Angela Hawken

Quasi-legal cannabis in Colorado and Washington: local and national implications

In November 2012, ballot initiatives in Washington state and Colorado legalized large-scale production, commercial distribution and sale of cannabis for use by adults [1,2]. This is unprecedented; no jurisdiction— not even the Netherlands—has previously removed the prohibition on commercial production and wholesale distribution for non-medical use. The consequences will depend not only on state-level policies yet to be developed, but also on the responses of the federal government, which still prohibits cannabis. Federal and state governments have overlapping jurisdictions. Colorado and Washington state have eliminated their cannabis prohibitions for licensed businesses, but all cannabis-related activities—even possession of a single joint by someone with a medical recommendation— remain prohibited under the federal Controlled Substances Act. Historically, the federal government has confined itself to enforcement abroad, at the border, and of larger cases (usually not bothering to prosecute cases below about 100 kg of cannabis), but it remains to be seen whether producers and perhaps even retail stores in Washington state and Colorado will be subject to federal arrest and prosecution. Of the two states, Washington has higher taxes and stricter controls on production and sale. Colorado’s regulations make it potentially more hospitable to an ‘export’ industry that could serve—and potentially depress prices in—other states. Besides lower taxes, Colorado’s proposition allows any individual over the age of 21 years (no license necessary) to grow up to six cannabis plants and give away (but not sell) the product, and contains a ‘smurf protection clause’ that bans the state from requiring stores to ask for, or record, identification (beyond proof-of-age) from their customers. Voters in Colorado and Washington state have presented the Obama administration with difficult choices. Large businesses that follow regulations and pay taxes are entirely vulnerable to federal intervention; shutting down a known and named list of producers and sellers presents an easy enforcement task. But shutting down networks of unregulated ‘grow-your-own’ activity in Colorado might well prove beyond the limited capacity of federal drug-law enforcement. Furthermore, other states are now introducing legislation to legalize cannabis, and the question will likely be on state ballots in future elections. If the federal government shuts down regulated production in Colorado and Washington, billand proposition-writers in other states might respond with less-stringent policies: in the extreme, simple repeal of state cannabis laws with no requirement that producers register or seek any license. Another federal option is to allow the state-level regulatory schemes to go into effect. That would have hard-to-predict consequences. It is far from clear that acquiescence in state-level legalization would be consistent with the obligations of the USA under the Single Convention on Narcotic Drugs and its successor treaties, or whether other countries would perceive it as giving a green light to ending their own prohibitions, and perhaps not just for cannabis [3]. A third option would be for the federal government to exploit its considerable discretion to shape, but not eradicate, legal state markets by prioritizing enforcement against certain business practices (e.g. large producers that sell at low prices, passively facilitate interstate commerce, or market aggressively—particularly to youth or drug tourists from other states). As both the extent of the price decreases and the responsiveness of consumption to price—as well as to increased availability and reduced stigma—remain unknown, no firm prediction can be offered as to the extent of the resulting consumption increase [4]. Based on current knowledge, we do not even know what the order of magnitude would be in the near term or over time; however, one would expect changes in prevalence and dependence, and harms to health, to be smaller than would result from legalizing heroin, cocaine or methamphetamine, both because cannabis is currently easier to obtain (making legalization a smaller change) and because the consequences of even heavy cannabis use are, on average, much less dire than the consequences of heavy use of those other drugs. This is not to suggest that cannabis dependence is not consequential: more than two million Americans report that their cannabis use is causing them significant life problems [5]. Another major uncertainty involves the interaction with alcohol: whether the two drugs, when both are legal, will prove to be substitutes or complements remains EDITORIAL bs_bs_banner

Behavioral Triage: A New Model for Identifying and Treating Substance-Abusing Offenders

Over the last decade there have been several large-scale efforts to leverage the law to encourage substance-abusing offenders to enter treatment. A routine practice has developed in most states in which offenders undergo an assessment for drug abuse or dependence, and based on their self-reported behavior, those deemed to have a substance use disorder are referred to treatment programs. The problem with applying the assessment-treatment model in correctional systems is that both components of this approach are seriously flawed. An alternative model, using regular random testing coupled with modest sanctions, relies on offender observed behavior rather than self report, to signal need for treatment services. Many offenders are able to desist from drug use without treatment. This reallocation of resources creates greater opportunity to provide more-intensive treatment services to those who really need it. This paper proposes replacing the traditional assess-and-treat approach with an alternative model that bases treatment decisions on observed behavior: the behavioral triage model.

