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This is the power point that Dr Sabet presented on September 23, 2013.
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Current Drug Use Trends
Kevin A. Sabet, Ph.D.
Co-Founder, Project SAM (Smart Approaches to Marijuana)Asst. Professor, UF College of Medicine
www.kevinsabet.comwww.learnaboutsam.org
Overview
• Prescription Drug Abuse• Synthetics• Other Drugs
• (Cocaine, Heroin, Methamphetamine)
• Marijuana
Prescription Drug Abuse
1. Depressants: central nervous system include sedatives (calm and drowsy) and tranquilizers (reduce tension or anxiety). Ex. Zyperxa, Seroquel, Haldol
2. Opioids and Morphine Derivatives: Painkillers. Ex. Codeine, Hydrocodone, Oxycodone, Fentanyl
3. Stimulants: Increase energy, alertness but also blood pressure and heart rate. ADD/ADHD Ex. Ritalin, Concerta, Dexedrine, Adderall
4. Antidepressants: Psychiatric drugs supposed to handle depression.
Ex. Prozac, Celexa, Zoloft, Paxil
Commonly Abused Prescription Drugs
Youth: Prescription Drugs (RX)
• Every day in the US, 2,500 youth (12-17) abuse a prescription pain relievers for the first time.– The average age for first time users is now 13 to 14. – 8% of American 12th graders used narcotics in the past 12
months (MTF, 2012).
• A 2012 study in the US found that 1.7% of 12 and 13-year olds and 2.5% of 14 and 15-year olds had abused a prescription drug in the past month (NSDUH, 2013).
• Almost 50% of teens believe that prescription drugs are much safer than illegal street drugs.
Youth: Prescription Drugs (RX)
• 2.5 million teenagers (12 to 17) in the US have used prescription drugs in their lifetime (NSDUH, 2013).
– Over 2 million used pain killers such as OxyContin
– Nearly half a million used stimulants such as methamphetamine.
• According to the National Center on Addiction and Substance Abuse at Columbia university, teens who abuse prescription drugs are 2x as likely to use alcohol, 5x more likely to use marijuana, and 12-20x more likely to use illegal streets drugs such as heroin, ecstasy, and cocaine.
Prescription Drug Abuse (Rx)
• Of the 1.4 million drug-related emergency room admissions, 598, 542 were associated with abuse of prescription drugs
• Prescription drug abuse causes the largest percentage of deaths from drug overdosing. Of the 22, 400 drug overdose deaths, opioid painkillers were the most commonly found drug, accounting for 38.2% of these deaths.
Prescriptions Dispensed for Select Opioids in U.S. Outpatient Retail Pharmacies, 2000-2009
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
20,000,000
40,000,000
60,000,000
80,000,000
100,000,000
120,000,000
140,000,000
Hydrocodone Oxyocodne methadone buprenorphine tramadol
Num
ber o
f Pre
scrip
tions
Source: SDI, Vector One: National. Extracted June 2010.
Sources of Nonmedical Prescription Drugs1
9
1 2010; Most recent nonmedical pain reliever use among past year users ≥12 years.2 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s
Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”
Bought/Took from Friend/Relative16.2%
Drug Dealer/Stranger 4.4%
Bought on Internet0.4% Other 2
4.9%
Free from Friend/Relative7.3%
Bought/Took fromFriend/Relative4.9%
OneDoctor79.4%
Drug Dealer/Stranger2.3%
Other 2
2.2%
Source Where Respondent Obtained:
Source Where Friend/Relative Obtained:
One Doctor17.3%
More than One Doctor1.6%
Free from Friend/Relative55.0%
More than One Doctor3.3%
SAMHSA 2010, 2011
Emergency Department Visits
Persons Classified with Substance Abuse/Dependence on Psychotherapeutics
Results from the 2009-2013 National Surveys on Drug Use and Health (NSDUH)
NSDUH
12
Percent Increase in Admissions for Specific Opioid Analgesics1:2000-2006
1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone. Analysis restricted to 13 States that reported detailed drug codes for 2000 and 2006.
13
% Increase in Admissions for Heroin and Opioid Analgesics1: 2001-2011
1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone.
Total visits Heroin Opioid Analgesics0%
50%
100%
150%
200%
250%
300%
350%
400%
450%
47.66%
0.33%
406.92%
N-SSATS, 2011: TEDS 2001-2011
14
Treatment Admissions Involving Opioid Analgesics1
1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone.
SAMHSA 2007
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011300
320
340
360
380
400
420
440
460
480
Nu
mber
of
adm
issi
on
s x1
000
N-SSATS, 2011: TEDS 2001-2011
Drug-Induced Deaths vs. Other Injury Deaths, 1999–2009*
Source: National Center for Health Statistics, Centers for Disease Control and Prevention. National Vital Statistics Reports Deaths: Final Data for the years 1999 to 2007 (2001 to 2009); Deaths: Preliminary Data for the years 2008 and 2009 (2010 and 2011).
*Data for 2008 and 2009 are provisional and subject to change. Causes of death attributable to drugs include accidental or intentional poisonings by drugs and deaths from medical conditions resulting from chronic drug use. Drug-induced causes exclude accidents, homicides, and other causes indirectly related to drug use. Not all injury cause categories are mutually exclusive.
