May 31, 2007
Public Health, Booze, and the Drug War
The flap over Public Health officials' inability to stop a honeymooner from flying round-trip to Europe with a rare, drug resistant form of Tuberculosis begs comparison with the tactics of the drug war, in which heavily armed SWAT teams routinely serve search warrants to look for drugs. The drug war can thus be thought of as merely a variant of Public Health–– one practiced by police in accord with Department of Justice standards –– a kind of Epidemiology run amok.
The TB story resonated with me because during my intership at San Franciso General Hospital in 1957, its treatment was then very much in transition; we still had long-term patients who'd been hospitalized for years with far-advanced disease that was too extensive to be removed by recently developed surgical procedures. The surgery had only become possible because of new drugs which allowed it to be performed with relative safety in relatively early stages of the disease. Thus newer cases in younger patients could undergo arduous, but potentially curative, treatment, but more advanced cases, judged too sick for surgery, faced a lingering death on the hospital's chronic wards. Because they often had cavities that were shedding organisms, many weren't allowed to go home. Some, judged uncooperative, were essentially incarcerated on 'legal orders of isolation' and their rooms were sometimes locked between staff visits.
Since a high percentage of TB patients were chronic alcoholics, visitors were often searched; on Sunday mornings, it was common to find ward bathrooms littered with empty whisky and wine bottles supplied the night before by certain compliant orderlies. That was ten years before the Summer of Love; pot use was almost unknown (except by those scandalous and newly-christened 'beatniks'). My impression, formed during internship, was that San Francisco must be the alcohol capital of the world. Half our emergency admissions, whether from trauma, assaults, burns, seizures, DTs, or cirrhosis, seemed directly related to excessive drinking. At any one time, it seemed that perhaps fifteen percent of the patients on male medical wards were deeply jaundiced; we interns could count of doing a minimum of five needle biopsies of the liver during our one month rotations.
When I returned to 'The City' ten years later, the Summer of Love was in full swing, pot and LSD had replaced alcohol, and cirrhosis was on the wane. Surgery for Tuberculosis was a thing of the past because the newer TB drugs were usually curative by themselves, and most of the sanitoria, like mental hospitals, were either closed or in the process of closing. Four years later (1971), after leaving the Presidio for private practice, I was told by surgical residents working at the 'General' that heroin addicts had replaced the alcoholics and they were being kept far busier with abscessed injection sites than with drunken misadventures. Also, the gunshot and stab wounds, so common in both eras, had become both more frequent and deadlier when related to drug trade disputes.
Come to think of it, pot was never mentioned as a cause of hospital admission...
May 30, 2007
The Ultimate Whistle Blower (personal/political)
Rachel Carson was born 100 years ago last Sunday and lived only 56 years before dying of breast cancer, but her relatively short life consistently exemplified the best human qualities; not the least of which were her courage and intellectual honesty. As a solitary biologist with no political backing or experience, a book she wrote in longhand so effectively called attention to a destructive government policy, that not only did it force that policy to stop, it gave birth to the Environmental Movement.
By the time Silent Spring was published in 1962, the vested interests it quietly exposed were campaigning stridently against it and subjecting her to the usual unwarranted criticism; all to no avail. The book was published and became an overnight success, which tragically, Carson did not get to savor for very long before succumbing to the breast cancer that was diagnosed long before she could finish writing it.
While there is a clear parallel between the mindless ‘war’ the Department of Agriculture was waging on insects in the Fifties and the equally mindless drug war our federal government has been pursuing since the First Nixon Administration took office in 1969, it’s not that simple. One significant difference was that as soon as Carson exposed the environmental damage from indiscrimnate use of pesticides it stopped because the American public was largely unaware of what had been happening and was shocked by Carson’s objective account. Even so, as Elizabeth Kolbert points out in this week’s New Yorker, the proponents of environmental exploitation have not gone away and the Bush Administrtation has been quietly and effectively eroding those protections for the past six years.
A comparison with the drug war requires some additional insights: although the American public has been well aware of the failure of our drug policy since at least 1997, it seems to have accepted it as a necessary evil; probably because support for it is so deeply entrenched at the federal level. It should also be clear by now that our drug policy won’t be changed by simply pointing out its failures again and again; what’s needed is a realistic account of just how much it is costing our distracted and self-absorbed American society. Just consider another shocking incongruity: we are arguably in the midst of an even more urgent environmental crisis in the form of global temperature change, yet I don’t recall any questions being raised about our national enthusiasm for auto racing over the past week-end.
