Food for thought on marijuana

Marijuana AdvertisingFirst, a post on American use of and beliefs about marijuana:

There has been a significant increase in the number of Americans using cannabis, rising from 21.9m in 2002 to 31.9m in 2014. The number of regular users doubled over the same period to 8.4m. This coincides with an increasingly liberal approach to cannabis regulation in several US states. The authors of a new study, published in The Lancet Psychiatry, also found that people perceived cannabis to be less harmful. This perception seems justified as problems related to cannabis use, such as dependency, remained stable during the study period.

These findings are not what you would expect when cannabis use becomes more popular and is thought to be increasingly potent. This study also contradicts another study, using data over the same period, which found that disorders associated with cannabis use have doubled. So which one should we believe?

Second, a post examining the complicated questions around marijuana taxation:

Can I let you in on a little secret? No one knows the best way to tax either medical or recreational cannabis. Every option has trade-offs.

What should the tax be based on? What should the rate be?

Consider a price-based tax such as 25 percent at the retail level. While it would be easy to implement, the effective tax per joint would decrease as the price declines — something expected to happen as competition, innovation and scale-economies push down costs.

Taxing by weight, say $2 per gram, would also be easy to implement, but it means low- and high-potency products face the same tax. This creates incentives for producers to sell more potent cannabis to minimize the tax per hour of intoxication. Some public health researchers worry that more potent cannabis is associated with more health problems, an issue that is the subject of serious debate.

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Who’s “we”?


This article is making the rounds and getting some attention. The post below addresses the issues raised. (originally posted on 10/31/2014)


This article has been forwarded to me by several people. Its author has been writing a series of articles that seek to redefine addiction and recovery.

As Eve Tushnet recently observed, “There’s another narrative, though, which is emerging at sites like The Fix and” This sentence is representative of this alternative narative:

“The addiction field has struggled with defining recovery at least as long and as fiercely as it has with defining addiction: Since we can’t even agree on whether it’s a disease, a learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.”

But are “we” really unable to agree that addiction is a disease? Who’s “we”?

It’s not unlike suggestions that there’s wide disagreement on climate change.

“Since we can’t even agree on whether it’s a diseasea learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.” “. . . just so you know, the consensus has not been met among scientists on this issue. Or that CO2 actually plays a part in this global warming phenomenon as they’ve come up with somehow.”
Health organizations that call addiction a disease or illness:

  • American Society of Addiction Medicine
  • American Medical Association
  • American Psychiatric Association
  • American Hospital Association
  • American Public Health Association
  • National Association of Social Workers
  • American College of Physicians
  • National Institute of Health
  • National Alliance on Mental Illness
  • World Health Organization
Scientific organizations that recognize human caused climate change:

  • American Association for the Advancement of Science
  • American Astronomical Society
  • American Chemical Society
  • American Geophysical Union
  • American Institute of Physics
  • American Meteorological Society
  • American Physical Society
  • Federation of American Scientists
  • Geological Society of America
  • National Center for Atmospheric Research
  • National Oceanic and Atmospheric Administration
Health organizations that dispute the dispute the disease model:

  • I can’t find any. If you have some that are similar in stature to those above, send them to me.
Scientific organizations that dispute human caused climate change:

  • None, according to Wikipedia.

To be sure, there are people who don’t accept the disease model, some very smart people, but they represent a small minority of the experts. (The frequent casting as David vs. Goliath should be a clue.) And, if you look at their arguments, you’ll find other motives (I’m not suggesting nefarious motives) like protecting stigmatizationdefending free will from “attacks”, discrediting AA and advancing psychodynamic approaches, resisting stigma and emphasizing environmental factors.

Attending to some of their concerns makes the disease model and treatment stronger, not weaker. Lots of diseases have failed to do things like adequately acknowledge environmental factors. And, one takeaway from these critics is the importance of being careful about who we characterize as having a disease/disorder explicitly or implicitly (by characterizing them as being in recovery).