9/2011
0
1
2
3
4
5
6
7
8
9
10
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
De
ath
rate
pe
r 1
00
,00
0
HeroinCocaine
27,658 unintentional drug overdose deaths
Unintentional Drug Overdose DeathsUnited States, 1970–2007
National Vital Statistics System, http://wonder.cdc.gov
Year
Rx Drugs
Public Health Impact of Opioid Analgesic Use
Mortality figure is for unintentional overdose deaths due to opioid analgesics in 2007, from CDCTreatment admissions are for with a primary cause of synthetic opioid abuse in 2007, from TEDSEmergency department (ED) visits related to opioid analgesics in 2007, from DAWNAbuse/dependence and nonmedical use of pain relievers in the past month are from the 2008 National Survey on Drug Use and Health
Nonmedical users
People with abuse/dependence
ED visits for misuse or abuse
Abuse treatment admissions
450
148
29
7
For every 1 overdose death in 2007, there were…
Economic Costs
• Illicit drug use in the United States is estimated to have cost the U.S. economy more than $193 billion in 20071
• $55.7 billion in costs for prescription drug abuse in 20072
– $24.7 billion in direct healthcare costs
• Opioid abusers generate, on average, annual direct health care costs 8.7 times higher than nonabusers3
1. National Drug Intelligence Center. The Economic Impact of Illicit Drug Use on American Society. 2010. http://www.justice.gov/ndic/pubs44/44731/44731p.pdf 2. Birnbaum HG, White, AG, Schiller M, Waldman T, et al. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. Pain Medicine.
2011;12:657-667. 3. White AG, Birnbaum, HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United States. J Manag Care Pharm. 11(6):469-479. 2005
Prescription Drug Abuse Prevention Plan
• Coordinated effort across the Federal government
• 4 focus areas– Education– Prescription Drug
Monitoring Programs– Proper Medication
Disposal– Enforcement
Education
• Education Goals for youth, parents, and patients
• Increase awareness about prescription drug abuse• Patients and parents understand how to use
medications safely, and how to store and dispose them properly
• Main Actions• Evidence-based public education campaign
partnering with local anti-drug coalitions, and other organizations (chain pharmacies, community pharmacies, boards of pharmacies, boards of medicine)
Education Gaps
• Physicians:• 2000 survey: 56 % of residency programs required
substance use disorder training, median number of curricular hours ranged from 3 to 12 hours1
• 2008 follow-up: “Although the education of physicians on substance use disorders has gained increased attention, and progress has been made to improve medical school, residency, and postresidency substance abuse education since 2000, these efforts have not been uniformly applied.”2
1. Isaacson JH, Fleming M, Kraus M, Kahn R, Mundt M. A National Survey of Training in Substance Use Disorders in Residency Programs. J Stud Alcohol. 61(6):912-915. 2000. 2. Polydorou S, Gunderson EW, Levin FR. Training Physicians to Treat Substance Use Disorders. Curr Psychiatry Rep. 10(5):399-404. 2008.3. Lafferty L. Hunter TS, Marsh WA. Knowledge, attitudes and practices of pharmacists concerning prescription drug abuse. J Psychoactive Drugs. 2006 Sep:38(3):229-232.
Education Gaps• Pharmacists
• 67.5% report receiving two hours or less of addiction or substance abuse education in pharmacy school
• 29.2% reported receiving no addiction education
Pharmacists with greater amounts of addiction-specific education:
• Higher likelihood of correctly answering questions relating to the science of addiction and substance abuse counseling
• Counseled patients more frequently and felt more confident about counseling
Prescription Drug Monitoring Programs
http://www.pmpalliance.org/pdf/pmpstatusmap2010.pdf
Prescription Drug Monitoring Programs
• Develop and implement “interoperability” system (PMIX, NABP, others)
• Link PDMP with State Health Information Exchanges (HIE)
• Liberate PDMP data to healthcare providers as part of provider “work flow” operation
• Ensure Emergency Departments have “real-time” access to RX data
Proper Medication Disposal
• Goals: • Easily accessible, environmentally friendly method of drug
disposal that reduces the amount of prescription drugs available for diversion and abuse
• Main Actions• Publish and implement regulations allowing patients and caregivers
to easily dispose of controlled substance medications
• DEA will continue holding a take-back day at least every 6 months until a Final Rule is implemented
• Once regulations are in place, partner with stakeholders to promote proper medication disposal programs
Pharmacy Based Programs
• Completes the drug distribution loop– Patient/pharmacist relationship already exists
• Potential for clinical intervention– Reasons for unused medication - adverse events, ineffective, cost, etc. – Stronger patient/pharmacist/prescriber relationship– Improved health outcomes
• Reverse distribution and disposal mechanisms already in place
• Security and diversion safe guards already in place for current drug inventory
• Pharmacy based programs have been effectively operating in other countries and in the U.S.
Enforcement
• Goals:• Assist states in addressing “pill mills” and doctor
shopping
• Main Actions• Provide technical assistance to states on model
regulations/laws for pain clinics
• Encourage High-Intensity Drug Trafficking Areas (HIDTAs) to work on prescription drug abuse issues
• Support prescription drug abuse-related training programs for law enforcement
Conclusions
• This is a critical time for the “marriage” merging of Public Health and Public Safety Strategies…
• Striking the right balance of strategies will ensure the critical availability of these medications while preventing/reduce diversion and abuse .
What Can The Rx Problem Teach Us About
Illicit Drug Use?
• Rx Drugs Are “Highly” Controlled
• Available and Abused at Extremely High Rates
• Medical Properties
• Cause Billions in Societal Costs
First Choice Drugs:Youth(Grades 8, 10, 12 Combined)
Substance Past Month Use Past Year Alcohol 25.5% 45.3%
Cigarettes 18.2% 23.7%
Marijuana 15.2% 25%
Monitoring the Future: Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor: Institute for Social Research, The University of Michigan.
Alcohol• Alcoholic beverages have been and are the
most widely used psychoactive substances by American young people.
• Binge drinking (5 > drinks in a row during the prior two-week interval at least once) is probably of greatest concern from a public health perspective.
• In 2011, all measures of alcohol use—lifetime, annual, 30-day, and binge drinking in the prior two weeks—reached historic lows.