Another discouraging example is the folly in Iraq, from which the now ascendant Democrats have been unable to force a withdrawal. If a majority in Congress can’t force change in a such a blatantly failing war, what does that auger for political change in the war on drugs?
The last time I looked, drug policy ‘reform’ wasn’t even on Congressional radar— let alone supported by a majority.
May 16, 2007
Homelessness & Drug Use (Political)
The tendency of humans to engage in illogical behavior was exemplified by two articles appearing on successive pages of the Metro Section of today’s San Francisco Chronicle. The first described new efforts of the Berkeley Mayor and City Council to rid their city of the homeless by enforcing a ban on smoking. Interestingly, they’d made the same connection that first attracted my attention to the relationship between adolescent trials of pot, alcohol, and tobacco: all three agents tend to be tried at the same time in adolescence and are often followed by further use and associated with aggressive initiation of other agents. However, since the Mayor and the Council were merely trying to get rid of a nuisance, they were not inclined to see their actions as either futile or inhumane. Smoking is smoking; it’s all bad, so let’s ban it. The feds couldn’t agree more.
The next article described the beginning of the federal government’s dogged efforts to punish Ed Rosenthal for growing medical pot, which I have contrasted with their far more successful effort to punish Dustin Costa for growing approximately the same number of plants. Further irony is added by the fact that Costa’s thoughts about how an inexpensive ‘Pot 4 Meth’ (or a ‘Pot 4 Booze’) program might have a galvanizing effect on public perceptions.
Sadly, that would require some courageous original thinking from a ‘reform’ bureaucracy which is little more than a pale reflection of the prohibition bureaucracy they are locked into unequal combat with.
May 14, 2007
Adding to the Indictment (Political)
The lead editorial in this morning’s SF Chronicle just happened to be written about the side effects of antidepressant therapy, a subject that’s been much on my mind recently. I was tempted to write a letter to the editor pointing out that pot is safer and does a much better job at treating emotional symptoms for (at least) the population of chronic users I’ve been seeing for five years. While I have no way of knowing how accurately they represent the total population of pot smokers in California; nor can I extrapolate how asccurately California pot smokers represent the general population of the US, nor the degree to which Americans reflect the rest of humanity, the evidence from my sample is simply overwhelming: pot, in its inhaled form, is a very safe and predictable short acting anxiolytic which is clinically effective at treating PTSD, ADD, bipolar disorder, and chronic insomnia— all quite predictably and over prolonged intervals.
However, I resisted the impulse to send such a letter; for one thing, I don’t think the Chron has printed a letter from me since they were bought by the Hearst Corporation. For another, I have reason to believe I’ll eventually reach more readers by posting my opinions right here.
However, the most telling reason I didn’t write to the Chronicle is that such a statement would be seen by the majority of Americans as ‘heresy.’ The vexing question beyond that is how many think the heresy may be true but is simply too dangerous to assert as opposed to those who firmly believe in the need to punish all abusers of illegal drugs, as opposed to those— probably a majority— who always tune out drug war items in the news because they are so ‘boring and predictable.’
As for the drug warriors, all they need for continued ‘success’ is that their policy be accepted as a necessary evil by the bored/frightened majority of Americans.
May 13, 2007
Adding to the Indictment (Medical)
Ten days ago, I posted a protocol (Pot 4 Meth) suggested by Dustin Costa for dealing with probationers and parolees with known methaphetamine problems. Basically, it called for their voluntary use of inhaled cannabis, an agent known for its long term safety, as a meth substitute. Also for the results to be closely monitored by drug testing, with retention dependent on participants remaining amphetamine free. It’s not likely anyone reading Costa’s proposal would see it as one with a chance of being adopted anytime soon in the present US political climate, even though there is considrable evidence that cannabis already serves as a less problematic ‘substitute’ for alcohol and other drugs.
