Essay based on "Opioids" slide presentation. encompassing medication-assisted treament, the criminal justice system, harm reduction and marijuana.

1. 1
Controversial Responses to Opioid Addiction
Sarasota, FL, Jan., 2019; updated Santa Monica, CA, Dec., 2020
Thisessayhas manysources,too numeroustomention,butIwouldparticularlynote The New
York Times,articlesbyGermanLopez on Vox.comandShianne Bowlin’sthoroughandtimelyarticle,
Resolvingthe OverlookedTragedyinCorrectional Facilities:MedicationAssistedTreatment
Accessfor Inmates,LincolnMemorial UniversityLaw Review,vol.8,Issue 1,2020. I alsowishto
acknowledge the help andsupportof mywife,InaraKlein,andmydaughter,Ali Klein.
1. Medication-assistedtreatment(MAT)
2. The criminal justice system
3. Harm reduction
4. Marijuana
The opioidepidemicisanextensive subject,so Iwill limitmyself tofactsand opinionson these
fourimportanttopics.The subjecttranscendspolitics. However,there issome polarizationof views,
withsome political implications.Inthe extremes,theseviews canbe describedasfollows: Atone end,
opioidaddictionisacrime and a moral failingandshouldbe treated assuch,as by incarcerationwithout
treatment.Inthe otherextreme, itisadisease,deservingof compassion,evenasfaras the radical idea
of prescribingherointoaddictswhoare resistanttostandard treatment.
Opioids are drugs derivedfromthe opium poppyandsimilarsyntheticdrugs,including (a) pain
relieversavailable legallybyprescription,suchas hydrocodone, codeine, morphine andthe notorious
OxyContin®, (b) heroin,whichisillegal,andamajor cause of addiction.and(c) fentanyl,whichisalegal
drug,but isalso soldillegally, isverypowerful,andamajorcause of overdose death.
Opioids acton opioidreceptors,notablythe muopioidreceptorinthe brain, resultinginachain
of eventscausingthe releaseof dopaminewithconsequentpainrelief andeuphoria,and theycanalso
cause respiratorydepression,whichoccurswithoverdose andcanbe fatal.
There are alsosimilarnaturallyoccurringchemicalsinthe body,calledendorphins,whichacton
the mu opioidreceptorwithsimilarpositive effects,forexample creatingagoodfeelingafterexercise,
like the so-calledrunner’shigh.
Use of opioidscanleadto powerful cravingsanddependence,suchthatwithdrawal causes
agonizingsymptomslike anxiety,insomnia,abdominalcramps,diarrhea,nauseaandvomiting.

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Dependence isn’tquite the same asaddiction,which hasbeendefinedasachronicrelapsing
disorderthatischaracterizedbythe compulsive desire toseekand use drugs, withimpairedcontrol
oversubstance use despite negativeconsequences.The termis often usedmore loosely. The psychiatric
profession’sstandardcompendiumof mental diseases,the DSM-5listsopioiduse disorder, withamore
nuanceddefinitionthatallowsforlevelsof severity.
In anycase, that there isa spectrumof opioidmisuse.
1. Medicationassistedtreatment
There are three medications foropioidaddiction thattargetthe muopioidreceptor,including
two,methadone and buprenorphine,whichare themselvesopioids,andathird,naltrexone,whichis
not.Theiruse is calledmedication-assistedtreatmentorMAT,whichispreferablyaccompaniedby
psychosocial support.
Again,there has beenpolarization.One viewstresses detoxificationfollowedby abstinence and
12-stepprograms like AlcoholicsAnonymousandNarcoticsAnonymous,aroutine thatisfollowed by
abouthalf of rehabilitationfacilities. The otherstresses MATincludingthe opioidmedications.
However,there isroomfora meetingof the minds.The Hazelden-BettyFordCenter,perhapsthe most
influential treatmentcenterinthe country,wasonce committedtoabstinence and12-step,butin2013
integratedMAT,includingbuprenorphine,afterwhichoutcomesimproveddramatically.
Methadone stimulatesthe muopioid receptorandiscalledafull agonist.Buprenorphine hasa
more limitedstimulatoryeffectandiscalleda partial agonist.Naltrexone blockseffectsonthe receptor
and iscalledan antagonist.

