Pot Ponder
September 6, 2016
Five states have recreational marijuana legalization on the ballot this fall, if I heard correctly.
I feel as though we should probably talk about this over the next couple of months.
ETA:
Arizona
As most of you are aware, these follow successful recreational legalization initiatives in Washington (2012), Colorado (2012), Oregon (2014), Alaska (2014) and the District of Columbia (2014).
DrugMonkey 
September 6, 2016 at 12:17 pm
Which five states?
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September 6, 2016 at 12:32 pm
I think I know exactly what the discussion will consist of: You (correctly) mentioning that pot is hardly the harmless pastime or wonder cure-all its devotees claim it is, and others (also correctly) mentioning that the war on drugs and the previous war on alcohol are/were failures and promoted both organized crime and filled prisons with people who probably shouldn’t have been there. There isn’t a whole lot of meaningful discourse to be had.
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September 6, 2016 at 12:44 pm
I just read that combined spending on the War on Drugs by federal and state governments totaled over 30 billion dollars in 2015….
That’s insane.
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September 6, 2016 at 12:48 pm
So NPR had a story from Colorado about a DUI case and a woman who hadn’t smoked at all on the day in question but did a lot in general. The specifics of the case made me cringe, but the basic idea seemed to be that legal assumptions about how to evaluate the impact of THC on impairment shouldn’t necessarily mirror how we evaluate the impact of EtOH on impairment.
Any thoughts on good field tests for sobriety/vehicle operating competence that would help? Is there even a way to develop one that a very devoted pot-smoker couldn’t game? I remember a crazy video where they took pot smokers on a closed course and showed them how many cones they knocked over (even the ones that swore up and down they weren’t impaired)- the lone partial exception being a medical marijuana smoker who was quite honestly used to driving with some concentration in the system.
I’d be more enthusiastic about legalized pot if we hashed this out first.*
*sorry for the pun
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September 6, 2016 at 12:56 pm
There isn’t a whole lot of meaningful discourse to be had.
I believe it is indeed meaningful to discuss what the science tells us, because it could be used to shape public policy after legalization, if this occurs.
As we’ve seen in WA, CO and OR (I’ve not heard much about what is going on in AK), there is a very long tail of State and local law/regulation hashing out numerous policy issues in the wake of legalization. My personal view is that it would be best if scientific understanding contributed to that process.
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September 6, 2016 at 1:13 pm
So NPR had a story from Colorado about a DUI case and a woman who hadn’t smoked at all on the day in question but did a lot in general. The specifics of the case made me cringe, but the basic idea seemed to be that legal assumptions about how to evaluate the impact of THC on impairment shouldn’t necessarily mirror how we evaluate the impact of EtOH on impairment.
Heard this bit too, hence the post.
The major discussion of the segment was two-fold and I think illustrates where policy based on the science can be helpful, even if only to point to what we need to know but do not at present. One, THC hangs around in the body for a very long time post-consumption, particularly in comparison with alcohol. Someone who is a long term chronic user can have blood THC levels that are…appreciable (no matter the particular threshold for presumed impairment, this is relevant). Some of the best data on this are from the laboratory of Marilyn Huestis when she was, gasp, an intramural investigator at NIDA! There are some attempts in the Huestis work to compare THC and metabolite ratios to determine recency of consumption-that’s a good direction. IMO.
The second argument was about behavioral tolerance. One of the scientist interviewed was quoted along the lines of saying the relationship between blood levels, repetitive use and actual impairment was more linear for alcohol than for THC. Pretty much. There is some evidence for substantial behavioral tolerance, meaning even when acutely intoxicated, the chronic user may have relatively preserved performance versus the noob. There’s a laboratory study here that makes the point fairly succinctly, even if the behavior itself isn’t that complex. As a counterpoint, this recent human study fails to confirm behavioral tolerance in an acute dosing study (see Fig 4A for baseline THC by frequency of use, btw). As that NPR piece noted, it would be very valuable to get some rapid field screen for THC/driving – relevant impairment on a tablet.