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Why Does Alcoholics Anonymous Work?

This video addresses two important questions:

  1. Can evidence be trusted if it’s not from a randomized controlled trial?
  2. Does Alcoholics Anonymous involvement really help alcoholics stay sober? Or, do AA attenders just stay sober because they are more motivated than non-attenders to stay sober?

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“Growing a Healing Forest is a mentality”



“What’s called for in this metaphor is treating the soil — creating a Healing Forest within which the health of the individual, family, neighborhood, community, and beyond are simultaneously elevated. The Healing Forest is a community in recovery.”

Derek Wolfe, a recent University of Michigan grad (soon to be a medical student), just posted an ambitous series of articles on Ann Arbor, MI as a “healing forest.”


He profiles several elements/contributors to Ann Arbor’s recovery readiness. Here’s my favorite:

Just a short walk from Zingerman’s Deli in Kerrytown sits The Lunch Room, a popular vegan restaurant in Ann Arbor. Co-owner Phillis Engelbert, formerly a community organizer before moving into the restaurant business, has worked like Weinzweig [Zingerman’s co-founder] to cultivate an inclusive culture and positive workplace, which may explain why 11 out of 27 of her employees are in recovery.

“Well I think with the first (employee in recovery), it probably was just building that personal relationship,” Engelbert said. “But then everyone who came after, the word was out: Lunch Room will support you. Or you know, there’s no stigma here. Or like, if you need to go to court dates, they’ll give you time off. Or if you end up going to a court date and you get thrown in jail for a couple days and then come back out, you won’t lose your job. Or like, they’ll celebrate your sobriety anniversaries. Or, just whatever, they’ll understand and there won’t be a stigma.”

But removing stigma in a workplace can’t just be an effort from top leadership. The mentality must make its way into the minds of every employee. One of the ways in which Engelbert is able to maintain a stigma-free culture and family atmosphere is through a careful hiring process.

Removing stigma in a workplace can’t just be an effort from top leadership. The mentality must make its way into the minds of every employee.

“I’m also really really careful about who I hire because I don’t want to wreck (the inclusive, stigma-free culture),” Engelbert explained. “So I tell people when they’re interviewing, I say, ‘We have people here from all walks of life. We have people here of different income backgrounds, education levels, prison history, lesbian, gay, trans, whatever. You have to be happy about that or you can’t work here. Like you have to look at that as a positive and help us embrace all that or this isn’t the place for you.’”

The result of Engelbert’s efforts is an environment in which recovery is able to be discussed openly among the staff. Conversations about recovery occur often at The Lunch Room.

“Everyday. All the time. It’s just like talking about the weather,” Engelbert said.

One Lunch Room employee put it this way: “It’s nice to be open about (recovery), have a boss that understands and just not have like a drug-fueled kitchen environment ’cause that’s just not what I want to be around.”

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The “rat park” guy

Bruce Alexander A Global Historical View Of Addiction And The Future Of Addiction Treatment FEADSeveral recent books have attempted to refute the disease model of addiction over the last few years. (See here, here, here and here for some examples.)

All of these books cite Bruce Alexander’s “rat park” experiments as important evidence that addiction is not a brain disease.

If you’ve ever been curious about Bruce Alexander, here’s your chance to watch a talk he gave earlier this year.

Is the disease model really in doubt?

I believe that there is no serious scientific disagreement about the matter.

Here are a couple of talks that explain the disease model.

First, NIDA Director Norak Volkow:

Second, Kevin McCauley in our own education series:


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Does “stigma reduction” miss the point?

missing the point

A provocative interrogation of stigma reduction campaigns:

Once we declared a war on stigma, I knew we were screwed. Like poverty, racism, drugs, terror and obesity before it—fighting stigma ensures that we will likely make little progress. Instead of doing anything about the things actually killing drug addicts and alcoholics, we focus on something vague and unbeatable. It’s like fighting smoke.