A recently launched method for treating problematic amphetamine, cocaine, and alcohol use, the Prometa Protocol, is now in active use and being heavily advertised. Basically a proprietary treatment plan administered to outpatients by specially trained physicians at 12-15 thousands dollars a copy, It’s also being promoted in advance of any clinical evaluation of the method itself. Finally, although the three drugs it relies on have been approved by the FDA, their use in this instance is ‘off label’.
Prometa’s boosters rely heavily of testimonials, endorsements and frequent reference to the various prestigious institutions that have already signed contracts for what amount to Prometa franchises. Some ads have also exhibited questionable taste.
Despite reservations expressed by some normally treatment-friendly organizations, and the checkered past of its chief promoter, it’s a program that’s being taken seriously by investors.
May 10, 2007
Prelude to an Indictment (Personal)
A while back, I wrote that I wanted to organize this blog, but must confess that at the time I wasn't sure just how I'd do so. I've now decided to start by describing my involvement with Proposition 215 applicants because it seems like a convenient way to outline what I've learned from being closely involved with them over the past five years. Two of the most important realizations from that experience have been the key role emotions play in human behavior and the critical role point of view plays in shaping how we deal with uncertainty. My point of view has undergone a sea change since I began screening pot smokers towards the end of 2001; outlining how that happened may be the most efficient way to tell a complex story to an audience that undoubtedly represents several points of view
Over ten years ago, California voters overruled the near-unanimous objections of federal and state politicians, numerous bureaucrats, and most career policemen by passing California's medical marijuana initiative by a comfortable margin. It was, without doubt, the most important and far-reaching political victory over an apparently impregnable drug policy ever. Subsequently, several watered-down versions were passed in other states; most by initiative, some directly by the legislatures. In terms of how 'patients' might qualify as 'legal,' all state laws except California's were turned into window dressing by restrictions written into them as part of the political price (eagerly) paid by 'reformers' to either to get them on a ballot or through the legislative process. Nevertheless, advocates of drug policy reform hailed each new law as a 'victory' and were careful not to say too much about the restrictiions. All were seen as inevitable signs that a 'failing' drug policy would soon be forced to become more rational.
Unfortunately, no one bothered to check with either the federal drug policy guardians or their legions of supporters at every level of government. First they dug in their heels, and later they went on a delayed attack. In California, the problem was highlighted from the beginning by then-Drug-Czar McCaffrey's threat that physicians could lose their right to practice for even discussing cannabis with a patient. Although blocked by the Ninth Circuit on First Amendment grounds, McCaffrey's ploy had a chilling effect on California doctors. Thanks to a few courageous ones, Tod Mikuriya most prominently, several thousand patients received recommendations in the first few years. By late 2001, they were numerous enough to support a small network of buyers' clubs in the Bay Area and a few other venues around the state.
Although I was deeply committed to drug policy reform, I was then pot-naive because I'd never been part of 'cannabis culture.' The key reason was that I'd finished High School twenty years before pot's arrival in the Sixties. Ironically, the corollary was another lesson I was also slow to learn: one's generational age is of crucial importance in determining one's attitude towards all 'drugs,' especially pot.
I got a chance to play catch-up with cannabis culture when I began screening patients at a busy Oakland club in November 2001. The timing also turned out to be important, because its owner, the person who recruited me, was very uniusual; something I had no way of knowing at the time. Without going into detail, I will say he was honorable in all his dealings with me; also that he had an important impact on the evolution of medical marijuana in California by treating the opportunity to supply cannabis to patients as a business. One of the things he understood clearly was that his cutomers had to be properly qualified as patients, before he could sell to them legally ; however, he never pressured me to speed up their processing; even after I reduced the number I could see by more than half because what I was hearing from them caused me to expand the protocol used for screening them.
Two great features of blogging are that one gets to control tempo and is always free to revise what's been written on the basis of new information. In addition to 'personal,' I'm already thinking about multiple entries under two other headings: 'medical' and 'legal.'
May 09, 2007
'Discontinuation' or Withdrawal?
An article in last Sunday’s New York Times Magazine, describing the author’s struggle to get off the anti-depressant Effexor (vinlafaxine), caught my attention because I had recently taken histories from two cannabis users who were both frightened and bitter about their own inability to stop, or even significantly reduce, their use of the same drug for reasons that were quite similar to those described by author Bruce Stutz, who also happens to be a a well informed popularizer of science. Effexor is a second generation SSRI, which, it was apparently hoped, would combat depression more effectively than Prozac or Paxil because it increases the ‘reuptake’ of both norepineophrine and serotonin. Cymbalta is another such agent. Now known as ‘SNRIs, a new class of agents that have also gained recent fame because of their association with a new clinical problem known as the ‘discontinuation’syndrome.