Alcohol Trends
• In 2011, all measures of alcohol use—lifetime, annual, 30-day, and binge drinking in the prior two weeks—reached historic lows.
• In 2011, 40% of 12th graders and 27% of 10th graders reported drinking alcohol in the past month.
• Since 2003, perceived risk as well as disapproval of weekend binge drinking has risen in all grades including in 2011.– Accredited to public service advertising campaigns.
Tobacco
• In 2011, 18.7% of 12th graders and 11.8% of 10th graders reported using cigarettes in the past month.
• Perception: 77% of 12th graders perceive smoking one or more packs of cigarettes a day as harmful.
• For all three grades, the 2011 levels of perceived risk are the highest ever observed.
Synthetic Marijuana (K2, Spice)
• Synthetic marijuana is a new and major concern – it refers to herbal mixtures laced with synthetic cannabinoids, chemicals that act in the brain similarly to THC, the primary psychoactive active ingredient in marijuana.
• These mixtures can be obtained legally as “herbal incense” and are perceived as a safe alternative to marijuana.
• Marketed as a “legal” high.
Synthetic Marijuana • Synthetic marijuana (K2, Spice) was added to
Monitoring the Future, University of Michigan study in 2o11.
• In that year, 11.4% of 12th graders or 1 in 9 reported using the substance in the past year.
• According to data from the American Association of Poison Control Centers, 2,915 calls were received related to synthetic marijuana in 2010, and 5,471 calls were received in 2011.
Synthetic Marijuana• Health warnings have been issued in
numerous State and local health departments describing the adverse health affects associated with its use.
• Hallucinations, Withdrawal, Anxiety, Nausea
• The DEA and state drug control agencies have recognized the need to monitor and, when necessary, control these substances. In March 2011, five synthetic cannabinoids were categorized as Schedule 1 substances.
Cocaine
• According to the 2013 National Survey on Drug Use and Health, the estimated percentage of persons 12 or older who use cocaine in the past month was 0.6%, which were similar to the 2011 and 2008 rates.
• Over the last decade, annual prevalence among 12th graders has been declining and stands at a historical low in 2012 at 2.7%
Heroin• According to the 2013 National Survey on Drug
Use and Health, the number of current (past month) heroin users 12 or older increased from 281,000 in 2011 to 335,000 in 2012.
• In 2012, there were 156,000 persons aged 12 or older who used heroin for the first time within the past year.
• The annual prevalence of heroin users among 12th graders have fluctuated between 0.7% and 0.9% from 2005 through 2011. Use has declined in the past two years.
Methamphetamine• According to the 2013 National Survey on Drug Use
and Health, the number of past-month methamphetamine users aged 12 or older decreased by over 20% between 2010 and 2012 (and even more since 2008).
• 530,000 – 2010• 439,000 – 2011• 440,000 – 2012
• From 2002 to 2008, past-month use of methamphetamine declined significantly among youth aged 12-17, from 0.3 percent to 0.1 percent, and young adults 18-25 also reported a decline from 0.6 percent to 0.2 percent in 2008.
Past Year Methamphetamine Initiates among Persons Aged 12 or Older and Mean Age at First Use of Methamphetamine among Past Year Methamphetamine Initiates Aged 12 to 49: 2002-2012
Marijuana
Marijuana
• The number and percentage of persons aged 12 or older who were current marijuana users in 2012 were 18.9 million or 7.3% - similar to 2010 and 2011 rates, but higher than those in 2002 through 2009.
• After a decline in marijuana use among 12th graders
from 2006-08, an upturn occurred until 2011.
• In 2012, 22.9% of 12th graders used marijuana in the past month – an increase from 18.8% in 2007.– Only 22% of 12th graders perceive smoking marijuana
occasionally as harmful.
19911993
19951997
19992001
20032005
20072009
20110
5
10
15
20
25
30
8th graders10th graders12th graders
Perc
ent r
epor
ting
past
mon
th u
se
Trends in current use of any illicit drugs – Past 30 days
47
What drugs do we use?
0%
10%
20%
30%
40%
50%
60%
52.10%
26.70%
7.30%
Current use among persons 12 and older: 2012
NSDUH, 2013
TobaccoAlcohol Marijuana
48
Myth 1:
Marijuana Is
Harmless and
Non-addictive
49
1 in 6 teens become addicted
• The adolescent brain is especially susceptible to marijuana use.
• When kids use, they have a greater chance of addiction since their brains are being primed.
Wagner, F.A. & Anthony, J.C. , 2002; Giedd. J. N., 2004
1 in 10 adults and 1 in 6 adolescents who try marijuana will become
addicted to it.
50
Addictive Nature of Drugs When Different Drug Use
Starts in Adolescence
Tobacco
24%
15%
8% 9%
Alcohol Marijuana Cocaine Stimulant Analgesics Psychedelics
Source: Anthony JC, Warner LA, Kessler RC (1994): Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology 2: 244 - 268
Heroin
25%
20%17%
14%
Primary Substance: Admissions (Aged 12 -17) 1993 (Orange) and 2008(Purple)
Ad
mis
sion
Nu
mb
ers
in
T
hou
san
ds
Substance(s)
Marijuana Alcohol Stimulants
Opiates Cocaine
Other Drugs
52
Dependence on orAbuse of Specific
IllicitDrugs
Persons 12 or Older, 2008
Substance Abuse and Mental Health Services Administration. (2009). O$ ce of Applied Studies. Treatment Episode Data Set (TEDS): 2009 Discharges from Substance Abuse Treatment Services, DASIS.
1,411Cocaine
4,199
Marijuana 1,716Pain
Relievers
126Sedatives
175Inhalants
282Heroin
351Stimulants 358
Hallucinogens
451Tranquilizer
s
53
Today’s marijuana is not the marijuana of the 1960s.