Forget stigma, let’s focus on what’s actually decimating care for mentally ill and addicted persons—corporate greed. Some health care is lucrative. Hospitals usually have some great digs for these golden geese. The hospitals in my area show off their outpatient surgery recovery suites . . .

Treatment of the addicted and mentally ill will never be a money maker, nor should it have to be. I would love to see a beautiful new psych ward in the ads for my local hospital, but apparently this is not a demographic with disposable income—nor is this a group of people with a voice. This leads to efforts at reducing stigma. This would make a lot of sense if the thing blocking change in these massive healthcare systems was a misunderstanding of mental illness or addiction, or an active antipathy toward helping these people. I do not think this is the case. I just think it’s irrelevant.

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Does rehab kill?

“Rehab kills people,” Willenbring said

Dr. Willenbring is right that bad and/or inadequate rehab is dangerous. HOWEVER, this is true of a lot of treatments. For example, an inadequate course of antibiotics is dangerous.

So, what does good treatment look like? He suggests it comes in the form of medication.

Another way to identify what good treatment looks like is to ask one question can cut through a lot of confusion about treatment options—“What kind of treatment do addicted doctors get?” This question avoids arguments about treatment models, evidence-based practices and the effectiveness of 12 step groups. It moves past what physicians recommend for people like you (or your loved one) and what they actually do for people like themselves.

Fortunately, a few days after Dr. Willenbring’s comments were published, the NY Times published an article on a doctor with addiction who was arrested for diverting medication. What kind of treatment did she get?

She was allowed to attend a rehabilitation program while still seeing patients.

Rehab? It doesn’t say what kind of rehab but, rehab?  Really?

She didn’t want to go to the New York Health Committee for Physician Health, a program funded by the American Medical Association to identify and treat doctors with mental health or drug problems, she says, “because I didn’t want anybody to find out.”

Nobody wants to admit defeat or weakness; but only doctors (and airline pilots) thought to have drug problems have such rigorous drug-testing programs, according to Terrance M. Bedient, the director of the Committee for Physician Health. Some lose their livelihoods temporarily, some permanently.

. . .

“I saw people with less privilege, less education, treated the same way I was,” she says. “The judge in my case understood addiction so well. It’s a disease.”

And that is what many in the addiction field think we should remember: not that Dr. Karcher didn’t have advantages — she did — but that she got the kind of treatment that more substance abusers should get. Physicians in New York State have some of the best outcomes in the country, according to Brad Lamm.

“It’s not that they’re better people or better addicts,” he says.

They don’t get specific about the kind of rehab Dr. Karcher got, but what kind of rehab do doctors usually get?

Physicians’ Health Programs (PHPs) do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step-oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years.

Does this care kill them?

A sample of 904 physicians consecutively admitted to 16 state Physicians’ Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

It’s worth noting that there is other evidence for the use of residential. (See here, here and here.) But, let’s stay focused on the PHP approach.

Is there another approach that rivals the outcomes found in PHPs?

Back to Willenbring:

. . . adding that the model for the 28-day rehab, Minnesota’s Hazelden Foundation, began offering buprenorphine maintenance itself in 2012 after a series of patient deaths immediately after treatment. Hazelden’s medical director, Dr. Marvin Seppala, told me when the rehab announced the change that using these medications is “the responsible thing to do” because of their potential to save lives.

That was 4 years ago. A year in, they were teasing pretty impressive early outcomes and promised more outcomes studies were to come. 4 years is a long time to keep the world waiting. However, they just posted that they expect to publish their outcomes next year. We’ll have to wait and see what they end up reporting.

To be sure, some people have good outcomes with medication assisted treatment. At the same time, it’s not as simple and obvious as the article suggests. First, the evidence doesn’t match the hype. (See here, here, herehere and here.) Second, while the inadequacy of many residential/inpatient treatment programs has gotten a lot of attention, medication assisted treatment has its share of problems. (See this recent photo essay on Boston’s “methadone mile” and this recent article on problems with buprenorphine in northeast Tennessee.)


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