Federal Government

Just a day after the Office of National Drug Control Policy (ONDCP -- the drug czar's office) released its latest annual national drug control strategy, the Government Accountability Office (GAO) has issued a report finding that ONDCP has fallen well short of goals enunciated in its 2010 national drug strategy.

In the report, Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program Coordination, GAO noted that ONDCP and the federal government "have not made progress toward achieving most of the goals articulated in the 2010 National Drug Control Strategy." In some areas, including reducing teen drug use, reducing drug overdose deaths, and reducing HIV infections from injection drug use, GAO found, ONDCP was not only not making progress, but sometimes the numbers were moving in the opposite direction.

For instance, under the broader goal of "curtailing illicit drug consumption in America," ONDCP had set use reduction goals to be achieved by 2015. It sought to reduce last month drug use by teens by 15%, but has achieved no movement. Similarly, it sought a 15% reduction in past month use by young adults, but has achieved no movement. It also sought to reduce lifetime use of drugs, alcohol, and tobacco by 8th graders by 15%, and was making progress toward its goal with alcohol and tobacco, but not with illegal drugs.

Likewise, under ONDCP's broad goal of "improving the public health and public safety of the American people by reducing the consequences of drug use," ONDCP identified goals of reducing overdose deaths, drug-related hospital emergency room visits, and drug-related HIV infections by 15% by 2015, but showed "movement away from goal" between 2010 and 2012.

Drug czar Gil Kerlikowske is talking up a "21st Century Approach" to drug use with a heavy emphasis on treatment and prevention, but the latest national drug budget still allocates 58% of funding to law enforcement and interdiction. And those remaining funds for treatment and prevention are "fragmented" across 15 federal agencies, with much overlapping. GAO reviewed 76 federal drug treatment and prevention programs and found 59 of them overlapped.

GAO did note that while ONDCP was not showing progress in most of its goals, it had implemented 107 of the 112 "action items" contemplated to meet those goals. The auditors noted that "ONDCP officials stated that implementing these action items is necessary, but may not be sufficient to achieve Strategy goals."

The White House Office of National Drug Control Policy (ONDCP -- the drug czar's office) released its 2013 National Drug Control Strategy Wednesday. The strategy is being billed as a "21st Century Approach" to drug use and trafficking, but despite some rhetorical softening maintains the US hard-line approach to the issue.

"The president has outlined his vision of an America built to last -- where an educated, skilled workforce has the knowledge, energy and expertise to compete in the global marketplace. Yet -- for far too many Americans -- that vision is limited by drug use, which not only diminishes the potential of the individual, but jeopardizes families, communities and neighborhoods," ONDCP wrote on a blog post announcing the strategy's release and touting reductions in cocaine and prescription drug abuse as progress made.

"Today we are releasing a science-driven plan for drug policy reform in America to build upon this progress," ONDCP continued. "This 21st century drug policy outlines a series of evidence-based reforms that treat our nation's drug problem as a public health issue, not just a criminal justice issue. This policy underscores what we all know to be true: we cannot arrest or incarcerate our way out of the drug problem."

The strategy emphasizes treatment and prevention, but despite the rhetoric, the Fiscal Year 2014 federal drug budget it accompanies continues to be imbalanced, with 58% of federal anti-drug spending directed at law enforcement and interdiction efforts. That figure does mark a decline from previous years, but only a marginal one.

And even its emphasis on treatment also includes punitive criminal justice elements, such as its embrace of the drug court system, where drug-addicted people are subjected to legal sanctions for such addiction-related behaviors as failing a drug test or missing an appointment. That has some drug reformers calling foul.

"The administration says drug use is a health issue but then advocates for policies that put people in the criminal justice system," said Bill Piper, director of national affairs for the Drug Policy Alliance. "Until the drug czar says it is time to stop arresting people for drug use, he is not treating drug use as a health issue no matter what he says. I know of no other health issue in which people are thrown in jail if they don't get better."

While much of the strategy is little more than the same old same old, the strategy does call for expanded access to naloxone, a low-cost antidote that can reverse the effects of opioid overdoses. That is in response to the rapid growth in prescription drug overdose deaths in recent years.

"Director Kerlikowske should be applauded for taking steps to reduce drug overdose fatalities, but he's not doing much to reduce drug arrests or the many other problems associated with treating drug use through the criminal justice system," said Piper.

But while the drug strategy shows flexibility in its efforts to deal with fatal drug overdoses, it maintains a staunch opposition to marijuana reform and includes attacking outdoor and indoor marijuana cultivation as one of its key goals.

"The administration's continued opposition to marijuana law reform shows they're not serious about reforming US drug policy," said Piper. "At the very least they should stop getting in the way of states that are trying to improve public health and safety by regulating marijuana like alcohol."