• In the past 15 years, marijuana potency has tripled and since 1960 it grown 5 times stronger.
Increased Potency
54
1960
1965
1970
1974
1975
1978
1980
1983
1984
1985
1986
1992
1993
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
THC
0.2 0.24
0.39
0.47
1 1 1.5 3.3 3.3 3.5 3.5 3.1 3.1 4 4.54
5.16
4.96
4.67
5.4 6.18
7.26
7.18
8.33
8.09
9.08
10.27
10.25
9.91
10.96
11.42
CBD
NaN
NaN
NaN
NaN
NaN
NaN
NaN
NaN
0.28
0.31
0.38
0.36
0.33
0.31
0.42
0.4 0.41
0.43
0.45
0.47
0.42
0.46
0.46
0.46
0.53
0.48
0.41
NaN
NaN
NaN
1
3
5
7
9
11
13
MAR
IJUAN
A PO
TEN
CY CBD:NON-
Psychoactive Ingredient
Average THC and CBD Levels in the US: 1960
- 2011
Mehmedic et al., 2010
THC:Psychoactive Ingredient
55
Cannabis-related emergency hospital admission rates have been
rising sharply in the US
• From an estimated 16,251 in 1991 to over 374,000 in 2008
ER admission rates rising
SAMHSA, 2011
56
Harmful effects on the brain
Marijuana use directly affects the brain• It affects parts of the brain responsible for:
• memory, • learning attention, • and reaction time.
• These affects can last up to 28 days after abstinence from the drug
Giedd. J.N., 2004
57
• Increased risk of mental illness
• Schizophrenia (6 fold)• Psychosis• Depression• Anxiety
Harmful effects on mental health
Andréasson S, Allebeck P, Engström A, Rydberg U. , 1987; Arseneault, L., 2002
58
Research shows that marijuana smoke is an irritant to the lungs.
• Results in greater prevalence of:• bronchitis, • cough, • and phlegm production.
Harmful effects on the lungs
Tetrault, J.M, 2007
59
• It contains 50-70 percent more carcinogenic hydrocarbons than tobacco smoke.
• Evidence linking marijuana and cancer is mixed. However, marijuana smoke contains an enzyme that converts hydrocarbons into a cancer-causing form.
• Evidence on cancer is mixed.
Marijuana smoke is carcinogenic.
Hoffman, D., et al., 1975; Brambilla, C., & Colonna, M., 2008; Bello, D., 2006; Tashkin, D. P., 1999
60
• Persistent and heavy use among adolescents reduces IQ by 6-8 points
• Dunedin study; vigorously defended • According to a government survey, youth
with poor academic results are more than four times likely to have used marijuana in the past year than youth with an average of higher grades.
Marijuana use has significant effects on IQ and learning
Meier, M.H., et al., 2012; MacLeod, J., et al., 2004.
61
• Linked with:• dropping out of school, • unemployment, • social welfare dependence,• and lower self-reported quality of life
Marijuana use is linked to low productivity and job performance
Fergusson, D. M. and Boden, J.M., 2008
62
• Employee marijuana use is linked with increased:• absences, • tardiness,• accidents,• worker’s compensation claims,• and job turnover
Marijuana use is linked to low productivity and job performance
NIDA, 2011
63
Increased use can lead to increased drugged driving
• “Drivers who test positive for marijuana or self-report using marijuana are more than twice as likely as other drivers to be involved in motor vehicle crashes.”
Mu-Chen Li, J.E., et al., 2011
64
Myth 2:
Smoked/Eaten
Marijuana is
Medicine
65
Marijuana has medical properties, BUT we don’t need to smoke or eat it!We don’t smoke opium to derive the benefits of morphine.So we don’t need to smoke marijuana to receive it’s potential benefits.
• A distinction must be made between raw, crude marijuana and marijuana’s components
Is marijuana medicine?
66
Is marijuana medicine?
No: smoked or inhaled raw marijuana is not medicine
Yes: there are marijuana-based pills available and other medications coming
soon
Maybe: research is ongoing
Kevin A. Sabet, Ph.D., www.kevinsabet.com
Marijuana is NOT approved as medicine by:
• The FDA• The American Medical Association• The National Multiple Sclerosis Society• The American Psychiatric Association• The American Glaucoma Society• The American Academy of Ophthalmology
• The American Cancer Society• The American Academy of Pediatrics
68
Studies show that components or constituents within marijuana
have medical value.• For instance, dronabinol (also known as
Marinol®) contains lab-made THC and is widely available at pharmacies as capsules to treat nausea/vomiting from cancer chemotherapy
Marijuana has medicinal properties
69
Marijuana-based medicines are being scientifically developed.
• However this process needs improvement• Research must be done on marijuana’s
components, not the raw, crude plant
Marijuana-based medicines
70
• Sativex® is in the process of being studied in the USA.
• THC:CBD = 1:1• It is administered via an
oral mouth spray• Already approved in
Canada and Europe
Marijuana-based medicines
72
• 87.9% had tried marijuana before age 19
• 75% of Caucasian patients had used cocaine and 50% had used methamphetamine in their lifetime.
Average medical marijuana patients
O’Connell, T.J. & Bou-Matar, C.B., 2007
Profile: 32-year old white male history of alcohol and substance abuse no history of life-threatening illnesses
73
• In Colorado, 2% reported cancer, less than 1% reported HIV/AIDS, and 1% reported glaucoma as their reason for using medical marijuana.
• In Oregon, these numbers are less than 4%, less than 2%, and 1%, respectively.