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September 6, 2016 at 1:14 pm
Of course, given that “science” is broader than just addiction/toxicity studies.
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September 6, 2016 at 1:23 pm
Seems like we should just let the experiment play out and ask for money to study the results. Beyond that, start buying stock in Altria / Phillip Morris. If people experience rampant hyperemesis and who-knows-what, then just throw in some taxes and put warnings on the side of the pack.
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September 6, 2016 at 1:24 pm
[…] had a few reactions in a comment that ended up being post-length, so here you […]
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September 6, 2016 at 1:28 pm
we should just let the experiment play out and ask for money to study the results
I disagree with this when there are entirely predictable and therefore preventable or mitigatable harms at stake. Also when we can identify clear areas of focal investigation that we could start right now that would ultimately generate better policy and better personal and public decision making.
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September 6, 2016 at 6:14 pm
This is a little off topic but DrugMonkey have you seen the claims that pot is widely used as a substitute for pain or anxiety meds?
http://promarket.org/medical-marijuana-still-not-accepted-50-statesask-george-stigler/
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September 6, 2016 at 6:21 pm
Yes, I’m familiar with so-called medical marijuana. Why?
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September 6, 2016 at 9:42 pm
If ‘”medical” marijuana is actually substituting for pain prescriptions on a large scale then I guess it’s more medical than I thought. And maybe less harmful, in that being a pot head is not as dangerous as opioid dependence…
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September 7, 2016 at 1:08 am
You do understand that a lot of drug addiction is associated with mental health disorder, right? Consuming psychoactive substances that are available doesn’t mean they are specific medications.
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September 7, 2016 at 9:15 am
DM – what does that have to do with MP’s point? Which is that some possibly large fraction of people who would, in the absence of alternatives, take opioid pain killers are actually getting relief from marijuana? And that, all things considered (especially the current pharma-driven opioid abuse epidemic), this might actually be a good thing from the standpoint of harm reduction.
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September 7, 2016 at 11:25 am
There are people getting “relief” from all sorts of ailments with various psychoactives. This doesn’t prove a specific medical effect, nor does it prove anything about relative harms versus the alternatives or potential future alternatives. It is an integral point to this notion.
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September 7, 2016 at 11:28 am
Do note carefully, as the skepti-docs say once marijuana is established as safe and effective by the usual measures than sure, it is medicine. Not alt-Med, simply Med.
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September 7, 2016 at 7:39 pm
It is undeniable that people use marijuana because it makes them feel better than without it. It would, correspondingly, not be at all surprising if using marijuana makes some people feel good enough to not use opiates (whether for pain alleviation or because of addiction, or somewhere on the spectrum in between). It is certainly undeniable that a shift from opiate use to marijuana use would be wholly positive.
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September 7, 2016 at 7:53 pm
“This doesn’t prove a specific medical effect”
The placebo effect is a “medical effect.” If you can rescue thousands of people from chronic pain with a relatively harmless placebo, then why not prefer that method over highly addictive opioids?
“nor does it prove anything about relative harms versus the alternatives”
No, what proves that is evidence. Which I think we have.
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September 7, 2016 at 11:24 pm
If you can rescue thousands of people from chronic pain with a relatively harmless placebo, then why not prefer that method over highly addictive opioids?
There is no way it is a “placebo”. The question is whether it is nonspecific sedation or numbing using something which by the way is not actually “relatively harmless”, akin to drinking, or is it something specifically useful. Look, one of the four major signs of cannabinoid activity in rodent models prior to the cloning of CB1 was antinociception. There are good odds it does something specific.
It is certainly undeniable that a shift from opiate use to marijuana use would be wholly positive.
Is a shift from temporary, physician overseen use of opiates to a chronic addiction to pot “wholly positive”?
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September 7, 2016 at 11:40 pm
I’m just a lurker, but I don’t think that the other posters are talking about “temporary, physician overseen use of opiates.” Rather they’re comparing the chronic addiction to pot and the chronic addiction to opiates.
