Americans Spending $100 Billion on Illegal Drugs Annually

The U.S. White House Office of National Drug Control Policy (ONDCP) commissioned the RAND Corporation to investigate how much Americans were spending on the four most common illegal drugs from 2000-2010. The study, published recently on the whitehouse.gov website, uses a variety of sources to develop an estimate in yearly spending by consumers of cannabis, heroin, cocaine (including crack), and methamphetamine. Their conclusion: over $100 billion is spent on just these four drugs, every year. Interestingly, this number has stayed relatively constant throughout the past decade, despite the $25.2 billion that was spent "to reduce drug use and its consequences" in the US in fiscal year 2014 alone (!).

Since 2002, spending on cocaine and marijuana has flipped. Researchers note that cocaine consumption has dropped by about half, while marijuana consumption has increased by around 40%. Heroin consumption has remained stable throughout the decade, with a small increase detected in the later years. Methamphetamine consumption, the authors note, has been harder to track, as "national datasets do not do a good job of capturing its use." Across the board, heavy users are the main drivers of spending and consumption, and are defined as folks who use at least 21 days/month.

The authors culled data from a variety of sources, including the National Survey on Drug Use and Health, the Arrestee Drug Abuse Monitoring Program, various law enforcement and seizure databases, and more. Despite the apparent rigor involved in the creation of these estimates, the authors caution about the inherent uncertainty in this type of data analysis - especially considering that the bulk of the data came from self-report surveys.

Nevertheless, the fact remains that despite the increasing public investments in the so-called War on Drugs, demand-side consumption and expenditures are constant or rising throughout the country. Could this be one reason the Attorney General has agreed to endorse changes to Federal drug sentencing? What do readers think about the current state of availability and expense?

You can read the full report here:

http://www.whitehouse.gov/ondcp/research-and-data/estimation-drug-expenditures-consumption-supply

Study: Sex-Dependent Differences in Subjective Cannabis Effects (Do Women Enjoy Pot More Than Men?)

A new article by researchers at the New York State Psychiatric Institute and Department of Psychiatry at Columbia University explores the differences in the way men and women report their subjective experiences of the effects of cannabis. The authors reviewed data from four separate outpatient studies evaluating a range of cannabis-induced effects. In the final analysis, the subjects (35 men and 35 women) were all daily or near-daily cannabis users and their responses to standardized measures of mood, physical symptoms, and cannabis-related drug effects were recorded over time, beginning immediately after consumption.

It turns out, women were significantly more likely to report more feelings associated with enjoyment (and abuse liability) than men were:

According to the authors: "The results from this study demonstrate that when cannabis smokers are matched for use, ratings of cannabis’ subjective effects that are associated with abuse liability are higher in women compared to men. Although men and women significantly differed in body weight, sex differences were not observed for all subjective effects, including ratings of cannabis intoxication. "

In addition, cannabis use is more prevalent among men than women in the US (51.4% vs 37.4%, resp.). "Yet among cannabis smokers, women have a faster trajectory to cannabis-use disorders, which the current findings might in part explain." The authors call for more research to further explain the clinical significance of sex differences in the effects of cannabis and cannabis-use disorders.

The article by Cooper & Haney can be viewed here:

http://www.drugandalcoholdependence.com/article/S0376-8716%2813%2900529-2/abstract

Illicit Online Retailers Expand In Response to Silk Road Closure

In an editorial published last week in the journal, Addiction, researchers from the University of New South Wales, Australia, sought to quantify the movement of illicit online drug retailers to alternative marketplaces on the so-called "dark web". On October 3, 2013, the FBI shut down the Silk Road, the largest of these marketplaces for illicit substances, and often referred to in mainstream media as the eBay of illegal drugs. Since then, consumers and sellers have simply moved to other sites, which themselves have seen an explosion in the number active retailers since October 3rd.

Two sites in particular have seen dramatic increases: "Black Market Reloaded" has experienced a two-fold increase in active retailers, and "Sheep Marketplace" a five-fold increase. A new version of the Silk Road, "Silk Road 2.0", opened in November and had 92 vendors by their second day of operation.

Here's the graph from the editorial:

Via:
http://onlinelibrary.wiley.com/doi/10.1111/add.12422/full

Study: Hallucinogen Use Predicts Reduced Criminal Justice Recidivism

In a potentially fascinating article, published in this month's Journal of Psychopharmacology, researchers identified a correlation between naturalistic hallucinogen use and reduced recidivism among substance-involved offenders under community corrections supervision. The sample is very large (n=25,622) and it appears the relationship remains after controlling for "an array of potential confounding factors." Given the report last year that lifetime psychedelic use was not associated with current mental health problems in an adult population, this study's implications could be especially interesting.