Skeptic that I am, I began to wonder how discontinuation differed from old fashioned withdrawal, so I googled them consecutively. That they are similar is evidenced by finding the same antidepressants on the first few pages of the‘withdrawal’ search. What was different was the company: alcohol other agents were also listed as associated with withdrawal syndromes. Another study that caught my attention was one by Dr. Elena Kouri, who had devised a complicated experiment to look for evidence of a marijuana withdrawal syndrome.
Rather than parse her article in detail. I will simply say that, in common with most studies of ‘drugs of abuse,’ it's laden with evidence of unconscious investigator bias, and describes only a mild, transient, and completely reversible increase in aggression distinguishing chronic users as compared to two groups of controls. As someone not committed to strict observance of federal dogma, i would suggest an alternative: what Dr. Kouri’s chronic users were exhibiting after three weeks of abstinence was an exacerbation of the symptoms they ususally kept under control with pot.
It comes down to what I’ve been maintaining all along: the only ‘success’ our drug war has enjoyed as policy has been its ability to scare parents about ‘drugs of abuse;’ if that requires glossing over real problems with FDA approved agents, what's the harm?
May 07, 2007
More from the Gulag
I’m an incorrigible sloppy desk person; the other day, I found a hand-written letter from Dustin, one I didn’t remember seeing before. The date tells me it had been written just before he was whisked off from Bakersfield to Oklahoma City. In fact, he probably never made that phone call...
Planning to call you in a few minutes, but I wanted to get these thoughts down first. The biggest problem you and I face is not that people don’t listen or even that they don’t understand. In fact, I think what we believe with respect to marijuana and anxiety is readily understood by almost everyone we explain our views to. Not only are we understood, I think most folks actually believe us, or are at least willing to give us the benefit of the doubt. We are fighting a cultural problem— a preference for the warm and fuzzy thinking that assumes there is a ‘solution’ for every problem.
What you (and I) are doing is not simply pointing out the ‘truth,’ but suggesting ramifications of that truth that go well beyond disturbing. We represent the equivalent of the 1906 San Francisco Earthquake and the Hiroshima Bomb— and then some.
What we are engaged in is the beginning of a cultural paradigm shift that is stunning in its scope. We are really talking about far more than what’s wrong with the drug war. We are talking about the need to transform traditional notions of parenting and rearing children.
It is a noble fool’s errand we are engaged in, but one I believe can actually succeed because of pot’s enormous popularity and because we offer the best explanation of how and why that popularity came about. It is incredibly important, therefore, that your work be made public as soon as possible, so as to encourage the kind of studies needed to both investigate/explain the ABYM problem. You know what I’m talking about better than I do, but I simply wanted to give you some support and, hopefully, additional perspective. There has to be a key to unlocking the cultural problem for folks like ____, and even ____ ______ .
Perhaps simply publishing your data will give you enough standing to get the creative intellectual side of their brains working. Perhaps, too, if you could link your data in a functional way to notions like my Pot4Meth idea, it would show that not only is the notion of ‘substitution’ a great insight, but there’s a way to make it work productively.
Think about it this way— how often in your lifetime have you heard someone say to a critic: “if you think (the thing being criticized) is so bad, what do you suggest we do about it?”
I think not only is Dustin more than a little OCD, he also makes a lot of sense...
May 03, 2007
Prescription for Bettering Society, a proposal by Dustin Costa
By working to benefit society as a whole, the concept of ‘medical marijuana,’ if coupled creatively with such use as California Law already allows, has the potential to play a much bigger role than the one local police and the DEA are now trying to restrict it to, one that would also be in sharp contrast to a drug war that has had an opposite effect and actually made society worse.
Specifically, marijuana has been found to be extraordinarily effective at weaning substance abusers from hard drugs and alcohol; a small, but increasing number of doctors also realize it’s an alternative to alcohol and other ‘abused’ substances. A program created to take advantage of that quality of Marijuana, by showing just how effective it is in that role, would be the fastest way to rehabilitate pot's false public image. In other words, medical marijuana care-givers and their patients now have it within their power to show the world that it’s not merely a healer of individuals, but has considerable capacity for healing society as well.
