The Boston Globe reports Colorado Senator Cory Gardner is crafting a bill that would prevent the federal government from interfering with states that have voted to legalize cannabis for recreational or medicinal purposes. The Senator is busy recruiting several co-sponsors for the bill, and he has received assurances from President Trump that he would sign such a bill into law.

This would be a step in the right direction and would alleviate concerns in many states that the Department of Justice, under new guidance from Attorney General Sessions, might enforce federal marijuana prohibition.

Unfortunately, as long as the Drug Enforcement Administration continues to classify cannabis as a Schedule 1 drug, quality clinical research on the potential medical applications of cannabis will remain significantly inhibited. By definition, a Schedule 1 drug has “no currently accepted medical treatment use.” Recent studies have shown that chronic pain patients have been able to reduce their opioid dosage and consumption by adding cannabis to their pain management regimen. A study of Medicare Part D patients from the University of Georgia published in JAMA earlier this month demonstrated this effect in states where medicinal marijuana has been legal. Another study published the same week from the University of Kentucky showed this effect was even greater in states where marijuana is legal for recreational use. And another recent study from the Minnesota Department of Health earlier this year found 63 percent of patients taking medical marijuana for their chronic pain were able to reduce or eliminate their opioid use within 6 months.

But this is old news. Studies from the University of Michigan in 2016 and from the University of California in 2017 also had similar findings. And researchers in Greece reported in 2012 that cannabidiol in marijuana “interferes with brain reward mechanisms responsible for the expression of the acute reinforcing properties of opioids” and might potentially be useful in medication-assisted treatment of opioid addiction. Researchers at Mt. Sinai School of Medicine point to this potential as well. 

While it is hoped that Senator Gardner succeeds in getting legislation to the President’s desk for his signature that would allow states to go their own way on the issue, it would be even better for Congress or the President to go a step further and put an end to the misguided and unjustifiable classification of cannabis as a Schedule 1 drug. In any event, one hopes this is the beginning of the end for marijuana prohibition. 

In a recent letter to the Trump administration, leading congressional Democrats ask the administration not to allow protections for enrollees in short-term health plans.

Yes, you read that right. Dated April 12, the letter comes from Sens. Patty Murray (WA) and Ron Wyden (OR), as well as Reps. Frank Pallone (NJ), Bobby Scott (VA), and Richard Neal (MA), each the top Democrat on a different congressional committee with jurisdiction over health care. They ask the administration to withdraw in its entirety a proposed rule that, if implemented, would offer significant protections to enrollees in so-called “short-term limited duration plans.”

The administration has proposed lengthening the maximum term for such plans from 3 months to 12 months, which had been the limit for nearly two decades before the Obama administration shortened it. The administration has also asked for public comments (due April 23) on whether it should allow insurers to offer short-term plans with “renewal guarantees”—a consumer protection that allows enrollees who develop expensive illnesses to continue paying low, healthy-person premiums.

The letter asks the administration to “withdraw the proposed rule in its entirety,” which would block those consumer protections. These Democrats literally want to prevent short-term plans from giving consumers the peace of mind from knowing they will be covered for an entire year. Worse, these Democrats want to prohibit short-term plans from offering a consumer protection that protects the sick from premium spikes. 

The reason for this animosity toward short-term plans is rather clear: ObamaCare supporters don’t want the competition. Federal law exempts “short-term limited duration plans” from ObamaCare and other federal health-insurance regulations. Short-term plans free consumers to purchase only the coverage they want, rather than have ObamaCare force them to buy coverage they don’t want, including coverage for things they may find morally repugnant. ObamaCare supporters do not want consumers to have that freedom, because when consumers leave ObamaCare coverage for short-term plans, ObamaCare premiums will reflect more and more of the cost of that law.

It is the height of irony for Democrats to call consumer-oriented short-term plans “junk plans” when ObamaCare is making coverage worse for the sick. One study found ObamaCare’s preexisting-conditions provisions penalize insurers $6,000 per opioid addict they enroll—so whichever health plan offers the best coverage pays the most penalties—and that ObamaCare is making coverage for opioid addiction and other ailments worse and worse as a result. At the same time, the law is causing premiums to rise so rapidly they double every few years. The only “junk” plans here are ObamaCare’s.