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I’ll call the firsttwo agonistsratherthan dwell onthe distinction betweenthem.Or,one cancall
themopioidsubstitution therapy.Whenusedas treatment, the agonists suppresscravingswithout
normallyinducingeuphoria.Theyare usuallygiven daily. Anaddictmakesatransitionfromhisdrug,
such as heroin,tothe agonistwithouthavingtoexperienceanunpleasantfullwithdrawal. A patientcan
become dependentonthe medications.
Methadone issubjecttocumbersome legal constraintsonhow itisadministered,oftenbydaily
dispensinginspeciallyregulatedclinics. Buprenorphinecanbe prescribedordispensedinphysician
offices,butthe physicianshave to completean8-hourcourse and have limitations onthe numberof
patientsthattheyare allowedtosee.
I will concentrate onbuprenorphine(bestknownasa special formcalledSuboxone) inmy
discussionof agonists.Clinical studieshave reporteda50% or bettersuccessrate for buprenorphine
withpsychosocial support,ascomparedwith nomore than10% for psychosocial support alone. Intime,
a patientmaybe cautiously weanedoff of buprenorphine, butsome mayneeditforlife. The important
thingisthat while takingagonists,apersoncanlead a normal life,holdajob,etc.
There isa dark side to agonists.Like illicitopioids, buprenorphine can be diverted,thatis,fall
intothe wrong hands,includingminors,the blackmarket,andprisons. Itdoes have some potentialfor
euphoria,butmostof the divertedbuprenorphine isforthe purpose of self-treatmentof addictionby
people whoare notable to gettreatmentbylegal means.
Also,a pregnantwomantakingbuprenorphine isatriskforher babyhavingneonatal abstinence
syndrome,inwhichthe babyhasbecome dependentandmayrequire treatmentwithanopioid.
Despite these drawbacks,the advantagesof treatmentwithbuprenorphine outweighthe
disadvantages.
Naltrexone isanopioidantagonist,whichmeansthatanopioidlike heroinwill have noeffect
such as euphoriaif naltrexone isinthe system,sothatthere isnoincentive touse the opioid.Italso
relievescravings. Unlikemethadone andbuprenorphine,there are norestrictionsonwhere itcanbe
prescribedorbywhom.There isno concernabout diversionandithasno blackmarketvalue,andit is
quite safe,although,importantly,inordertobe treatedwithit,the patientmust firstundergoan

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unpleasantfull detoxification fromheropioid,whichisasignificantbarrier.Anoral formtakendaily was
not successful because patientswouldn’ttake itreliably.
However,along-actingformcalledVivitrol,whichisinjectedmonthly,showedasuccess rate
aboutthe same as that forbuprenorphine. Butthe comparisongroupforVivitrol omittedasignificant
numberof subjectswhowouldnotundergothe necessary detoxification.If youincludedthose people in
the statistics,Vivitrolwas inferior.
There isanothertheoretical disadvantage to Vivitrol.Itnotonlyblocksthe effectsof heroin,
etc.,but alsothe effectsof endorphins,those naturallyoccurringopioid-like substances.Thus,astudy
showedthatwhenpeople inanexerciseclasswere randomlyassignedtoreceive ornotreceive
naltrexone,thosewhoreceiveditdidnotexperience the pleasantpost-exercise sensationsthatthe
control group did.
Also,itisthe mostexpensive formof MAT.
The agonistshave beensubjecttostigmatizationbecause they are opioids.
In 2017, whenhe was Secretaryof Healthand HumanServices,TomPrice said"If we're just
substitutingone opioidforanother, we're notmovingthe dial much."Incontrast, hissuccessor,Alex
Azar,has saidhe would worktoreduce the stigma. It isalsoworth notingthat Vivitrol’smaker,
Alkermes, pushedthe drugveryaggressively,playingintothe stigma,andpressedparticularlyhardin
the criminal justice system. Thisincludes free shotstoinmatesatthe pointof discharge.Theyhave
assignedsalesrepstojudgeswhooverseedrugcourtsand have spentheavilyonlobbying.
That said,all 3 medicationsare useful,andthe choice shouldbe individual. Thisisnotone size
fitsall.
Medicaid,Medicare andprivate insurance have tobe adequate tocoverMAT andto cover itfor
as longas it isneeded.
39 stateshave implementedMedicaidexpansion,whichenablesObamacare tocoveraddiction
treatment. Inone report,afterMassachusettsandVermontexpandedMedicaid more than60 percent
of people withopioiduse disorderreceivedmedication-assistedtreatment,comparedwithlessthan30
percentinthree statesthatdid notexpandMedicaid—Georgia,Texas andFlorida.
In France overdose deaths decreasedby79% afterbuprenorphine treatmentbecame widely
accepted.
I don’twishto shortchange 12-stepprograms.Many recoveringaddicts give muchcreditfor
theirsuccessto suchprograms. However, the programs oftendisparage the medications.Forexample,
NarcoticsAnonymous literature says:“Bydefinition,medicallyassistedtherapyindicatesthat
medicationisbeinggiventopeople totreataddiction.InNA,addictionistreatedbyabstinence and
throughapplicationof the spiritual principlescontainedinthe Twelve Steps.”Ireadan essayby a
womanwhose lovedone diedof anopioidoverdose aftera12-stepprogrampersuadedhimtostop his
agonistmedication.Still,anaddictcanseekandfinda 12-stepgroup that acceptsthe medications.
Furthermore, anewkindof 12-stepprogram has beendeveloped,calledMedicallyAssistedRecovery
Anonymous, whichcombinesthe features of AA orNA withfull acceptance of on-goingMAT.That
soundsverypromising.
A bipartisanopioidbill, passedin2018, expandsaccessto MAT like buprenorphine, expands
Medicare and Medicaidcoverage,andexpands availabilityof the opioidantidote naloxone, butit
probablydoesn’tgofarenough.
There needtobe gatewaysthatbringaddictsintouch withsourcesof possible treatment.For
example,atthe MassachusettsGeneral Hospital EmergencyRoom, whenanaddictistreated foran
emergency,whenpossible,he orshe isstartedon buprenorphinewithprovision forfollow-upcare.
Theirdoctorshave takenthe 8-hourcourse.This policy hasspreadto otherhospitals.Otherpossible
gatewaysare harm reductionfacilities,likeneedleexchange programs;andthe criminal justice system.