Only a small proportion of medical marijuana users report any serious
illness
Colorado Department of Public Health and Environment, 2011; Oregon Public Health Authority, 2011
74
Majority of medical marijuana users report using marijuana to treat
‘chronic or severe pain’• 96% in Colorado• 91% in Oregon• 93% in Montana
Chronic pain
Colorado Department of Public Health and Environment, 2011; Oregon Public Health Authority, 2011; Montana Department of Public Health and Human Services, 2011
75
“We will use [medical marijuana] as a red-herring to give marijuana a good
name.” —Keith Stroup, head of NORML to the Emory Wheel, 1979
• Advocates have pushed their agenda through “medicine by popular vote” rather than the rigorous scientific testing system devised by the FDA.
Legalization behind the smokescreen
Emory Wheel Entertainment Staff, 6 February 1979
76
After the Compassionate Use Act passed in California in 1996, Allen St. Pierre, the
director of NORML admitted in a TV interview that
“in California, marijuana has also been de facto legalized under the
guise of medical marijuana”
Behind the smokescreen
CNN Newsroom 9 May 2009
77
Residents of states with medical marijuana laws have abuse/dependence rates almost twice as high as states with no such laws.
Pacula et al (RAND) found that two characteristics of medical marijuana states
– (1) Dispensaries and (2) Home Cultivation – were positively associated
with marijuana use
Medical marijuana has led to increased use
Cerda, M., et al., 2012; Wall, M., et al., 2011; Pacula et al. 2013.
• Dispensaries – Are these serving the sick and dying??
79
Bypassing the FDA Process
Before FDA approves a drug as medicine, testing is done to:
Determine the benefits and
risks of the drug
Determine how it may interact
with other drugs
Assure standardization
of the drug
Determine the
appropriate dosage levels
Identify and
monitor side effects
Identify safe drug
administration
Marijuana-Based Medications
• NIH is responsible for research into marijuana-derived medications.
• 288 NIH-supported projects on cannabinoids.
• Scheduling less relevant– Cocaine is Schedule II, no “Dispensaries”
allowed– But it Would Be A Symbolic Victory for
Advocates– Need an individual FDA-approved product
for medical use
A Compassionate Access Proposal
• Before marijuana-based medications become more widely available, offer non-smoked marijuana components, regulated in strength, purity, and composition, to:
• Cancer patients
• Terminally ill
• Those with MS, ALS, and AIDS whose bona fide physicians have recommended marijuana because other medications have not worked
Bottom Line
We don’t smoke opium to get the effects of morphine.
So why would we smoke marijuana to get its potential
medical effects?
83
Myth 3:
Countless People Are Behind Bars
for Smoking Marijuana
84
0%
2%
4%
6%6.00%
1.40%0.40% 0.30% 0.10%
Drug Possession Of-fenders in State PrisonsPercent of State Prison-
ers, 2004
Offense
Bureau of Justice Statistics, 2004
85
• Only 0.4% of prisoners with no prior offenses are in prison for marijuana possession
• 99.8% of Federal prisoners sentenced for drug offenses were incarcerated for drug trafficking
• The risk of arrest for each join smoked is 1 for every 12,000 joints
Countless people are NOT behind bars for smoking marijuana
Bureau of Justice Statistics, 2004 and 2012; Kilmer, B., et al., 2010
86
Num
ber o
f Sen
tenc
ed P
rison
ers
38,900148,600
224,900 263,800 251,400
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Estimated Number of Sentenced Prisoners and Drug Offenders Under State Jurisdiction, 1985 to 2009
Source: Bureau of Justice Statistics, Prisoners in 2009 (December 2010); Prisoners in 1996 (June 1997).
6/2011
All Offenses
Drug Offenses
87Bureau of Justice Statistics, 2010
18%
82%
99.80%
0.20%
Among sentenced prisoners under state jurisdiction in 2008, 18% were
sentenced for drug offenses.
Of those 18%, 99.8% were sentenced for drug
trafficking
Only 0.2% are for drug possession
88
Myth 4:
The Legality of Alcohol and
Tobacco Strengthen the Case for Marijuana
Legalization
Alcohol and Tobacco: A Model?
• Use levels for alcohol and tobacco are much higher than marijuana
• Industries promote addiction and target kids
89
Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat 10(256). 2012.
Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010. Morbidity and Mortality Weekly Report 2011;60(33):1207–12
90
Alcohol and tobacco use among teens
• 50% and 44% of youth report that they can obtain alcohol and cigarettes, respectively, within a day.
• Youth are least likely to report that they can get marijuana within a day (31%); 45% report that they would be unable to get marijuana at all
The National Center on Addiction and Substance Abuse at ColumbiaUniversity (CASA), 2012
91
What incentives do legal corporations have to keep price
low and consumption high?
• “Enjoy Responsibly”
• Taxes today for alcohol are 1/5 of what they were during the Korean War (adjusted for inflation)
Cook, P. J. (2007). Paying the tab: The economics of alcohol policy. Princeton, NJ: Princeton University Press.
92
Will legalization diminish the power of cartels and the black
market?
• Marijuana accounts for 15-25% of revenues gained from drug trafficking groups
• More money is found in human trafficking, kidnapping, and other illicit drugs
Kilmer, B., et al., 2010
93
Will legalization diminish the power of cartels and the black
market?• In a legal market, where drugs are taxed and
regulated (for instance to keep THC potency below a certain level or to prevent sale to minors), the black market has every incentive to remain
• Legalizing marijuana would not deter these groups from continuing to operate
Kilmer, B., et al., 2010
94
Can we trust companies and Big Corporations not to target youth and the
vulnerable?