Unfortunately, my institution doesn't allow me access to this journal - if there are any readers who can access the full article, please let me know.

(Comment after the fact: Keep in mind that this shows a correlation and that correlation does not establish directionality. That it, it's at least equally plausible that people with a diagnosis of psychedelic use disorder (a tiny fraction of the population) are different in ways that statistical controls cannot compensate for, and are therefore less like to reoffend. This makes sense in that psychedelic drug use is minimally addictive, if at all, and craving and urges are not typical in this group. It seems highly implausible to me that hallucinogen use had a beneficial effect. The authors should never have been allowed to make that claim, a fault of the editor. In addition, use of LSD or psilocybin has never been associate with increased incidence of mental disorders, in contrast to MDMA or synthetic cannabinoids.)

Here's the abstract via SagePub:

Abstract

Hallucinogen-based interventions may benefit substance use populations, but contemporary data informing the impact of hallucinogens on addictive behavior are scarce. Given that many individuals in the criminal justice system engage in problematic patterns of substance use, hallucinogen treatments also may benefit criminal justice populations. However, the relationship between hallucinogen use and criminal recidivism is unknown. In this longitudinal study, we examined the relationship between naturalistic hallucinogen use and recidivism among individuals under community corrections supervision with a history of substance involvement (n=25,622). We found that hallucinogen use predicted a reduced likelihood of supervision failure (e.g. noncompliance with legal requirements including alcohol and other drug use) while controlling for an array of potential confounding factors (odds ratio (OR)=0.60 (0.46, 0.79)). Our results suggest that hallucinogens may promote alcohol and other drug abstinence and prosocial behavior in a population with high rates of recidivism.

Sources:
http://jop.sagepub.com/content/28/1/62.abstract
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0063972

Update:
Thanks to Paul and Jason for sending the full piece. 
Treatment Accountability for Safer Communities (TASC)provided the authors access to de-identified records on 25,622 felony-charged individuals on community corrections supervision from  between 2002-2007. "Any hallucinogen use" was not a descriptor in the data, so they were confined to hallucinogen-use disorder, abuse or dependence, assuming that case workers would likely interpret any use as disordered. Interestingly, 73.6% of folks with a hallucinogen-use disorder in the sample were white/Caucasian. And, according to the researchers, hallucinogen-use disorder was the third strongest predictor of recidivism rates, behind cocaine- and cannabis-use disorder, respectively, which most strongly (but positively) predicted recidivism.The authors call for RCTs to explore hallucinogen-based therapies in the criminal justice population.

Vermont Governor Devotes Entire State of the State Address to Drug Addiction

From yesterday's NY Times:

In Annual Speech, Vermont Governor Shifts Focus to Drug Abuse

In a sign of how drastic the epidemic of drug addiction here has become, Gov. Peter Shumlin on Wednesday devoted his entire State of the State Message to what he said was “a full-blown heroin crisis” gripping Vermont.

“In every corner of our state, heroin and opiate drug addiction threatens us,” he said. He said he wanted to reframe the public debate to encourage officials to respond to addiction as a chronic disease, with treatment and support, rather than with only punishment and incarceration.

“The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards,” Governor Shumlin said, “while we fear and fight treatment facilities in our backyards.”

...

Read the rest of the story here: 

http://www.nytimes.com/2014/01/09/us/in-annual-speech-vermont-governor-shifts-focus-to-drug-abuse.html

Is Florida Turning a Corner?

According to a brand new study, published online this week in the journal, Pharmacoepidemiology and Drug Safety, Florida's recent legislative actions to 1.) strengthen the state's prescription drug monitoring program, and 2.) toughen the regulation of the state's pain clinics, seem to be having the desired effect: drug diversion has been dropping steadily since 2011. In addition, according to the state's commission of medical examiners, prescription opioid overdose deaths are dropping too. Here's the abstract from the article and a figure of the models of longitudinal change, according to each drug: 

Reductions in prescription opioid diversion following recent legislative interventions in Florida

Surratt, et al., 2013

Purpose
Florida has been at the center of the nation's ongoing prescription opioid epidemic, with largely unregulated pain clinics and lax prescribing oversight cited as significant contributors to the opioid problem in the state.