Imagine that, Marijuana making a better America. I know many of us always felt that pot had the potential to do great things. Just believing that isn't enough. We are up against a cultural juggernaut; the Robber Barons who brought us Reefer Madness have also created a, law enforcement establislhment addicted to easy tax dollars and heavy tactics. But they are vulnerable; the truth is that the war on drugs has been a disaster. Instead of wiping out substance abuse as intended, substance abuse has remained steady, with about 1% of the American population suffering serious addiction problems at any one time. That fraction hasn't changed in one hundred years, according to CA NORML.The drug war, has achieved no positive results, despite its nearly 70 billion dollar a year expense (according to Walter Cronkite). In fact, the war on drugs has turned America into the world’s biggest per capita jailer of its own citizens, with the total growing by 1,000 new prisoners per week.
So how does Marijuana become the hero that saves the day? How does Marijuana reverse a cultural bias against it that took decades to create? How can Marijuana reduce prison populations, dependence on hard drugs or alcohol or, for that matter, the growth of gangs and even domestic violence? I believe, there's a way to show how. It would require courage, compassion, and shrewd management, but I'm convinced it could be done
So, here it is. I call it Pot 4 Meth.
Run ads or find some other way of recruiting potential participants. The message would be simply this; "If you have a problem with alcohol, cocaine, heroin, Methadone or methametamine, and are currently being drug tested by Probation, you can volunteer to use Marijuana instead. We will provide a doctor’s recommendation and enough medical grade cannabis for your needs on a weekly basis, subject only to the same clean drug screens required by Probation. One or more days of volunteer service per week to help support of the organization could be added.
The cannabis would have to be provided by the same activists now providing it through whatever distribution networks still exist, and those participating would have to interview candidates carefully to select the best prospects. Particpants would also have to understand how essential their cooperation would be.
Those selected would be given a doctor's recommendation for
the express purpose of diverting them from whatever substance they’d gotten in trouble for abusing; Probatiion would be notified, and if not cooperative, a court order granting participants permission to possess and use cannabis could be obtained (yeah, the Judge has to do it). At this point, Probation would be compelled to cooperate.
Probation usuallly requires drug testing twice a week, so the Caregiver should dole out meds in two or three day quantities, and only to participants with clean, current drug screens.
Volunteering would be a way to show good intentions toward the community at large. Volunteers could be employed in a variety of projects, community clean-up, restoration such as graffitti removal, or helping the disabled, etc.
A shrewd caregiver whose aim is the betterment of society would construct their programs in ways that encourage participants to remain involved after their Probation ends. This is just one way to showi bow Marijuana can help create a better society. It’s an idea that invites more ideas; for example, the need to make a program financially self-sustaining could by a cadre of volunteers. This could have the effect of turning volunteers into paid employees.
The quickest way to gain social acceptance for Medical Marijuana is to show how it can benefit all of society. While it’s true tbat Marijuana should be permitted on purely humanitarian grounds, the fact that it remains a black market drug will continue to bedevil us until we can trump fraudulent claims that it’s a menace to society, and its medical use just a screen for a black market. A program like this could grow quickly and also show who’s telling the truth; a truth that can embarrass our opponents and, more importantly, set us free.
Just an idea
Dustin Costa, a.k.a. dc greenhouse
May 02, 2007
A Letter from the Gulag...and my Reply
The following hand-written note from Dustin Costa, now serving a 15 year sentence in a federal ‘Correctional Facility’ in Texas was received yesterday afternoon. Because it seems so pertinent to current developments in the war on drugs, I’m posting it, together with my real-time reply.
Those who wish to write to Dustin should address mail to:
Dustin R. Costa 62406097
FCI Big Spring
Federal Correctional Institution
1900 Simler Ave
Big Spring, Tx 79720
Reviewing some of the ASA literature that _____ sent me, I got a sinking feeling, an epiphany of sorts, of how reform might “win,” and it is this: a great and unfortunate compromise is reached allowing doctors to prescribe Mj, but only for cancer, AIDS, and pain untreatable in any other way. Pharmaceutical companies will be the only entities permitted to produce pot and the gov’t will continue with the message that it is a dangerous drug and nothing changes in the war on drugs. ASA and NORML will declare victory while the arrests and prosecutions of the ‘mood disordered’ will continue.