Expanding short-term health-insurance plans would give consumers the freedom to vote with their feet. Democrats don’t want consumers to have that freedom, because they know what the outcome of that vote will be. ObamaCare would continue to crumble, and Democrats would have to work with Republicans to replace it. The letter from Murray, Wyden, Pallone, Scott, and Neal provides all the more reason for the Trump administration to allow short-term plans to offer renewal guarantees.

On April 11 the Washington Post cited a new study from the American Action Forum that reinforces arguments I have made here and here, that despite a dramatic reduction in the opioid prescription rate—a 41 percent reduction in high-dose opioid prescriptions since prescriptions peaked in 2010—the overdose rate continues to climb, as nonmedical users have simply migrated to more dangerous substitutes like fentanyl and heroin while the supply of diverted prescription opioids suitable for abuse continues to come down.

I have a minor quibble with the study’s finding that “the annual growth rate of prescription opioid-involved overdose fatalities significantly slowed from 13.4 percent before 2010 to just 4.8 percent after.” In fact, the Center for Disease Control and Prevention end-of-2017 Data Brief No. 294 reported:

The rate of drug overdose deaths involving natural and semisynthetic opioids, which include drugs such as oxycodone and hydrocodone, increased from 1.0 [per 100,000] in 1999 to 4.4 in 2016. The rated increased on average by 13% per year from 1999–2009 and by 3% per year from 2009–2016. (Emphasis added)

As an aside, it is worth mentioning that four researchers working in the CDC’s Division of Unintentional Injury Prevention reported in the April 2018 American Journal of Public Health that the CDC’s method for tracking opioid overdose deaths have over-estimated the number due to prescription opioids, calling the rate “significantly inflated.” Many overdose deaths actually due to fentanyl are folded into the “prescription opioid” numbers since, technically, fentanyl is a prescription drug even though it is rarely prescribed outside of the hospital in a form suitable for abuse. 

The AAF report understates the significant role that the abuse-deterrent reformulation of OxyContin and other opioids have played in driving nonmedical users to heroin and fentanyl. The researchers “suggest” abuse-deterrent formulations “could be a major factor driving the rise in heroin fatalities.” But evidence of the connection is much more powerful and convincing, as I presented in the Cato Policy Analysis “Abuse-Deterrent Opioids and the Law of Unintended Consequences” in February of this year.

The Washington Post says Ben Gitis, the lead investigator, stated that “many people became dependent on prescription opioids, and when the narcotics became difficult to obtain, people turned to whatever alternative they could find. The cartels saw that market and filled it rapidly.” He suggests in his study that overprescribing by doctors in the late 1990s and early part of this century was the driving force behind opioid abuse and addiction. This is another area where I have to disagree.

While there were undoubtedly unscrupulous doctors operating “pill mills,” some doctors who prescribed opioids too liberally with the best of intentions, and dishonest and overzealous pharmaceutical sales reps falsely representing the safety of their product, these factors were exceptions to the rule, and peripheral rather than central to the opioid overdose problem. 

It must be remembered that numerous studies throughout the 1970s, 1980s, and 1990s documented that patients were being undertreated for pain because of an irrational fear of opioids. In 1989, Charles Schuster, the Director of the National Institute on Drug Abuse, stated. “We have endowed these drugs with the mysterious power to enslave that has been overrated.” The “opiophobia” of the time gradually—and correctly—gave way to a more rational and humane approach to patients in pain. Furthermore, numerous studies, including Cochrane systematic analyses in 2010 and 2012, as well as a report this past January in BMJ by researchers at Harvard and Johns Hopkins show that opioids have an addiction rate of roughly 1 percent or less in the medical setting. And Dr. Nora Volkow, the current Director of NIDA, in a 2016 New England Journal of Medicine article, stated, “addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with preexisting vulnerabilities.”

The National Survey on Drug Use and Health repeatedly finds that less than 25 percent of nonmedical users of prescription opioids obtain them from a doctor. Three-quarters obtain them from a friend, family member, or dealer. The NSDUH also found that nonmedical use of prescription opioids peaked in 2012, and total (medical and nonmedical) opioid use in 2014 was less than in 2012.

