No change in teen pot use after medical marijuana passage?

From the Washington Post:


The chart above shows the trend in teen marijuana use, as measured by state Youth Risky Behavior Surveys, in Alaska, Arizona, Colorado, Delaware, Maine, Mississippi, Montana, Nevada, New Mexico and Vermont. The x-axis is standardized to track the three-year periods before and after each state passed its medical marijuana law. The lines are essentially flat.

I asked study co-author Daniel Rees if there were any significant changes within individual states. He told me that “no single state stood out — the effect of massing a medical marijuana law on youth consumption appears to be zero across the board.” These results are consistent with earlier research showing little change in youth pot consumption in Los Angeles after marijuana dispensaries opened there.

I’ll be interested to see what kind of responses this study gets.

It will also be interesting to see the effect of legalization in Colorado and Washington on pot consumption.

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Sentences to ponder

wpid-wp-1406109969456.jpeg“For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.” –Dirk Hanson

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the gaping nothingness of one’s future


GREGGS: How long you been clean?
BUBBLES: Three days.
GREGGS: You serious about it?
BUBBLES: Who knows?

I just finished season 1 of the The Wire. (I know I’m way late to the party. What can I say? I have young kids and no HBO.) This Bill White post came out at about the same time I watched Bubbles trying to kick.

It is one of the most beguiling qualities of the experience of addiction:  it sucks up everything of importance in your life and casts those cherished assets into the remotest reaches of one’s heart, leaving nothing but itself. This all occurs an inch at a time and second by second–increments so small they escape the category of decisions.  It is at the end of such a process that one cluster of fears stands greater than the full awareness of what has been lost.  That is the terror of one’s own emptiness and the gaping nothingness of one’s future.  Those latter breakthroughs of consciousness can fuel unending cycles of oblivion and sickness and take damaged souls to, or beyond, the brink of suicide.  These same fears pose a significant obstacle to recovery initiation.  That’s why the promise of recovery must offer more than the removal of alcohol and other drugs from one’s life.  For the person staring into the abyss, the promise of recovery to a life of meaning and purpose may be far more potent than the promise of recovery from addiction.

There’s a great scene with Bubbles here. Check it out. (I can’t embed it.)


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NY Times goes pro-pot

marijuana marlboroWe’ve always argued that no one should go to jail for possession of marijuana and I agree that it makes sense for the federal government to step out of the way of states that want to try another path. The NY Times editorial board comes out in favor of marijuana legalization.

I’m ambivalent about full legalization and worry about the effects of unleashing capitalism on marijuana. (This is where people point to alcohol and I respond, “Yeah, look at alcohol–it’s a celebrated drug in the culture with huge public health challenges and a powerful lobby.)

In the midst of all this skepticism about the possibility of an effective prohibition policy, a couple of sentences lept out at me.

There are legitimate concerns about marijuana on the development of adolescent brains. For that reason, we advocate the prohibition of sales to people under 21.

Seems like there’s a little dissonance there, no? (On second thought, I’m convinced that an absence of dissonance is a sure sign of someone who is ideological or isn’t very serious about the matter. I guess the key is to be aware of your dissonance.)

In any case, everyone’s a critic of the status quo. The real question is how to implement policy change, whether it’s full legalization or some option short of that. This will separate the critics from the more serious thinkers on the issue.

I’ve said it many times here. There is no such thing as a problem-free drug policy. The reality is that we have to choose which problems we’re willing to live with and which problems we can’t tolerate and then craft a policy around those values.

We seem to have decided that we’re willing to live with marijuana use by adults but we’re not willing to live with incarcerating large numbers of people for using it and we don’t want young people using it heavily. There are a lot of policy options to fit those criteria.

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Readiness for change and drug use outcomes after treatment


This week’s Throwback Sunday is a post about a study on the Transtheoretical Stages of Change (TSOC). It’s relevant due to the ongoing and recent media love for Motivational Interviewing (MI), which is fairly closely tied to the TSOC. (This is disputed, but the motivational interviewing website as 12 pages of search results for “stages of change”.)

Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold as a treatment for addiction. It may be helpful as a stand-alone intervention for people with low-severity substance use problems. For addiction, it can be very helpful to engage people into other treatments more appropriate for high-severity problems.
Another study finding that the client’s stage of change is a poor predictor of outcomes:

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.

There has been high profile criticism that the rush to embrace the stages of change has outpaced the evidence. The question isn’t whether the stages of change have any utility. The question is what are they useful for? Patient/family eduction, counselor education, conceptualizing interventions, matching treatments, etc.

The stages of change have undoubtedly changed the field for the better, but there are a lot of weak points that have not been adequately explained–failure to recognize the instability of motivation; disagreements about how to determine the client’s stage of change; failure to account for stable, unplanned change; failure to explain for stable, initially coerced change. I’ve been especially concerned about practitioners relying on the stages of change for treatment placement and the inevitable post hoc deconstructions of treatment “failures” that blame the client’s motivation and then conclude that we wasted money treating them (and suggest that better assessment would have led to the conclusion that the client wasn’t motivated and a better referral).

Robert West, the editor of Addiction, has offered a new model for understanding change, he has called the PRIME theory.

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Stanton, you have deep unresolved pain

typesI’m not a fan of either of these high profile addiction experts, but Stanton Peele’s recounting of his meeting with Gabor Maté illuminates a lot about both men and their approach to addiction. It also helps in understanding the conceptual boundaries of harm reduction, at least as Peele sees them. The boundaries are more rigid than I would have imagined.

Seeking common ground with Gabor, I noted his work with psychedelics as a chance to teach people how to manage drug experiences. But he told me that teaching people competency in drug use is the last thing on his mind. I emailed him in March this year:

I DO like this title—Substance Use Competency. It is interesting to play that idea out—including dealing with people’s traumas (without allowing them to grow to life-overcoming proportions) while also actually teaching them to manage substance use (as you are doing in Mexico). Perhaps we can combine around this.

Gabor responded by rapping my knuckles:

We are not teaching substance use competency with this process. The goal and process is to help people shed the physical and psychological patterns of old trauma, so that they are no longer trapped in the past. If successful, substance use is no longer an imperative. [My emphases.]

The last thing in the world Maté wants people to do is to take drugs as a normal part of life experience. In this way, he is no more a harm reductionist than Nancy Reagan.

Hmmm. Like I said, I’m no fan of Maté, but the goal of eliminating substance use as an imperative puts one in the same category as Nancy Reagan? Count me in that club.


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Characteristics of the best treatment programs

big-question-logoIn that Points interview, Bill White is asked about the treatment provider that he would choose for a loved one.

I receive calls every day from people asking variations of these questions. There isn’t a universally “best program.” What we are looking for is the best match between the characteristics of a particular person at a particular point in time and the characteristics of a treatment setting at that same point in time. What could be the best choice for one person would not necessarily be a good choice for another, and a good match today might not be so a year from now—because both individual/family needs and organizational capabilities evolve dynamically. But those best matches do seem to share some common characteristics: accessibility; affordability; organizational and workforce stability; individualized, evidence-based, and family-focused care; a recovery-infused service milieu; effective linkage to recovery community resources; and sustained support for both the individual and the family. What also matters as much as the treatment approach and the treatment institution is the primarily clinician who will be providing that treatment. Recovery outcomes vary widely from counselor to counselor.

Interesting to see affordability on that list. Again, I’m grateful to be part of a place that resembles this description.


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