Doom & Gloom? I don’t know, but it is a scenario that is likely enough to happen to keep me up at night; all the more reason for a demonstration program* similar to what I suggest.
ASA & NORML are close— perhaps within a year or so of achieving the kind of deal I describe. We CAN”T let them control this thing; if we do, we probably gain nothing and lose everything. It’s a gut reaction, probably a little paranoid, but I think there is good reason to beconcerned. What do you think?
* this refers to a ‘Pot 4 Meth’ program, an original idea of Dustin’s, conceived on the basis of his systematic interviews of county jail prisoners and federal prison inmates since his arrest on August 5, 2005. An outline of the project in his own words will appear here soon.
Here’s the reply to Dustin’s query I'll mail later today:
May 2, 2007
Rec’d your note of 4/26 yesterday; actually, I‘ve been concerned for quite some time that we’ve been heading in the same general direction your scenario suggests. In fact, I believe reform would settle for it right now and that any reluctance by the government probably comes from doctrinaire crazies who still believe they can ‘uproot’ and ‘weed out’ illegal drug markets, in other words, true believers (mostly federal) who still can't accept that a policy that feeds them is both a short-term loser and long-term disaster.
Actually, if they’d been smarter back in 1937, they’d have made pot a limited prescription item, just like opium and coca derivatives were treated under the Harrison Act. They’d have accomplished what they wanted— and more. Whether Anslinger was more stupid than arrogant (we know he was both) is a moot point. What might have occurred, under a ‘schedule two’ status for pot in 1937 is the current prosecution (both state and federal) of pain doctors accused of prescribing opioids too liberally: if one of their patients dies, the doctor can be tried for murder; if, on the other hand, a patient resells prescribed drugs, the doctor is tried as a drug dealer. I don’t know if you’ve heard yet, but Dr. William Hurwitz of Virginia, who is about your age and whose 25-life sentence was recently overeturned on appeal, was just retried and the second jury also found him guilty. He’s due to be sentenced in a few weeks.
What it amounts to is that the American public remains convinced that 'legal' alcohol and tobacco are the only permissible drugs ordinary citizens should self-medicate with. Our male-dominated macho society has contempt for all emotional symptoms and barely trusts those for whom ‘legal’ pychotropic agents have been prescribed. One way understand that is our national eagerness to punish 'perpetrators' who are obviously mentally ill; especially with illnesses that have been so poorly defined by Psychiatry.
As a nation, I’m afraid we’e far more vindictive than ‘compassionate.’
One way I see things changing for the better would be if government duplicity were completely exposed; but I don’t see that happening anytime soon. In a real sense, for those who think, it has already been exposed by the political battle over Iraq. It doesn’t help that, just like the war on drugs, neither side is being completely truthful
However, boy scout that I am, I continue to hope that if what we’ve learned is phrased in just the right language, it might convince enough thinking people see drug issues in a different light and eventually make a real difference. My reason for believing so is my own experience: I had no idea where my ‘study’ would lead after intuiting five years ago that 215 had created a golden opportunity to study the phenomenon of pot use.
Two years later, when I had enough data to report to my ‘allies’ in reform, I was forced to understand their nearly unanimous rejection of things I knew to be true, but they refused to even discuss. Thus, I was forced to answer an entirely new set of questions. As you might imagine, it’s been a lonely process; especially after the federal government was prompted by its ‘success’ in the Raich case to reach out and pluck you off the street.
Because your enthusiasm and organizing skills had made you such an effective ally, it was like losing my right arm. Among the things that have impressed me most about you have been your tenacity and ability to remain focused on basics despite the miserable circumstances you find yourself in; to say nothing of your forced abstinence from a helpful medicine.
BTW, I did find the original papers I’d misplaced and forwarded them all to Bill. I have retained copies which can be OCR’d (when I have a bit of time). Also, the paper is inching towards publication. Now seems like a time to be patient and respond to new opportunities as they present themselves. I realize that’s a lot easier for me than for you...
in the meantime, please stay well and remain hopeful,