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2. The criminal justice system
The involvementof the criminal justice systeminopioidproblems beginswiththe “waron
drugs,”startedunderNixon.
El Chapo, a Mexicandruglord considered tobe the "mostpowerful drugtraffickerinthe world"
was triedinNewYorkin 2019 andfoundguiltyof a numberof criminal chargesrelated tohisleadership
of the SinaloaCartel,andiscurrentlyservingalife sentence at a maximumsecurityprisoninColorado.
He deserves noless. The war,rangingfromhighendprosecutionslike El Chapodowntothose whose
only offense is the felonyof possessingandusingillicitdrugs,hasnotbeenverysuccessful.Ithas
overcrowdedprisons atgreatexpense.There is disproportionate targeting of minorities.
Now,considerwhatcan happenatthe lowerendof offenses,like possessionanduse of a small
amountof heroin.Tolookat the positive side,asImentionedbefore,the criminaljusticesystemcanbe
a gatewayto treatment.Furthermore,incentivesplayapart,includingpositive incentives,like rewards
for abstinence,andnegative incentives,like the threatof incarcerationif one doesnotremainabstinent.
However,there are anumberof negative aspects.
Whena heroinuserisjailedforsucha low endoffense,he isbrandedwithacriminal recordthat
decreaseshischancesof employment,obtainingcredit,housing,etc.Thisisnowayto helphimturn his
life around.
There are alternatives.Drugcourtsprovide treatmentandotherservices,overseenbyajudge,
inlieuof beingprocessedthroughthe traditional justice system.Butdrugcourts have beenfaultedfor
havingnonmedical personnel make medical decisions.Theycanalsoendupbeingnearlyaspunitive as
the full criminalizationof drugs.Relapse isanormal part of rehabilitation,butinthe drugcourt system,
nonviolentdrugoffenderscanendupin jail because of relapse. Anadjustmentof theirtherapywould
be preferable.Manyof the courts are averse to MAT, especiallythe agonistmedications.Inanycase,
the personisat riskof gettinga criminal record.
There are otheralternatives.InPortugal,heroin use wasdecriminalized,becomingan
administrativeoffenselikeatrafficticket,andaddictsare referredfortreatmentandothersupport.
Drug use and overdose deathshave declined.Thishasbeenamodel forotherlocations.A programin