‘Big marijuana’
95
96
The “Yale MBAs Are Here”
Steve DeAngelo Troy Dayton
97
ArcViewwith investors at the
Washington Athletic Club
“Business is driving the change. Business is the most powerful
platform for political change that’s existed, when there is money for government, money for investors,
money for entrepreneurs, and benefits to communities, that’s a powerful incentive for change”
ArcView Co-Founder Troy Dayton
99
“The use of marijuana ... has important implications for the tobacco industry in terms of an alternative product line. [We] have the land to grow it, the machines to roll it and package it, the distribution to market it. In fact, some firms have registered trademarks, which are taken directly from marijuana street jargon. These trade names are used currently on little-known legal products, but could be switched if and when marijuana is legalized. Estimates indicate that the market in legalized marijuana might be as high as $10 billion annually.” From a report commissioned by cigarette manufacturer Brown and Williamson (now merged with R.J. Reynolds) in the 1970s.
‘Big marijuana’
100R.J.Reynolds, 1984 est.: http://legacy.library.ucsf.edu/tid/eyn18c00
101Tobacco Institute, 1989: http://legacy.library.ucsf.edu/tid/pvt37b00
102
Brown and Williamson, 1972: http://legacy.library.ucsf.edu/tid/wwq54a99
103
‘The 2nd Annual National Marijuana Business Conference And Expo’ – Nov.
6-8, 2013 in Seattle• Expecting nearly 600 people including:
• Dispensary owners and license holders• Professional cultivators• Edibles and infused product makers• Ancillary goods and services firms, from
attorneys to security technology• Investors and angel investing group leaders
• Conference registration costs $600
‘Big marijuana’
104
Will Big Marijuana become the new Big
Tobacco?
105
Several vending machines and billboards have already emerged
throughout the country
106
A variety of medical marijuana products and ‘edibles’ can be found at
dispensaries:
• Brownies, cake, cookies, peanut butter, granola bars, ice cream
• Many such as ‘Ring Pots’ and ‘Pot Tarts’ are marketed with cartoons and characters appealing to children:
107
Alcohol and Tobacco
legalization teach us there is no
money in this for anyone other than
Big Marijuana
108
Myth 5:
Legal Marijuana Will Solve the Government’s
Budgetary Problems
109
Will legalization solve budgetary problems?
• Few people are currently in jail for smoking marijuana
• Arrests and regulatory costs will increase with legal marijuana
110
2.7 million
Arrests for alcohol-related crimes in 2008
847,000Marijuana-related
arrests in 2008
(Does NOT include violence;Includes violations of liquor laws
anddriving under the influence)
“If Only We Treated It Like Alcohol…”
111
Alcohol & Tobacco:Money Makers or Dollar Drainers?
• For every $1 gained from alcohol and tobacco tax revenues, $10 is lost in legal, health, social, and regulatory costs
$$$$$$$$$$$
Urban Institute and Brookings Institute, 2012; Tax Policy Center, 2008
112
Alcohol & Tobacco:Money Makers or Dollar
Drainers?
Alcohol Costs
T obacco Costs
$14 billion
Costs
Revenues
$25 billion
$200billion$185
billion
Revenues
State estimates found at http://www.nytimes.com/2008/08/31/weekinreview/31saul.html?em; Federal estimates found at https://www.policyarchive.org/bitstream/handle/10207/3314/RS20343_20020110.pdf; Also see http://www.tobaccofreekids.org/research/factsheets/pdf/0072.pdf; Campaign for Tobacco Free Kids, see “Smoking-caused costs,” on p.2.
There are 8x as many alcohol outlets in
poorer, communities of color than in upper-class
white communities.
New Message
A new Big Marijuana industry will target the most vulnerable, just like Big
Tobacco and the Liquor Lobby have.
We don’t need more arrests in these communities, BUT we also don’t need
more drugs -- we need job opportunities, health screening, and proper education – all things that are
compromised when more people smoke marijuana.
115
Myth 6:
Portugal and Holland Provide
Successful Examples of Legalization
116
Neither Holland nor Portugal have legalized
ANY drug
117
In 2001, Portugal changed policy to send users with small amounts of drugs to
“dissuasion panels” – social worker panels who refer individuals to treatment,
administer fine, etc.
Portugal also implemented robust treatment plan
Portuguese policy
118
• Youth use has increased since 2001 • Deaths have gone down • The impact of is policy unclear, despite
extreme rhetoric
Results are mixed
119
The Dutch established the Non-enforcement Policy in 1976 and saw the birth of “Coffee Shops”
Dutch policy
120
• Experienced a three-fold increase in marijuana use among young adults
• Before Non-Enforcement, the Dutch always had lower rates of drug use than the US.• Holland is now #1 country in Europe with marijuana
treatment need
• Scaling back policy• Coffee Shops Closing• Cannot sell to non-residents
Results
What about Jolly Ole’ England?
122
Myth 7:
Prevention, Intervention, and
Treatment are Doomed to Fail – So
Why Try?
123
Policy Implications
The groups pushing for marijuana legalization
have found a way to make their issue resonate with
everyday people.
124
They have reframed the issue so it is about:
• Voting for compassion for the sick and dying
• Reducing our prison population
• Stimulating the economy125
Advocates have organized across US states and around the world
to push their initiatives.
126
They have major donors who fund their work and
messages.
127
Spent over $250 Million on Legalization
The National Organization for the Reform of Marijuana Laws estimates that Peter Lewis has spent between $40 million and $60 million funding legalization of marijuana campaigns since the 1980s.
John SperlingOver $50 Million
They’ve secured legislative champions at all levels – local, state, federal, international.
131
They’ve gotten the attention of editorial boards and media –
including print, television and social media.
132
Case of Sanjay Gupta: “Gupta Changes His Mind
On Weed”
133
They’ve mobilized major grassroots and student
supporters.
134
They are present and active in every single
academic, think-tank, UN, and other international and domestic discussion
on drug policy.