Studies repeatedly show upwards of 90 percent of opioid overdose victims have multiple drugs on board. In New York City in 2016, 75 percent of opioid overdoses were from heroin or fentanyl, and 97 percent also were found to have multiple drugs in their system at the time—46 percent of the time it was cocaine. And a November 2017 study from Washington University found 33.3 percent of heroin users entering rehab in 2015 stated that their gateway drug was heroin—as opposed to 8.7 percent in 2005. These numbers do not describe the profiles of patients victimized by doctors who were too liberal in their prescription of opioids. These are nonmedical users seeking drugs in the illicit and dangerous market that results from drug prohibition. 

And the problem is not confined to the US. In the European Union, where doctors historically have been “stingy” in prescribing opioids, expecting stoicism from their patients (and where it is much harder to “doctor shop”) there is an opioid crisis as well. EU overdose rates have increased for the last three consecutive years for which data have been collected. It seems to be worse in the UK, Spain, and Sweden. And the distribution of drugs follows the same pattern as in the US: predominantly heroin and fentanyl. The same is happening in Australia.

Overdose deaths from methamphetamine and other stimulants have also been surging in recent years and now are at record levels. And recent reports from New England point to a surge in deaths from fentanyl-laced cocaine, the latest version of the “speedball.”

The reasons behind the rise in the illicit use and abuse of mind-altering drugs in the developed world is a subject worthy of serious investigation. The causes are most likely multifactorial. But policymakers need to disabuse themselves of the notion that the prescription of opioids to patients by doctors is at the heart of the problem. That notion has made too many patients suffer needlessly as the old “opiophobia” of the 1970s and 1980s has returned. 

The American Action Forum study provides yet another reason for our policymakers to end their focus on the supply-side. If they lack the political will to re-examine drug prohibition, they should at least put the focus on harm reduction programs, such as needle exchange and supervised injection facilities, medication-assisted treatment for addiction, and making naloxone available over-the-counter.

In a surprising move, former House speaker John Boehner has joined the board of directors of Acreage Holdings, a multi-state company focused on growing and selling marijuana. Boehner was a long-time opponent to marijuana legalization but is quoted in the Washington Post as saying:

I have concluded descheduling [marijuana] is needed so that we can do research and allow [the Department of Veterans Affairs] to offer it as a treatment option in the fight against the opioid epidemic that is ravaging our communities.

The Post article goes on to note that:

Descheduling cannabis would not legalize it nationally, but it would end federal marijuana enforcement and allow states to set their own marijuana policies without federal interference.

It remains to be seen whether Boehner’s reversal on marijuana legalization is indicative of a larger trend, but at a minimum it is a step in the right direction.

Speaking at the National Rx Abuse and Heroin Summit in Atlanta, John Eadie, coordinator for the National Threat Initiative, warned, “We’re now facing a very significant stimulant epidemic.” Abuse of prescription stimulants such as Adderal and Ritalin (used to treat Attention Deficit Disorders) as well as illicit stimulants, like cocaine and methamphetamine, are surging. “No one is paying attention to this,” Eadie said, because the focus has been on opioids.

Law enforcement has seized 15 kilograms of stimulants for every kilogram of heroin it has seized during the last 5 years. The Centers for Disease Control and Prevention reports that psychostimulant overdose deaths rose 30 percent in the past year. There is evidence to suggest stimulant abuse is now outpacing opioid abuse. And the Drug Enforcement Administration reports that cocaine use and availability are at their highest level in a decade.

I wrote here about the resurgence of methamphetamine abuse once meth labs, especially in Mexico, found a substitute for Sudafed after the federal and state governments made it more difficult to obtain. And Oregon health authorities reported overdose deaths from heroin dropped in 2016 to 107 while overdose deaths from methamphetamine rose to 141.

There are lessons to be learned from this news if anyone chooses to learn them. The obvious one is that the “War on Drugs,” America’s longest war, is unwinnable. This lesson was apparently not learned when the nation experimented with alcohol prohibition in the early 20^thcentury. When a market exists for willing buyers and sellers, prohibition just drives that market underground. Waging a war on drugs is like playing a game of “Whac-a-mole.”