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Seattle called LawEnforcementAssistedDiversionactsina similarwayand has beenadoptedbyseveral
cities.
Some people have tobe incarceratedinanycase.At best,jail canbe a leverwithwhichto
encourage or force an addictto seektreatment.Sarasota,FL, CountySheriff TomKnightsaid,“Mostof
our crime isfueledbyaddiction.”Here,too,however,stigmaandthe aggressive marketingof
naltrexone have actedagainstthe use of agonists.ManyAmericanprisonersreceivenotreatmentatall
for substance abuse.Theyhave nochoice butto go throughwithdrawal once theyare behindbars.Jails
and prisonshave bydefaultbecome majordetox centers.Youcan’tcounton detoxificationbeingdone
by medical means,ratherthan“coldturkey.”Withoutmedical treatment,prisonersare prone torelapse
and overdose whentheyare released.
In 2016, Rhode Islandlaunchedaprogram of treatmentof addictedprisonerswithmethadone,
buprenorphine,ornaltrexone,withsubsequentmarkeddecreaseindeathsfollowingrelease. Thatisthe
exception.
In Sarasota,the jail has a voluntaryrecoverypodforsubstance abusers.Participantsagree toa
12-hour day of programmingthatincludesAA andNA meetingsandclassesandcounselinginmatters
like wellness,parenting,jobpreparation,andrelapseprevention.
Justbefore release,inmatescanalsoreceive aninitial monthlyshotof Vivitrol,the opioid
antagonisttherapy,withoutpatientfollow-up.Clearlythissituationisagreatdeal betterthanno
treatmentat all injail.A growingnumberof jailshave optedtotreatinmateswithVivitrolonthe way
out.
The recoverypodlikelyhasacertainsuccessrate, butit seemstofall shortof the beststandard
for treatment,because there isapparentlynooptionfortreatmentwithbuprenorphine ormethadone
while injail.Itcanbe arguedthat thisomissiongoesagainstanethical principle tothe effectthateven
as prisoners,individualsdeserve the besttreatmentavailable.Italsomightbe illegal.
In Massachusetts,aman whowas beingtreatedwithmethadoneforopioiduse disorderwas
foundguiltyof drivingwithasuspendedlicense,andhastoserve time ina jail that,as a matter of policy,
wouldnotsupplyhimwithmethadone.The AmericanCivil LibertiesUnionbroughtsuitonhisbehalf on
the basisof cruel andunusual punishmentandviolationof the AmericanswithDisabilitiesAct,andthey
won. Subsequently,several MassachusettsjailsofferingMAT to inmatesaddictedtodrugs.
Accordingto Shianne Bowlin,“The criminal justice systemisthe ‘largestsource of organizational
referralstoaddictiontreatment;’therefore,thereisavaluable opportunitytofacilitatethe pathto
recovery…While63%of inmatesmeetthe criteriaforOUD,…onlyalimitedpercentage of incarcerated
individualswithopioidaddictionreceive[MAT]…Typically,onlydetaineeswhoare alreadyon
methadone atthe start of detentionmayreceive aweek’sworthof treatment.Pregnantwomen,
however,are allowedtoremainontreatmentuntil theygive birthas MAThelpsreduce the withdrawal
effectsona fetus…[Inmates] are ata higherriskof overdose withinthe firsttwoweeksof releasefrom
correctional facilitiesthatdonotprovide MAT”
In individual cases,courtshave ruledthatinmates have arightto receive MATbasedonthe
AmericanswithDisabilitiesAct..For example,“InWashington,the AmericanCivil LibertiesUnion
reacheda settlementwithWhatcomCountyJail inwhichthe jail mustprovide MATto‘clinically
appropriate …inmateswhoare inwithdrawal fromopioidsas medicallyindicated... regardlessof
whethertheywere already takingMATat theirtime of entry.’”
A bill thatwouldfacilitatethe use of MAT inprisonsandjailshas beenintroducedinCongress,
the CommunityRe-Entrythrough AddictionTreatmenttoEnhance (CREATE) OpportunitiesAct,but
there hasnot as yetbeendefinitiveactiononit.
Otherwise,all inall,the case-by-casecourtdecisionsandpendinglegislationnotwithstanding,
there isas yetno existingblanketpolicythatwouldcoverthe whole country.