Methods
In an effort to mitigate prescription opioid abuse and diversion in Florida, legislative interventions were implemented during 2010 and 2011, which included two primary elements: (i) comprehensive legislation to better regulate the operation of pain clinics; and (ii) a statewide prescription drug monitoring program to promote safer prescribing practices. Using systematic longitudinal data collected on a quarterly basis from law enforcement agencies across Florida, this report examined changes in prescription opioid diversion rates following implementation of these regulatory initiatives. Quarterly diversion rates for buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, and tramadol were calculated, and subsequently, hierarchical linear models were fit to test for differences in diversion rates over the 15 quarter period of interest.

Results
Significant declines in diversion rates were observed for oxycodone, methadone, and morphine; hydrocodone displayed a marginally significant decline.

Conclusions
This study documented reductions in statewide opioid diversion rates following implementation of Florida's pain clinic and prescription drug monitoring program legislative interventions. Although these initial findings appear promising, continued surveillance of diversion is clearly warranted. Copyright © 2013 John Wiley & Sons, Ltd.

NIDA/NIAAA Merger Called Off!

This morning, Francis Collins, MD, PhD, the Director of the National Institutes of Health announced that he had decided to reverse his earlier decision to proceed with the merger of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). This is a cause for celebration, as the merger was a solution in search of a problem right from the start.

For most of us at NIAAA (this process started when I was still there) it always looked like a simple power grab by NIDA and a relatively small but influential group of researchers and policymakers closely affiliated with it. The White House Office of Drug Control Policy (ONDCP; the Drug Czar), former NIDA Director Alan Leschner (who coveted NIAAA when he was at NIDA,) and current NIDA Director Nora Volkow all pushed very hard to make this happen. The "problem" it was supposed to solve were "missed opportunities" to pursue research involving both alcohol and drug disorders, but that's actually never been a problem in reality. The two institutes collaborate on multiple initiatives, and both alcohol and other drug disorders are frequently studied together, if only because they often occur together. But few of us involved with this ever thought there was a problem with the two institutes.

At any rate, without getting into details right now, I think this is very good news indeed.

MW

George McGovern Understood the Cost of Addiction

I once heard George McGovern speak at a meeting of addiction psychiatrists. He spoke so movingly of the futility of efforts to save his daughter from alcohol dependence. Tragically, she froze to death in a snowbank. As a father of now adult sons, I can imagine but not really understand how painful this must have been. His daughter took advantage of all available treatments. Many, many attempts at rehab. "Worked the program." All to no avail. The disease killed her. This is the reality that people avoid at all costs. Addiction kills people. And they cannot help it. And neither can we, not yet.

I've dedicated my career to developing ways to help people with severe addictions, people who often have other severe chronic illnesses. People on whom everyone else has given up , especially rehab programs and counselors, doctors and social service agencies. And yet, inevitably, if I talk about the limitations of current treatments, someone will accuse me of "giving up on them." Underlying that accusation is the assumption that "anyone can overcome addiction and recover, if they really want to."

This is arguably the cruelest thing about current treatment approaches. People are blamed for the inadequacy of available treatments. This doesn't only apply to addictions, it applies to chronic or fatal illnesses in general. Especially here in the West, we are uncomfortable with death. In the US, perhaps more than anywhere else in the world, we fear not feeling in control of our lives, or deaths. In order to maintain the illusion of control, we criticize others who have "lost control," believing that they could have prevented it, except for their laziness, moral depravity and/or lack of motivation. This helps us fend off our fears, but it is devastating to those whose lives fall apart around them, no matter what they do. Too often, when they turn to others for help, they encounter condemnation, criticism, and rejection.

Even worse, the belief that those who succumb are somehow responsible, that effective treatment was available but those affected rejected it, leads to the idea that we don't need more effective treatments. We just need more availability (and payment.) That's one reason that families and people with addictions aren't effective advocates for more research. Today, I bought something at Walgreens. After I swiped my card through the machine, I was asked if I wanted to contribute to the Susan G. Komen Foundation for breast cancer. It seems like every other week, there is some sort of "pink ribbon" campaign on this topic. And what do breast cancer advocates want? More research. They don't ask for more availability of current treatments, because they are not anywhere good enough. What's required is more research and scientific breakthroughs.

Is this what the addiction and recovery communities advocate for? No, they don't. They typically advocate for more treatment, and more support for funding available treatments. Are treatments for addiction that much better than for breast cancer, or heart disease? No they aren't. In fact, there have been very significant advances in the treatment for and survival of people with those disorders. Advances that came through scientific research.