Criminal Justice Treatment Admissions for Methamphetamine Use in California: A Focus on Proposition 36

Abstract Methamphetamine (MA) use is considered as one of the nations most pressing drug problems. In California, MA use has outstripped all other drugs in epidemiological extent, law enforcement activities, and treatment services demand. An opportunity for further study of MA use and its treatment emerged from a change in offender sentencing options introduced by Californias Substance Abuse and Crime Prevention Act of 2000 (SACPA). Results indicate that statewide admissions for MA rose from 8.4% in FY 1992/1993 to 34.6% in FY 2004/2005, a four-fold increase over the 13 years. From the year before SACPA implementation to the year after, the percentage of treatment admissions due to MA use increased from 18.8% to 25.6%, an increase largely due to the fact that SACPA admissions were over 50% MA users. With the exception of alcohol, MA users entering treatment through SACPA had higher completion rates (about one third) from community based treatment than users of other primary drugs. This result held true for demographic and other subgroups of MA users. Multivariate regression results illuminate the relative importance of the variables examined. Implication of the findings for policy, intervention services, and research are discussed.

All Implementation Is Local

The Celebrators From its inception, many were unenthusiastic about HOPE. To be fair, several of us who were involved with assessing early implementation were similarly skeptical, especially those of us who prefer a public-health approach to substance-use disorders. But the manner in which Judge Steven Alm engaged the probationers who came before him in his courtroom demonstrated his interest in improving their futures. There was an atmosphere of goodwill in his court, in the probation office, and even at the jail. HOPE seemed worth exploring further, especially in light of positive evaluation findings produced by the research division at the Hawaii Office of the Attorney General. Our first evaluation confirmed those findings: Compared with those on probation as usual, probationers who had been assigned to HOPE had fewer new arrests, missed appointments, and positive urines, and they were less likely to be revoked and returned to prison. The reduction in revocations was especially important as the probationers included in the study were facing long open terms (up to 20 years). Despite criticisms that there was little to justify considering HOPE as a promising program (see Duriez, Cullen, and Manchak, 2014), several studies indicated that the approach was promising (by any reasonable standard). Judge Alm did not invent the notion of swift, certain, and proportionate sanctions, nor was he the first to attempt to implement a program that embodies those principles. In the same year as Judge Alm implemented HOPE, a similar approach was being implemented in Texas. The Special Sanctions Court (SSC) in Fort Bend County was launched at the same time as—and with no prior awareness

Tracking and incentivizing substance abusers in longitudinal research: results of a survey of National Institute on Drug Abuse-funded investigators.

Objectives:Increased recognition that addictive behaviors tend to be chronic and relapsing has led to a growing emphasis on longitudinal substance abuse research. The purpose of this study was to identify effective follow-up strategies used by National Institute on Drug Abuse-funded investigators who have conducted at least 1 study involving follow-up data collection from human subjects. Methods:A web-based survey was administered to a representative sample of National Institute on Drug Abuse-funded researchers (N = 153) with a history of conducting longitudinal research. Results:Reported study response rates were generally high, although 27% of the studies fell below the 80% benchmark. Face-to-face and telephone-based interviews commanded the largest subject payments—2 to 3 times higher than compensation rates for collection of biologic samples. With regard to the presumed impact of low follow-up rates on the generalizability of study findings, one-third of investigators who compared baseline characteristics of those who did and did not participate in the follow-up found meaningful differences. Support was found for the hypothesis that follow-up rates and total compensation would be positively related, with the mean compensation amounts between studies achieving <80% follow-up rate versus those achieving rates ≥80%, revealing a statistically significant effect in the predicted direction. Conclusions:The majority of respondents reported difficulty in tracking and locating subjects, and study respondents often proved to be quite different from nonrespondents. Incentives improved follow-up rates to a point, although the relationship was not linear. Efforts to improve follow-up rates may be better spent on addressing tracking and locating logistics rather than on strategies to compel participation once the subject has been located.

Unintended Consequences of Cigarette Taxation and Regulation

Tobacco smoking harms health. Taxes and regulations can reduce that harm. But evasion reduces the efficacy of taxes and regulations and creates harms of its own in the form of illicit markets. Enforcement can reduce evasion but creates additional harms, including incarceration and violence. Peter Reuter has pointed out that a flat ban on cigarettes would be likely to generate illicit-market harms similar to the harms of existing illicit drug markets. Taxes and regulations can be thought of as “lesser prohibitions,” subject to the same sorts of risks. Minimizing total harm means minimizing the sum of abuse harms and control harms.Tighter regulations and higher taxes on cigarettes risk increasing the size of the existing illicit tobacco markets, which are already substantial. That risk can be somewhat blunted by increasing enforcement effort, but doing so can be costly on several dimensions and might, under plausible assumptions, lead to an increase in violence. Tobacco policymaking should therefore consider illicit markets and the need for enforcement; some of the health benefits of regulation and taxation may be offset by increased illicit-market side effects and enforcement costs. The presence of licit substitutes, such as e-cigarettes, can greatly reduce the size of the problem; the regulation of e-cigarettes should take this effect into account. If enforcement is to be increased to counterbalance tightened controls, positive-feedback dynamics suggest that the enforcement increase should precede, rather than follow, the tightening.