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3. Harm reduction
We can’t stopeveryone’saddiction, butharmreduction measures canbe implementedto
minimize itsharms. Thisissue really highlightsAmericansociety’slonghistoryof treatingdruguse asa
moral failinganda criminal justice issueratherthan a publichealthproblem.
The spectrumof harm reductionrangesfrom naloxone,the antidotetoopioidoverdoses,to
cleanneedle andsyringe exchange programs,tosafe heroininjectionsites,toactually prescribingheroin
for resistantaddicts. Iwill elaborateon the argumentsforharmreductionwhenItalkabout safe
injectionsites.
I have found commentslike this onthe Webregardingharmreduction:
“Darwin’sTheorysays‘survival of the fittest.’Letthese lostsoulspaythe price of theircriminal choices
and criminal actions.Societydoesnotowe themmultiple medical resuscitationsfromtheirownbad
judgment,criminal activity,andself-inflictedwounds.”
I disagree with suchattitudes,butwe needbe aware of them.
At the mostbasic level,we cantreatoverdoseswithaneffectivemedication,thussavinglives. It
isnaloxone (Narcan),which,like naltrexone,isanopioid antagonist.Itreverses the effectof the opioid
that causedthe overdose. Itthrowsthe personintowithdrawal,butotherwisedoes nothave adverse
side effects.There needstobe goodavailabilityof naloxone. Itneedstobe keptonhand byemergency
medical technicians,police officers,andfamilyandfriendsof those atrisk foroverdose.Insome places,
librarianshave itonhand.
Cleanneedle andsyringeexchangeprogramsaddressthe problem of the riskof transmitting
blood-borne infectionslike HIV andhepatitiswhenneedlesandsyringesare reusedbydifferentpeople.
These programsprovide accessto free sterile needlesandsyringesandfacilitate safe disposalof used
ones.Thisseemslike ano-brainer. Asof early 2018, 333 suchprograms were operationinthe U.S.and
over3,000 inAustralia, butthey remainedillegal inmany states.
In the face of the worsteverHIV epidemicinIndiana,needleexchange programswere allowed
there bynone otherthan then-GovernorMike Pence.
The nextstepissafe injectionsites.Here iswherethe linesreallybegintobe drawn,asyou will
see.They are locationswhere people canuse drugstheyhave alreadyobtainedelsewhere,withtrained
staff and naloxone onhandincase of complications.Thereare about100 supervisedinjectionsitesin66
citiesinthe world,butnone yetinthe U.S. exceptforsecretones.The firstCanadiansite openedin
Vancouverin2003. Nowthere are more than 6 in VancouverandsitesinMontreal andOttawa too.

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One reportliststhe benefitsasfollows:Theyare cost-effective;they increaseuptake into drug
treatmentprogramsandleadto drug use cessation;theyreduce publicdruguse, discardedsyringesand
relatedlitter;theyprevent blood-borne diseases;theyeliminatedrugoverdose death;theydonotlead
to increasedinjectiondruguse;theydonot leadto increasedcrime;theyengage users inmedical,
mental healthandothersocial services.Noteveryoneagreeswithall of that.
In cityblocksof Vancouverwithin 3/10 of a mile of the SIS,the fatal overdose rate decreasedby
35.0%. Inthe rest of the cityit decreasedbyonly9.3%.
In August, 2019, the CaliforniaLegislature passedabill tostart pilotsitesinSanFrancisco.The
verynextday,Rod Rosenstein,the deputyattorneygeneral,wrote inthe New YorkTimesthatsuchsites
wouldonlymake the opioidcrisisworse andhe threatenedswiftandaggressive actionbythe
Departmentof Justice.He citedadescriptionof the areanear an injectionsite inVancouveras“a war
zone”with“drug-addled,glassy-eyedpeoplestrewnabout”and“active drugdealinggoingoninplain
sight.”Gov. Jerry Brownendedupvetoingthe bill,partlytoavoidaconfrontationwiththe federal
government.
It is,indeed,afederal crime tomanage andmaintainsitesonwhichsuchillicitdrugsare used
and distributed, underthe so-calledCrackHouse Statute.However,justasstateshave legalized
marijuana,theycouldalsopasslawsauthorizingsafe injectionsites.Federallaw enforcementcouldthen
eitherturna blindeye,asithas largelydone withmarijuana,orbringstatestocourt.
The AmericanMedical Associationsupportsbothneedle exchange programsandsafe injection
sites.
Whereasonthe one hand,the Trump Administrationhasannounced $1.8BillioninFundingto
Statesto Continue CombatingOpioidCrisis,hisadministrationhasspokenoutagainstsafe injection
sites,callingthemillegalunderfederal law.
Likewise,president-electJoe Bidenhasvowedtotackle the opioidcrisisbymakingsure people
have access tohigh qualityhealthcare,includingsubstance use disordertreatmentandmental health
services,and,althoughhe supportsexpandingaccesstoneedle exchange programs,he doesnot
supportsupervisedinjectionsites.