How do you think we are going to achieve better outcomes in the treatment of addictions? If not through scientific research, then what? More 12-Step meetings? Imprisoning more addicted people? Making it even more difficult to recover by closing off access to school loans, jobs, health care, housing and other benefits? I for one believe the only way forward is through scientific research. If we are going to increase funding for research, we have to compete with the advocacy groups for autism, Alzheimers's Disease, heart disease, cancer and many others. Without the advocacy of people with addictions and their families and loved ones, we don't stand a chance. And without more research, we'll still be referring people to support groups 20 years from now, and just as many will die.

Family members: have you been satisfied with the response to addiction from available treatments? Do you just want more of the same? Who is going to organize and sponsor the first national campaign to raise funds for addiction research?

MW

Deaths from Prescription Opioids Not Evenly Distributed

Last November, the CDC issued a report detailing the rise of prescriptions for opioid (narcotic) pain killers such as oxycodone (Percocet, Oxycontin), hydrocodone (Vicodin, Norco), methadone, morphine (MS Contin), fentanyl patches (Duragesic), and others, from 1999-2008. As expected, prescriptions for these medications have increased pretty dramatically. Here's the chart from that report, showing sales of opioid pain relievers (OPR), admission for addiction treatment related to OPR and OPR deaths per 100,000 persons. Basically, sales more than tripled, treatment admission quadrupled and deaths almost tripled. Since 2008, these trends have continued if not accelerated. In Minnesota for instance treatment admissions for opioid addiction are now greater than that for cocaine, methamphetamine, cannabis or other non-alcohol drugs. (Alcohol of course, continues to be the elephant in the room, with all indicators much higher than all other drugs combined.)

However, the rates for these indicators are not evenly distributed across the states. Here are two graphs from the same report showing rates across the US. What they show is that the rates for OPR sales and rates for overdose deaths vary widely across the country. For the most part, the rates of sales and deaths track together although there are exceptions (Oregon, Hawaii for example.) The national rate for overdose deaths is 11.9/100,000 but rates vary from 5.5 in Nebraska to a whopping 27 in New Mexico, a five-fold difference. Of note, nearly all of the deaths are in people taking them for medical purposes and the rates of non-medical use are low across the country. What these figures indicate is that there is no single solution for the entire country. Rather, the approaches need to be tailored to the particular states and regions with the highest figures. Not surprisingly, given the number of older adults living there, Florida tops the country for example in kilgrams of OPR sold.  However, the overdose death rate is 8th highest. New Mexico, however, with the highest overdose death rate, has OPR sales lower than the national average. Unfortunately, the federal government has taken a blanket approach focused on training physicians, which suggests that the appearance of doing something is more important than actually doing something that works.

New Documentary on Alcohol Prohibition

PBS PROHIBITION Premieres October 2nd, 3rd & 4th, 2011 at 8 PM on PBS PROHIBITION is a three-part, five-and-a-half-hour documentary film series directed by Ken Burns and Lynn Novick that tells the story of the rise, rule, and fall of the Eighteenth Amendment to the U.S. Constitution and the entire era it encompassed. The culmination of nearly a century of activism, Prohibition was intended to improve, even to ennoble, the lives of all Americans, to protect individuals, families, and society at large from the devastating effects of alcohol abuse. But the enshrining of a faith-driven moral code in the Constitution paradoxically caused millions of Americans to rethink their definition of morality. Thugs became celebrities, responsible authority was rendered impotent. Social mores in place for a century were obliterated. Especially among the young, and most especially among young women, liquor consumption rocketed, propelling the rest of the culture with it: skirts shortened. Music heated up. America's Sweetheart morphed into The Vamp. Prohibition turned law-abiding citizens into criminals, made a mockery of the justice system, caused illicit drinking to seem glamorous and fun, encouraged neighborhood gangs to become national crime syndicates, permitted government officials to bend and sometimes even break the law, and fostered cynicism and hypocrisy that corroded the social contract all across the country. With Prohibition in place, but ineffectively enforced, one observer noted, America had hardly freed itself from the scourge of alcohol abuse – instead, the "drys" had their law, while the "wets" had their liquor. The story of Prohibition's rise and fall is a compelling saga that goes far beyond the oft-told tales of gangsters, rum runners, flappers, and speakeasies, to reveal a complicated and divided nation in the throes of momentous transformation. The film raises vital questions that are as relevant today as they were 100 years ago – about means and ends, individual rights and responsibilities, the proper role of government and finally, who is — and who is not — a real American. http://www.pbs.org/kenburns/prohibition/