But the other lesson relates to current opioid policy. Policymakers seem stuck in what should, by now, be an obviously false narrative: that the opioid overdose crisis is a product of doctors prescribing opioids to their patients. And even after considerable reductions in the prescribing and manufacturing of opioids for patients has shifted non-medical users over to heroin and fentanyl—now the dominant causes of opioid deaths—policymakers can’t disabuse themselves of this false narrative. They continue to double down on restricting prescriptions of opioids and make many patients suffer in the process. 

The opioid overdose crisis has always primarily been the result of non-medical users seeking opioids in the illicit market—where the dose, purity, and even the actual identity of a substance can never be known with confidence. 

The resurgence of stimulant abuse and overdose should not be viewed in isolation. It should be integrated with the opioid issue. Both should be viewed in the broader context of substance abuse in the presence of drug prohibition. Sociocultural and psychosocial factors may ultimately explain why the use and abuse of mind altering drugs is on the rise across much of the developed world. 

As long as policymakers continue using supply-side interventions, hoping to win an unwinnable war, the problem will continue to grow.

Two new studies released this week find that medical marijuana laws are associated with lower levels of opioid prescribing for Medicare and Medicaid patients. The authors find that:

“Medical cannabis policies may be one mechanism that can encourage lower prescription opioid use and serve as a harm abatement tool in the opioid crisis.”

and:

“Medical and adult-use marijuana laws have the potential to lower opioid prescribing for Medicaid enrollees, a high-risk population for chronic pain, opioid use disorder, and opioid overdose, and marijuana liberalization may serve as a component of a comprehensive package to tackle the opioid epidemic.” 

These studies add to a growing literature suggesting that marijuana legalization, not stronger prohibition, will help address the current opioid crisis.

The Surgeon General issued an “Advisory on Naloxone and Opioid Overdose” today, drawing attention to the effectiveness of the opioid overdose antidote naloxone. The drug, approved for use since 1971, is an effective remedy that can be safely administered by lay personnel who receive basic instructions. The Advisory cites research demonstrating that community-based overdose education and naloxone distribution reduces overdose deaths, and points out that first responders in most states and communities are now equipped with the drug.

Because naloxone is available only by prescription, most states have developed workarounds to make it more available to patients and, in some cases, third parties who have proximity to medical and non-medical opioid users. This way, witnesses to an overdose can be capable of rescuing the victim. This usually involves a state authorizing pharmacists to prescribe the drug or, in many cases, the state health director, acting as the state’s physician, issuing a “standing order” to pharmacists to distribute it.

The Advisory lists a number of conditions and situations that might place a person at risk of opioid overdose and encourages such people, or people who know them, to avail themselves of naloxone. It supports efforts at wider distribution at the community level.

Unfortunately, because of the stigma that has developed in association with opioid use, many opioid patients are reluctant to speak to the pharmacist and request a naloxone prescription. In some states, the naloxone will not be prescribed to third parties who know an opioid user. Also, numerous instances have been reported where pharmacists are reluctant to prescribe the antidote, believing they are “enabling” a drug abuser.

Recognizing this obstacle to naloxone distribution, Australia made it available over-the-counter in 2016, making it as easy to purchase as cold remedies or antacids. This way medical and nonmedical opioid users can discreetly make a purchase and check out at the cash register without having to answer any questions or face scrutiny from a pharmacist. The drug has been over-the-counter in Italy for over 20 years.

Based upon an August 2016 blog post, the Food and Drug Administration thinks it is reasonable to consider reclassifying naloxone as over-the-counter, and the FDA Deputy Director stated in the post that the agency would be willing to assist manufacturers in submitting applications for reclassification. But FDA regulations allow the commissioner to order a rescheduling review and allow petitions for OTC rescheduling from “any interested person”—not just drug manufacturers.

I’ve argued here that the FDA Commissioner should order an expedited reclassification review, and, if the Commissioner is unwilling to do so, then the Secretary of Health and Human Services—or even Congress—can see that it occurs. I’ve also contended that state legislatures—or even governors—as interested parties, can formally request an FDA review.

The Surgeon General’s April 5th Advisory singing the praises of naloxone and calling for its wider distribution in communities across the nation makes it obvious that the Surgeon General is an interested party. Because he thinks naloxone should be used more to reduce overdose deaths, the Surgeon General should formally request that the FDA Commissioner order an expedited review of naloxone in hopes that it will be available over-the-counter as quickly as possible.