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The location inthe UnitedStatesthatis closesttoestablishingasafe injectionsite is
Philadelphia, whereitwasapprovedbya federal judge lastyear.U.S.AttorneyWilliamMcSwain,an
appointee of PresidentDonaldTrump,opposesthe ideaandhopestooverturnthatdecision,whichhas
beenunderreview bythe 3rd
CircuitCourtof Appeals,where argumentsinitsfavorwere presentedon
Monday,November16, 2020, withthe outcome yetto be determined.
Let’sgo a stepfarther.Some people simplydon’trespondtoMATor have bad side effects.For
such people,somethingcanbe accomplishedbyprescribingheroin.If youthinkwe will have ahardtime
establishingsafe injectionsites,youcanimagine how difficultitwouldbe tostartheroinprescription.
However,thisisdone inseveral countries,includingDenmark,Germany,the Netherlands,the UKand
Switzerland,anditisdone inVancouver.There are somewhatstrictrequirementsforenrollment,such
as a certainlengthof time beinganaddictand a certainnumberof attemptsattreatment.A participant
mightgeta shotof herointhree timesaday,butis relievedof the needtosteal andpatronize the black
market,andis assuredof pure heroin,notcontaminated,suchasheroinlacedwithdangerousfentanyl.
He can leada somewhatnormal life,holdingajob,etc.
4. Marijuana
Marijuanahas beenapprovedformedical usesin32 states and forrecreational use in10 states
and D.C.
Studieshave shownthatfollowinglegalizationof marijuanathere weredecreasesinuse,abuse,
overdosesanddeathsfromopioids.Thishasbeen interpretedtoindicate thatmarijuanawas
substitutedforthe opioids,asforthe treatmentof painor as an alternative intoxicant,witharesulting
benefit.Surveysof chronicpainpatientshave supportedthis.Thissuggeststhatmarijuanaisanexit
drug ratherthan a gatewaydrug.However,inColorado,one of the keystateswhere marijuanahasbeen
legalized,there werealsoincreasedmarijuana-relatedautomobile accidents,andincreasedemergency
room visitsbychildrenwhohadeatenmarijuana-infused foodslike gummybears.
So the questionbecomeshowto exploitthe advantagesof marijuana,especiallyasitconcerns
the opioidepidemic, whileatthe same time minimizingitsharms.
Marijuana(or cannabis) isa plantthat containsmanychemical substances,includingabout100
relatedsubstancescalledcannabinoids.Analogoustoopioids,theyinteractwithreceptorsinthe human
body(includingthe brain) calledcannabinoid receptors.There are twomaincannabinoidsinthe plant,
tetrahydrocannabinol (THC) andcannabidiol(CBD). THCisthe psychoactive substance,the source of
intoxication,whereasCBDisnot,and appearsto be a ratherbenignsubstance.
To take marijuana,as fora medical purpose,canmeanusingthe whole plantbyanyof several
meanssuchas smoking,inhalingavaporor eatingit,or alternativelyusingisolatedchemical
components.
Much of the lore about medical usesisanecdotal,butthere isalsoreasonable evidence of
medical value, includingpain.In2017, the National Academyof Sciencespublishedthis reportwhich has
beencited asan authoritative guide.

10. 10
The authors conclude thatthere issubstantial evidencefromclinical researchthatcannabisisan
effectivetreatmentforchronicpaininadults.
They alsoconcludedthatmore researchis neededonthe variousforms,routesof
administration,andcombinationsof cannabinoids.Inotherwords,whenwe saythatmarijuanaisa
goodmedicationforpain,whatexactlyare we talkingabout?
The other waythat marijuana—specificallyCBD--mightbe usefulisthe treatmentof addiction,
alone or whencombinedwithanopioidagonist,basedonitsabilitytoreduce the cravingandanxiety
that can drive druguse,while itself beingsafe,nonintoxicatingandgenerally well tolerated,accordingto
Dr. Hurd. There isevidence forthisinratsand preliminarilyinhumans,soit needstobe further
researched.(HurdYL.Cannabidiol:swingingthe marijuanapendulumfrom‘weed’tomedicationtotreat
the opioidepidemic.TrendsNeurosci.(2017) 40:124–7. doi: 10.1016/j.tins.2016.12.006.)
Marijuanahas an ambiguouslegal status.Itisillegal atthe federal level, becauseitwasplaced
on Schedule Iof the Drug EnforcementAgency (DEA),whichencompasses drugs,substances,or
chemicalswithnocurrentlyacceptedmedical use andahighpotential forabuse—thisinspiteof the
fact that ithas beenlegalizedinmanystates.
On Dec.2, 2020, basedon recommendationsfromthe WorldHealthOrganization,the
CommissionforNarcoticDrugsof the UnitedNations (UN) votedtoremove cannabisformedicinal
purposesfromSchedule IV of the 1961 Single ConventiononNarcoticDrugs — where itwas listed
alongside dangerousandhighlyaddictive opioidslike heroin.Thatisthe counterpartof the DEA’s
Schedule I, where marijuana’sunfavorablestatusis,however,notnegatedbythe UN action. It is
noteworthythatonDec. 5, 2020, The House votedto decriminalize marijuana andremove itfrom
Schedule I,butthe measure isnotexpectedto passedinthe Senate.
Some otherSchedule Idrugsare:heroinand the psychedelicdrugs LSDand ecstasy.
Interestingly,alcohol andcigarettesare notonSchedule I, althoughtheyhave noaccepted medical use
and a higherpotential forabuse thanmarijuana (whichisn’tdeadly).In2017, if you countaccidentsand
diseaseslikecirrhosisof the liver, alcohol killed more peoplethanopioids,andalcohol deaths have also