Desistance Mandates Compared with Treatment Mandates in Criminal Justice Populations

Empowering those under criminal justice supervision to cease drug use on their own - rather than forcing them into formal treatment against their will - is a policy approach that warrants further evaluation.

Commentary on Friedmann et al. (2012): The importance of framing effects and popular understanding in drug policy research

Framing matters. If, on the morning after the 2012 Super Bowl, newspaper headlines heralded ‘Patriots dominated the second quarter’, that would be true, and would reflect a laudable achievement by the Patriots. Nevertheless, it would be a misleading summary of the game (the Giants won). Addiction published results of the Step’n Out evaluation, a multi-site trial of collaborative behavioral management (CBM) [1]. The intervention aimed at reducing illicit drug use and crime among drug-involved parolees. The authors’ research design and the potential for an effective and practicable intervention are encouraging. Their paper, however, frames an incidental finding as the principal result, which obscures the more fundamental, null finding. Of the carefully studied behavioral interventions for drug-involved offenders, contingency management (CM) has been shown to produce substantial reductions in drug use [2,3]. However, CM is rarely used in community corrections because most professionals balk at the idea of paying offenders not to do something they are not supposed to do in the first place [4]. One of the great appeals of CBM is that it shares the behavioral principles underlying CM but is packaged in a more politically palatable program. With a clearly articulated behavioral contract, reinforced with a series of graduated rewards and sanctions that can be delivered at a relatively low cost, Friedmann et al. offer a test of a model that could have important policy implications. That is, if the model yields improvements in outcomes. Reviews by Weisburd and colleagues have shown that very few approaches to managing offenders can withstand the scrutiny of a rigorous research design [5]. Standing out in this field, Friedmann et al. have executed a multi-site randomized controlled trial using an intentto-treat (ITT) design, the gold standard in evaluation research. Any conclusions of this study that are based on the original design warrant attention, and would be a substantial contribution to our limited knowledge about what works for this population. The principal conclusion of this study should be that the ITT randomized controlled trial of CBM showed no differences in outcomes compared with parole-as-usual. However, as is common in such circumstances, the authors appear to have identified a subsidiary, statistically significant result. CBM shows promise for reducing self-reported drug use among parolees who are primary ‘marijuana and “other” users’ (or, as they are sometimes described, ‘non-hard drugs’ users). That the authors emphasize the results of a subset of the population (non-hard drug users) limits the value of this paper. Marijuana users are only 16% of the entire sample. Results are reported for the category ‘marijuana and other’, but policy conclusions that follow from these results are drawn with respect to marijuana alone (which the authors note accounts for the majority of drugviolation arrests in the United States). This conflation of marijuana with (a diverse group of) other drugs is unfortunate, as parolees reporting marijuana as their primary drug are a minority even within this grouping, so it is not evident whether the results for the whole obtain with marijuana users. It is also not clear why the authors reported effects only on self-reported use, when they had drug-test results as well. Given the modest level of agreement between self-reported drug use and the urinalysis results (a reported kappa of only 0.38), it would have been helpful to at least have a footnote clarifying if the effects were comparable. This apparent shift in emphasis from the primary nullfinding to a positive subfinding could divert attention from the former, as these results will make their way into meta-analyses and into practitioner journals and will probably present a rosier view of the impacts of the program than the data warrant. However, in a field where so little shows promise we absolutely should attend to the rare effort that does. Friedmann and his team executed a rigorous study. Given the face validity of CBM, we need to know why it did not perform better in this trial. Did the researchers lack statistical power to draw stronger conclusions because (as they describe) they fell short of their recruitment goal, or do the challenges lie in program design, or in implementation? It is worth testing if, perhaps, CBM could demonstrate improved outcomes with a different implementation and with a larger sample to support the analysis—or with a sample of marijuana users in a prospective study.

United States Federal Drug Policy

The United States federal government plays an active role in setting and implementing drug policy. Federal agencies define the legal status of drugs and penalties for their trafficking and misuse; enforce drug-control laws; fund and conduct drug-abuse research, treatment, prevention, and public-information campaigns; and conduct drug-control operations abroad. Federal spending on drug control has increased dramatically in recent decades, with the “War on Drugs”, and is now approximately 14 billion dollars. The balance between public-health and law-enforcement approaches to combating drug abuse historically has shifted back and forth; the most recent developments suggest a turn toward public health. The policymaking process is often driven by political concerns more than evidence, and the objectives and effectiveness of federal policy are hotly disputed.