There is a not insignificant number of people who have become addicted to prescription opiates, and often those individuals eventually turn to cheaper alternatives (e.g. heroin). So in those cases, why wouldn’t a shift from opiate use (addiction) to marijuana use (addiction) be wholly positive?
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September 8, 2016 at 1:48 am
I think people talk about scenarios that best meet their uninformed beliefs about pot and opioid pain meds without regard for how likely they are, relative to other scenarios.
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September 8, 2016 at 9:17 am
Even if the probability of MJ addiction is similar to that of opioid addiction, I’d rather be hooked on something that’s hard (impossible?) to overdose on and therefore won’t kill me directly, and which doesn’t result in a severe withdrawal syndrome when I try to quit.
“one of the four major signs of cannabinoid activity in rodent models prior to the cloning of CB1 was antinociception. ”
I know that. I used “placebo” to point out that even if MJ had no biological effect other than a placebo effect of pain reduction, then it would be preferable for those who experience that effect to treat their chronic pain with it rather than opioids. The fact that there is evidence for an actual alalgesic effect just supports that point further.
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September 8, 2016 at 9:18 am
analgesic
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September 9, 2016 at 8:44 pm
Even if the probability of MJ addiction is similar to that of opioid addiction, I’d rather be hooked on something that’s hard (impossible?) to overdose on
Sure. But what if the probability of MJ addiction is way higher? Would you rather a short course of doctor overseen opioid medication or a lasting addiction to marijuana?
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September 10, 2016 at 8:36 am
Do you really think the risk of MJ addiction might be *way* higher?
Is this wrong?
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September 10, 2016 at 3:05 pm
DM, you have already nicely summarized the relative risks of developing addiction to different drugs:
“…the estimate suggests that the chances of becoming dependent on heroin (23% of lifetime users) are greater than the chances for alcohol (15%) or cannabis (9%).”
Which means that I actually would NOT prefer a short course of doctor-supervised opioid medication to MJ treatment, assuming I find them to be equally analgesic. Especially once I consider that MJ dependence, should it happen, is more benign than opioid dependence (overdose risk low to nonexistant, withdrawal syndrome is mild and not life-threatening).
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September 10, 2016 at 4:53 pm
Maker Of Dangerous Opioid Is Spending Big To Stop Legal Pot In Arizona
“A controversial pharmaceutical company that makes a highly addictive opioid donated $500,000 to a campaign fighting a ballot measure in Arizona that would legalize recreational marijuana.”
Hmmmmm.
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September 11, 2016 at 11:14 pm
“Would you rather a short course of doctor overseen opioid medication or a lasting addiction to marijuana?”
Having seen both up close, the later. No contest.
You can take out all of the fear of long term consequences and moralistic thinking about addiction out of the equation, and opioids are still terrible drugs. If you wanna have a Tylenol 3 around in case you need it after a root canal and believe you should deserve to feel morally superior to stoners, fine. But just watch someone dying of metastatic cancer and try to tell me how “short term” or “doctors supervision” is worth more than half a jar of warm piss. Oxycontin screws you up. And none of the kinetics of these drugs are consistent or work as advertised, essentially ensuring you walk a constant tightrope of ever escalating pain and a personhood robbing fog accompanied by risk of respiratory arrest.
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September 12, 2016 at 10:25 am
It’s amazing that a drug so completely useless for every possible situation, as witnessed by your anecdote of one, became so popular for medical use.
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September 12, 2016 at 1:28 pm
Opioids in general have redeeming value and legitimate uses, my personal hell notwithstanding. That said, cannabis also has redeeming value and medically legitimate uses (legally legitimate being another matter). The choice between them, *even* using the best case scenario for the former and a bad case scenario for the later, is not as clearcut as you seem to think.
However, OxyContin in particular was intentionally marketed as a twice a day drug to give it a market niche. Trying to make the pain relief last 12 hours is a recipe for disaster. The marketing of Oxy, taken as a whole, is appalling. See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ for scholarly discussion, or even the “so called profession” actually addressing the drug in the LA times (http://www.latimes.com/projects/oxycontin-part1/). This is not anecdotal.