11. 11
beenrising.Cigaretteskilled more than9 timesasmany people andare the leadingcause of
preventabledeathinthe UnitedStates.
MarijuanabeinginSchedule 1is meantto include itsconstituentchemicals,like THC,etc.Until
recently, CBDwasconsideredtobe illegal onthatbasis,althoughitwas more toleratedfrom the legal
pointof view aslong as itwas derivedfromhempratherthanconventionalmarijuana.Youcould buyit
inSarasota, withoutevencarryingthe State of FloridaMedical Cardthat isissuedtothose deemed
qualifiedformedical use.OnDecember20,the Farm Bill wassigned,legalizinghemp,andthusmaking
CBD from hemp unequivocallylegal.
The federal marijuanasituationisaCatch-22. It is judgedtohave no acceptedmedical use,but
itsSchedule 1status isa seriousroadblocktobetterresearchtoestablishmedical uses.
Here’sanotheranomaly.THCis,in fact,an FDA-approvedmedicationcalledMarinol orSyndros,
and so isCBD, calledEpidiolex.
Anyway,the Federal Governmenthasn’tcrackeddownonthe states,especiallyunderObama,
but alsosubsequenttohistime inoffice.
Accordingto YasminHurd, M.D., Directorof the AddictionInstituteatMount Sinai Hospital in
NewYork City, “…[T]hisisone of the firsttimesinUS historythat the questionof whetheraplant(or any
drug) is an effective medicine hasbeendecidedatthe ballotbox.Contrarytothe normal course of
medicationdevelopment,itisthe general publicandpoliticians,notscientistsandphysicians,
determiningthe medical value of marijuanainstateswhere marijuanause hasbeenlegalizedfor
medicinal purposes.
I like the waythe medical columnist inthe SarasotaHerald-Tribune putit:“Myideal future
regardingmedical marijuanaisone where itisstudiedopenlyandsubjectedtothe same scrutinyas
othermedicines,where boththe purified extractsare studiedaswell asthe whole plant.Marijuana
needstobe comparedagainstthe besttreatmentswe have…Onlythiswaycanwe confirmor refute the
benefitsandrisksof thisdrug.”
So whathas happened isnotthe ideal waytodevelopmedicine,butthe cat isout of the bag,
and we needtomake the bestof it.
I wouldfavorremovingmarijuanafromSchedule I, if onlytofacilitate furtherresearch.This
wouldalsomake legalizationatthe state level unambiguous.Otheradvantagesof legalizationwouldbe
freeinguplimitedprisonresources,allowingbetterregulationof the marijuanaproducts andreducing
the black marketwithitsattendantviolence,althoughthatisn’tacertainty: the blackmarketmay be
cheaper.Whenmarijuanaisillegal,youdon’tknow whatyouare getting. Ithas evenbeenlacedwith
deadly fentanyl.
One shouldbe undernoillusionsaboutthe drawbacksof legalization.Makingasubstance legal
mightbe expectedtoincrease itsuse. Idon’tthinkthatwe yethave a clearpicture of thiswithregard to
marijuana. Underprohibitionof alcohol,consumptionof alcohol declinedby30 to 50 percent,andother
illsassociatedwith it,suchascirrhosis, decreasedby50% or more.Followingthe repealof Prohibition,
alcohol consumptionincreased.
Also,the potential harmsof marijuananeedtobe appreciated.Itimpairsdriving,thoughnotas
much as alcohol.Itcan precipitate psychosis.
Whensmoked,itcan leadto respiratorysymptomsandbronchitis.There isgenerally
understoodto be such a thingas a pot-head,whotunesthingsoutandhas decreasedambition,what
some call amotivational syndrome. One authoritywasquotedassayingthata heavyuserwouldbe
unlikelytowina PulitzerPrize orfindacure for cancer. Onthe otherhand,no lessascientistthanCarl
Sagan wasan advocate of marijuanause andusedit regularlymostof hislife,soIdon’tthinkthat
appliestohim.
There issome evidence thatitis,infact, a gatewaydrugthat can leadto the use of otherdrugs
like heroin.Thisiscontroversial. DavidSheff, whose memoir“BeautifulBoy:A Father'sJourneyThrough