135
Most of all: They have captured the “sensible” ground, boxing us in as
extremists, old fashioned, and moralistic.
136
What has been the result of their framing of this
issue?
137
138Sources: Gallup http://bit.ly/olrSEQ and GSS
Support for Marijuana Legalization in the United States Has Reached
Unprecedented Levels
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Do not support legalization Support Legalization
139
National Policy
After 50 years of a movement to legalize marijuana, 2 states have now done it – Colorado and Washington
Marijuana Still Illegal Under Federal Law and Laws of 48 states
140
DOJ Guidance from Holder
Holder did not endorse legalization
He said that the government would defer its right to challenge states in court “right now”
141
DOJ Guidance from Holder
He laid out major areas of importance, including:
- youth use increases- drugged driving/health
consequences - advertising for youth
142
But has this already
happened?
143
• Passed medical marijuana in 2001• But no dispensaries until the mid-
2000s
• Between 2006 and 2012, medical marijuana cardholders rose from 1,000 to over 108,000
• The number of dispensaries rose from 0 to 532
Colorado post-2009
144
Marijuana use among Colorado teens is currently:
• Fifth highest in the nation• 50% above national average
Increased teen use
NSDUH, 2013
10.7%
7.6%
Colorado
National average
145
Average 5.6% of students per year between 2007 and 2009
Distribution to minors
Rocky Mountain HIDTA, 20132007-2009 2010-2012
Chart TitleDrug-related referrals for high school students testing positive for marijuana increased
Average of 17.3% per year between 2010 to 2012
Rose by over 150%
146
In 2007, tests positive for marijuana made up 33% of the total drug screenings, by 2012 that number increased to 57%
Distribution to Minors
Rocky Mountain HIDTA, 2013
147
• Teens who know somebody with a medical marijuana license are more like than those who don’t to report ‘fairly’ or ‘very’ easy access to marijuana
• 74% of Denver-area teens in treatment said they used somebody else’s medical marijuana an average of 50 times
Medical marijuana is easily diverted to youth
Thurstone, 2013; Salomonsen-Sautel et al., 2012
148
• 29% of Denver high school students used marijuana in the last month
• If Denver were an American state, it would have the HIGHEST public high school current use rates in the country
Denver high schools
Healthy Kids Colorado, 2012
149
Percent difference between national and Colorado past-month teen marijuana usage
averages – 2006 and 2011
2006 20110.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
9.41%
28.73%
Rocky Mountain HIDTA, 2013
150
In Colorado, fatalities involving drivers testing positive for marijuana
rose by 112%.
Increased traffic fatalities
Mu-Chen Li, J.E., et al., 2011; Colorado Department of Transportation, 2006
While the total number of car crashes declined from 2007 to 2011, the number of fatal car crashes with drivers testing
positive for marijuana rose sharply.
Colorado Dept of Transportation
2007 2008 2009 2010 2011500
550
600
650
700
750
800
850
Total car crashes
2007 2008 2009 2010 201115
20
25
30
35
40
45
50
55 Crashes with high drivers
151
152
In 2011, marijuana-related incidents accounted for 26
percent of the total ER visits, compared to 21 percent nationally
Increased ER admissions
Rocky Mountain HIDTA, 2013
153Under 5 6 to 12 13 to 14
200%
60%
92%
Chart Title
• 200% for kids under 5
• 60% for kids 6-12
• 92% for kids 13-14
Increased ER admissions
Rise in marijuana-related ER visits from 2006 and 2012:
Rocky Mountain HIDTA, 2013
154
As the price for marijuana plummets in legalization states, we can expect cheap marijuana to be sold in non-legalization states for a handsome
profit.
• According to the El Paso Intelligence Center (EPIC) National Seizure System, in 2012, there were 274 Colorado marijuana interdiction seizures destined for other states compared to 54 in 2005.
Diversion of marijuana
Rocky Mountain HIDTA, 2013
155
Two independent reports released in August 2013 document how Colorado’s supposedly regulated system is
not well regulated at all
Poor regulation
156
The Colorado State Auditor concluded that:
• The state had not “established a process for caregivers to indicate the significant responsibilities they are assuming for managing the well-being of their patients,” and that the state “cash fund” was out of compliance.
Poor regulation
Colorado Office of the State Auditor, 2013
157
The Colorado State Auditor concluded that:
• 50% of ALL recommendations made by only TWELVE physicians
Poor regulation
Colorado Office of the State Auditor, 2013
158
The city of Denver Office of the Auditor concluded that:
• The city of Denver “does not have a basic control framework in place for effective governance of the…medical marijuana program.”
• The medical marijuana records are “incomplete, inaccurate, inaccessible.”
• And that many dispensaries are operating without licenses.
Poor regulation
City of Denver Office of the Auditor, 2013
159
4/20 Rally in Denver
160
4/20 Rally in San Francisco
Responsible Regulations?
161
• Heavily influenced by CO’s massive medical marijuana industry
• Allowing character packaging, edibles, candies
• Can grow much more than you sell
• Advertising allowed in “Adult Periodicals”
162
With the DOJ’s announcement that it will not enforce the CSA, the reform group, Marijuana Policy Project (MPP), announced its plan to get legalization on the ballot in 10 states by 2017
Legalization on the horizon
163
Arizona
California
Maine
Nevada
New HampshireVermont
Maryland
Rhode Island
Hawaii
Alaska
These states include:
Massachusetts
Oregon
164
• MPP is currently supporting a petition – the “Campaign to Regulate Marijuana” – to place legalization on the 2014 ballot
• If passed: • The manufacture, sale, and possession of up
to one ounce of marijuana becomes legal for adults over 21.