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September 12, 2016 at 2:15 pm
is not as clear cut as you seem to think.
You need reading comprehension lessons or at least to read without your preconceived notions about all sorts of facts.
OxyContin in particular was intentionally marketed
what does “marketing” have to do with drug efficacy? or, conversely, why is the marketing of marijuana for alleged medical purposes not equally criticized by you?
back to the point:
Opioids in general have redeeming value and legitimate uses, my personal hell notwithstanding.
This statement is validated by accepted standards of evidence necessary for drug approval in this country.
cannabis also has redeeming value and medically legitimate uses
This statement is not validated by accepted standards of evidence necessary for drug approval in this country.
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September 13, 2016 at 11:24 am
“back to the point:
Opioids in general have redeeming value and legitimate uses, my personal hell notwithstanding.
This statement is validated by accepted standards of evidence necessary for drug approval in this country.
cannabis also has redeeming value and medically legitimate uses
This statement is not validated by accepted standards of evidence necessary for drug approval in this country.”
Now, why might it be that opioids are the drugs that have been found to meet the standard of which you speak, but marijuana has not? Could it be that it costs billions to bring a drug to market, and since MJ is only quasi-legal, and only recently so, no pharma company has found it worthwhile to spend those billions? And that as MJ becomes more available for recreational yse, pharma companies are not going to spend the money because there is no profit motivation to sell as a drug something that one can buy over the counter? And could it be that the government has made it VERY hard to obtain MJ to do the research that would lead to the validation you want?
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September 13, 2016 at 12:57 pm
Could it be that it costs billions to bring a drug to market, and since MJ is only quasi-legal, and only recently so, no pharma company has found it worthwhile to spend those billions?
It could be. Do note that GW Pharma got Sativex (half THC, half cannabidiol, mucosal spray delivery system) to market for MS spasticity (outside the US). And is pursuing pot-related approvals in the US from what I understand. I don’t know if they spent “billions” or not but clearly they found a way to make this all work from the business perspective.
as MJ becomes more available for recreational yse, pharma companies are not going to spend the money because there is no profit motivation
Could be. Still doesn’t address the point.
And could it be that the government has made it VERY hard to obtain MJ to do the research that would lead to the validation you want?
As someone who is very familiar with both the licensing procedure and with obtaining controlled substances for research from the gubbmint, this is not a credible complaint. Very common, yes. but it is nonsense whining.
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September 13, 2016 at 1:44 pm
“Still doesn’t address the point.”
No, it IS the point: you can’t argue that opioids are better treatments for certain kinds of pain than MJ if there no one has done the research to compare the two. Yet you assertion that opioids are validated etc whereas MJ is not makes exactly that argument.
“As someone who is very familiar with both the licensing procedure and with obtaining controlled substances …”
I am also someone who is familiar with those procedures, and I know what a huge PITA it is to get access to class I substances than even class II. That discourages researchers from even trying. So it is not nonsense, and it is not whining.
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September 13, 2016 at 3:26 pm
Read the second link before critiquing my reading comprehension, DM. Marketing has a great deal to answer for regarding the harms done by OxyContin. If you tell doctors it works great for 12 hours and if their patients don’t see relief that long they need to prescribe higher doses, you get overdoses. You get preventable deaths. All to maintain market niche, since extended release generic morphine works just as well over 8 hour periods. It’s a case study in ways we *shouldn’t* trust the pharmaceutical industry. It’s also a case study in a way the FDA approval is a terrible proxy for acceptable safety and efficacy of a particular drug and dosing approach.
I’m not mad they were wrong about how long their drug works (heck, I don’t have any trouble believing it *can* last 12 hours; drug metabolism variations being what they are). What I find deplorable is that they misrepresented the way their drug works to doctors, in a way that fueled escalating doses, addiction and death, *in order to maximize their profits*. If there’s anyone making 2 billion a year off of cannabis doing that, do let me know, and I will enthusiastically condemn them as well.
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