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His Son'sAddiction”was made intoa 2018 movie starringTimothée Chalamet,wrote,“Potwascertainly
a gatewaydrug forme…I became lessfearfulof otherdrugs.”SoI suspectitcan be an exitdrugfor some
and a gatewaydrug forothers.
It can leadto dependence andaddiction,butisnotasbad in that respectasalcohol or opioids.I
knowsomeone whose life wasprofoundlyaffectedbymarijuanaaddiction andwhoemergedfromitvia
a twelve-stepprogram.There isMarijuanaAnonymous,whoseliterature states,“Oursisa progressive
illnessoftenleadingustoaddictionstootherdrugs.Our lives,ourthinking,andourdesirescenter
aroundmarijuana—scoringit,dealingit,andfindingwaystostayhigh.”
I wantto discusstwospecial problemareas,where marijuanause hasbeenlinkedtospecific
harms.Such associationsdon’tprove cause andeffect,buttheyare concerning.
The firstis usingmarijuanain pregnancy,which hasbeenlinkedtolow birthweights, an
increasedriskof stillbirths,anemiaandplacementinneonatal intensive care,aswell as behavioraland
learningproblemsinchildhood.Thisimpliesinterference withdevelopmentof the nervoussystem. The
AmericanCollegeof ObstetricsandGynecology andthe AmericanAcademyof Pediatricsrecommend
againstusingmarijuanainpregnancy,butuse by pregnantwomenison the rise.
In a researchproject,a mysterycallerstatedthatshe was8 weekspregnantandhadmorning
sickness.69%of Coloradocannabisdispensariescontactedrecommendedtreatmentwithcannabis
products.More generally, unqualifiedso-calledbudtendersare providingmedical advice.
Unfortunately,medical schoolsteachverylittle aboutmarijuana.InFlorida,foraphysicianto
qualifytoissue amarijuanacard to patients,she musttake a special course for$250, but it appearsto
playup the lawsand regulationsasdistinctfromthe science of marijuanaasmedicine.
The secondproblemisuse inadolescence. The brainsof adolescentsare still undergoing
development. Marijuanause hasbeenlinkedtoimpairedbraindevelopment,pooreducational
achievement, adropinIQ, loweremploymentandincome,andimpairedsocial relationships. The riskof
psychosisis worse amongadolescents.Itisestimatedthatwhile,ingeneral, 9percentof usersbecome
addictedtomarijuana, thisnumberincreases toabout17 percentamongthose whostart young.

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Full legalizationmakesmarijuanaa bigbusinesswithaprofitmotive,likebigtobaccoor alcohol.
It isreasonable tobe concernedthatthiswill leadtoattemptstocultivate the underage market. The
marijuanaindustryalreadysells marijuana- orTHC-infusedchocolate bars,peanutbuttercups,Rice
Krispiestreats,hardcandies,andlollipops. Here are knock-offsof Reese’sPiecesandAlmondJoy. In
Colorado,there are marijuanaadsinthe free magazinesthatare clearlymarketedtoyoungpeople.
Here is a Coloradomarijuanastore front.
RememberJoe Camel?

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There isa precedentforthiswith electroniccigaretteslikeJuul,whichare chargedwithnicotine.
It isillegal tosell themtopeople under18, butthey have beenpackagedandadvertised inways
calculatedtoappeal to youngpeople aswell asbeingmade insweet,appealingflavors.

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Vaping,asit iscalled,hasskyrocketed. The percentageof 12th
grade studentswhoreported
vapingnicotine inthe past30 dayswentfrom11% to 21% between2017 and 2018. These,too,are
linkedtoadverse effectsonthe developingbrain, includingnicotinedependence andaddiction, andalso
to subsequentuse of regulartobaccocigarettes andevenmarijuana.E-cigarette use inpregnancymay
alsobe harmful tothe fetus.
Jerome Adams,whenhe wasSurgeonGeneral,officiallydeclaredthistobe anepidemic.
A solutiontothis danger,asit appliestomarijuana, couldbe,infuture legalizations, tohave it
soldby a state-runmonopoly sothatthere isnoprofitmotive.Thatiswhat isdone inUruguay. Previous
researchfoundthatstatesthat maintainedagovernment-operatedalcohol monopolies reducedaccess
to youth,overall levelsof use,andalcohol-relatedtrafficfatalities.
We maybe betteroff legalizingbothmedical andrecreationalmarijuanaforthe reasonsthatI
stated,butthere ismore thanone way to doit, and itshouldbe done right,includingregulation, sothat
people buy uncontaminated productsof knowncomposition;warninglabels,suchas“mayimpairthe
abilitytodrive”;restrictionsonadvertising; educationof cliniciansandthe public; aban on ediblesthat
are attractive tominors; and again, possiblyagovernment-runmonopoly.
oop201202Aopioidg