolescent Drug Programs, the guide catalogs 144 treatment centers nationwide that the authors say have at least some of the key elements needed for effective adolescent drug treatment.

Few scientific studies have attempted to show reliable success rates for individual programs -- let alone accurately and objectively compare one treatment center to another. The study's authors convened a group of 22 experts who reached agreement on qualities said to be desirable in a teen drug treatment center. Programs should include families in a teen's treatment and should also provide care for learning disabilities, psychiatric disorders and other problems that commonly go along with drug abuse in younger patients.

Continuing care (aftercare) that lasts several months and provides programs that are tuned to teens' age groups and intellectual abilities are also lauded.

Only a minority of teens who use drugs addictively ever get treatment and that parents often don't know how to choose the best programs.

Nearly 11% of US teens were classified as current users (the often-cited correlate of problem use) of illicit drugs in the federal (SAMHSA) 2001 National Household Survey on Drug Abuse.

Only 10 to 20% of those in need of help actually get treatment, according to estimates provided by Drug Strategies.

Still, most teens who need the kind of drug treatment described in the guide cannot afford to pay for it -- even when a suitable program can be identified.

According to the guide, other key elements of effective teen drug treatment programs include:
-- Programs to assess teen's problems and match them to different types of care.
-- Strategies to engage and retain teens' interest in treatment.
-- Qualified staff
-- Gender and "cultural competence"
-- Some measure of treatment outcomes, if available.

Alaska's Lieutenant Governor Snuffs Marijuana Decrim Effort

Readers of The Drug Policy Digest may recall that Alaska once had one of the nation's most liberal marijuana laws for years -- at lease they had such a policy some 15 years ago. An Associated Press report claims that backers of a marijuana reform measure in Alaska may be fighting an uphill battle. Juneau (Alaska) Lt. Gov. Loren Leman stopped an initiative drive seeking to decriminalize marijuana, ruling Tuesday that hundreds of signatures collected were not valid. Leman, a former state senator who sponsored a bill in 1999 to turn back the state's medical marijuana laws, said in a statement that the pro-marijuana group will have to begin from scratch to get its measure before voters in 2004.

The proposed initiative would have asked voters to decriminalize and regulate marijuana.

Backers submitted 484 booklets containing signatures of Alaskans who supported putting the measure on the ballot. But officials with the state Division of Elections found several discrepancies in the petitions, Leman said. In several instances the identity of those who signed the petitions could not be verified or were not registered voters, and
election workers omitted 194 booklets containing signatures because of poor record keeping.

Tim Hinterberger of Anchorage, one of three primary sponsors of the initiative, said Tuesday night that he "more than anticipated" Leman's reaction, saying "We're sure they'd prefer not to see this on the ballot." [This seems like a pretty good guess!]

Alaska law requires a petition drive to collect signatures equal to 10 percent of the voters in the previous statewide election to get an initiative on the ballot. Backers of the marijuana initiative needed 28,782 signatures to get the measure on the 2004 ballot. The state Division of Elections verified 21,737 signatures of registered voters, said a spokeswoman for the group. Well, there's always 2006...

Thursday, January 16, 2003
Former DEA Analyst Sentenced in Information Sale

Today's New York Times notes the story of a DEA analyst who has been sentenced to prison for selling information on a British businessman to, well.... The New York Times. The British businessman, one Michael Ashcroft (no relation to our AG), was said to have made huge donations to the Conservative Party from a business in Belize. The Times stories detailing this activity suggested that Ashcrofts' business had links to drug dealing. Subsequently, the newspaper settled a libel suit with Ashcroft and published a statement saying none of his businesses in Belize were suspected of having ties to drug dealing.

The DEA did not disclose what information Randel sold, although the agency said he had access to computer databases containing secret information about suspected drug traffickers. This information is of obvious value to journalists and would command far higher prices if offered to the targets of criminal investigations. It is a long-standing practice for senior government officials to authorize the leaking of selected information ("authorized leaking") to journalists in order to influence public opinion or policy decisions by other branches of government. This act, however, seems to have been a simple instance of profiteering committed in 1999.

Federal prosecutors said the analyst, Jonathan Clay Randel, sold the information for $13,000 to a British television correspondent who freelanced for The New York Times. Read the story here.

Monday, January 06, 2003
The Return of PCP

Those who recall the drug "Angel Dust" (PCP or phencyclidine) from 20 years ago will not be pleased by the story in The Washington Post documenting the drug's apparent reappearance in the Washington, DC area.

This development is alarming as people under the influence of PCP sometimes engage in some very destructive behavior, and may become violent. PCP's anesthetic properties can make traditional methods of controlling a person's behavior (restraint through holds that can cause pain if resisted) ineffective. This has resulted in the use of deadly force to subdue those under the influence of PCP.

Take a look at the Post report here.