• Creates establishments such as: marijuana retail stores and marijuana infused-product manufacturers
Alaska
165
• Arizona • California • Maine• Nevada
• Hawaii • Maryland• New Hampshire• Rhode Island• Vermont
Initiatives supported by MPP are in place to put legalization on the ballot by 2016 and 2017
in:
Also on the horizon…
Massachusetts
Oregon Montana
166
In all of these states, if the proposed amendments are passed,
the retail sale and production, and possession of marijuana will
become legal
If passed…
167
So What Are Our Choices?
All or nothing?
Legalization (“Regulation”) vs. Incarceration (“Prohibition”)
168
Not about legalization vs. incarceration
We can be against legalization but also for health, education,
and common-sense
Smart approach
169
Chair, Patrick J. Kennedy
Launched January 10th 2013
Over 15,000 press mentions
Public Health Board of Trustees
10 state-wide affiliates
1. To inform public policy with the science of today’s marijuana.
2. To have honest conversations about reducing the unintended consequences of current marijuana policies, such as lifelong stigma due to arrest.
3. To prevent the establishment of Big Marijuana that would market marijuana to children — and to prevent Big Tobacco from taking over Big Marijuana. Those are the very likely results of legalization.
4. To promote research of marijuana’s medical properties and produce pharmacy-attainable medications.
Project SAM
170
SAM is a national group with state and
local partners
Kevin A. Sabet, Ph.D., www.kevinsabet.com
SAMIA (SAM Interstate Alliance)
State partners who work on state/local issues
Can be separate 501 (c) (4) or PAC or simply an informal entity
173
174
175
176
Addressing current policy:
• People should not be stigmatized for their past use
• No sense in incarcerating users• People need job and economic
opportunities; by being blocked from them they will re-enter the illicit market
Smart Approach
177
• Robust community-based prevention programs • community coalitions
• Criminal justice intervention programs• Probation reforms• Drug treatment courts
• Non-drug interventions• Housing• Education• Healthcare
Non-legalization reforms
Recruit Champions
178
• Legislators at every level of government
• Executive branch leaders, at every level of government
• Media luminaries in every medium
• Business leaders
• Other key influentials (faith leaders, civic leaders, foundation leaders, other) 179
• Figure out how the marijuana legalization issues affect them and their constituents/members.
• Discuss these issues in a way that will appeal to them, their mission and their members.
180
How To Interest Grasstops Leaders:
Frames Win Debates
181
How to Frame Our Messages to Win Back The Public
182
Changing the Frame:
• From negative to positive• From “old” to “new”
183
Old Message
Marijuana legalization will increase drug use and workplace
related consequences.
184
According to the American Council for Drug Education in New York, employees who abuse drugs are:
• 10 times more likely to miss work• 3.6 times more likely to be involved in
on-the-job incidents • 5 times more likely to file a workers’
compensation claim.
185
Facts:
6.5% of high school seniors smoke
marijuana every day1, rendering them
virtually unemployable.186
1 Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. Monitoring the Future national survey results on drug use, 2012. Volume I:
Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan. Available: http://www.monitoringthefuture.org/data/10data.html#2011data-drugs
Fact:
New Frame:
If your community cares about jobs and employability, you need to care about reducing marijuana use.
187
Old Message
Marijuana use is bad for memory, motivation and learning
188
If you care about academic performance, you need to care about youth marijuana
use.
189
The New Frame
Connecting the dots for elected officials is crucial if we want results!
190
Kevin A. Sabet, Ph.D., www.kevinsabet.com
There are alternatives…
Smart InternationalPrevention Treatment Recovery Enforcement Efforts
Parental Involvement in Preventing Substance Abuse
• In 2012, most youths aged 12 to 17 believed that their parents would strongly disapprove of their having:– Alcoholic Beverage (one or two every day) – 90.5%– Smoking Cigarettes (one or more packs a day) – 93.1%– Marijuana or Hashish Use (once of twice) – 89.3%
Effect:
– In 2012, past month use of illicit drugs, cigarettes, and alcohol use were all lower among youths 12-17 who reported parental involvement.
• 7.6% - Rate of past month illicit drug use with parental involvement.
• 18.1% - Rate of past month illicit drug use without parental involvement.
Kevin A. Sabet, Ph.D., www.kevinsabet.com
Kevin A. Sabet, Ph.D., www.kevinsabet.com
Prevention:Community-based
■ Planning ■ Multi-Sector approach ■ Reduction in use of …
Alcohol Tobacco Marijuana
12% 28% 24%
Kevin A. Sabet, Ph.D., www.kevinsabet.com
Recovery
Enforcement:An untapped opportunity for progress
7 millionAmericans in the Criminal Justice System
Nearly a … and a quarter of Federalthird of State prisoners committed their crimesprisoners … under the influence of drugs
5 millionOn Probation or
Parole
2 millionIncarcerated
1/3 1/4
Kevin A. Sabet, Ph.D., www.kevinsabet.com
Enforcement and TreatmentCan Work Together
For every $1.00 invested in Drug Court, taxpayers saveas much as $3.36 in avoided criminal justice costs alone.
Project Hope
Reduction in missedappointments
85%
Reduction in positive urinalyses
91%
47%
Arrested Used Drugs
Skipped Appointments
Probation Revoked
46%
23%
15%
21%
13%
9%7%
Control
Project Hope
Drug Market Interventions (DMI)
In Rockford, Illinois, property crime declined by 24 percent.
In Nashville, Tennessee, drug crime declined by 39.5 percent.
In High Point, North Carolina, the first site, indicated that the target area experienced a substantial decline in violent (30.6%) and drug-related crime (32.2%).
In all three communities, interviews with local residents revealed a perceived decline in crime and disorder, reported improvement in the quality of neighborhood life, and appreciation for the police.
Kevin A. Sabet, Ph.D., www.kevinsabet.com
Re-entry