Access to medical marijuana continues to expand as more and more states embrace the healing power of the herb. At the same time, hundreds of thousands of veterans of America's decade of wars are returning home burdened with Post Traumatic Stress Disorder (PTSD), a condition as old as war itself, but that in years past went either unrecognized or was seen as a soldier's personal failure, his "shell shock" or "battle fatigue." Could medical marijuana help?

Scott Murphy of Newton, Massachusetts, is an Iraq combat veteran who uses medical marijuana for chronic pain. "I use medical cannabis for chronic pain from a motorcycle accident that was aggravated by my military service," Murphy said. "I had a severe accident when I was 18, I have a rod in my femur and four plates in my hip. The pain is to the point where it is affecting my walk."

But Murphy also wants to ensure that his state's new medical marijuana law provides for access to the plant for PTSD. A man Murphy described as his "best friend," a fellow veteran, committed suicide at age 22 after being kicked out of the Army for misconduct related to his mental issues rather than being given a medical discharge as promised.

"He had been showing signs of PTSD," Murphy recalled. "He was a good soldier, but when he got back from his second deployment he was having problems. When they kicked him out of the Army, he went home and killed himself."

Amid increasing evidence that medical marijuana can have a beneficial impact in helping people cope with PTSD, the push is on to expand access to the healing herb. Murphy spent Monday morning testifying at a public hearing on draft regulations for the Massachusetts medical marijuana program. Although voters voted for the initiative that listed specific qualifying conditions -- not including PTSD -- as well as "and other" conditions, state regulators are considering changing that to "and other debilitating" conditions, a change that Murphy and others fear could limit access to medical marijuana for PTSD patients.

In some medical marijuana states, adding PTSD requires going through a medical marijuana regulatory commission; in others, it is being pushed through the legislature. In Oregon, for example, Senate Bill 281, which would add PTSD to the list of treatable conditions, was approved by the state Senate last Thursday, and now moves to the House. In Michigan, by contrast, hearings on PTSD and medical marijuana were held recently by Michigan's Advisory Committee on Medical Marijuana (ACMM).

State legislatures are proving to be an easier path than unelected medical marijuana overseers, said activists. "There have been a number of states that have tried to petition to get it added to the list that have so far failed," said Kris Hermes, media liaison for Americans for Safe Access.

Air Force veteran Michael Krawitz of Veterans for Medical Cannabis Access (VCMA) and a plaintiff in Americans for Safe Access v. Drug Enforcement Agency, a case which seeks to see marijuana moved out of the Controlled Substance Act's Schedule I, agreed. "That Oregon effort is moving in the legislature because the state oversight panel was so intractable," said Krawitz, who was deeply involved in the effort there. "Any time we've had to go through the process provided by the state to address expanding access to medical marijuana, we've had trouble. Michigan is another example. There, there was a petition to add PTSD, but there was no actual process to do so. They were essentially keeping the process from moving forward until [vaunted Michigan marijuana attorney] Matt Abel sued them. Now, we have hearings before the advisory committee."

The need to do something for veterans is a major impetus behind the push, but PTSD effects lots of people who aren't veterans as well. "It isn't just veterans who suffer from PTSD," Krawitz said. "At that hearing, there were many veterans, but also other people who had suffered trauma -- child abuse survivors, rape survivors, emergency response workers."

Still, veterans mustering out after more than a decade of US wars in Iraq and Afghanistan are coming home with PTSD in record numbers. A 2004 study in the New England Journal of Medicine estimated that 18% of returning Iraq combat veterans had PTSD. And a 2008 RAND Corporation report estimated that up to 225,000 veterans will return from the wars with PTSD.

The trauma of war is reflected not only in the number of vets suffering from PTSD, but even more ominously, in sky-high suicide rates. US military veterans are committing suicide at a rate of 22 per day, up 20% from just five years ago. And according to a Veterans Administration study released in February, that number almost certainly undercounts the number of veteran suicides because of data limitations.

The military and public health workers are keenly aware of the problem, and are attempting to address it through means both conventional and unconventional. The military and the Veterans Administration have been open to therapeutic interventions including yoga, meditation, and the use of companion dogs; they have also armed themselves with the arsenal of psychotherapeutic drugs -- anti-depressants, anti-psychotics, tranquilizers -- available in the standard pharmacopeia. But those drugs can have some nasty side effects, and their utility in treating PTSD is questionable; noting reports of negative consequences, the Army has warned against over reliance on them.

In the search for succor, more and more vets and other victims of PTSD are turning to medical marijuana. But there is a problem. Not only do a majority of states not recognize medical marijuana, even in those states that do, many of them do not allow its use for PTSD. Despite mounting evidence that medical marijuana can help with PTSD, only a handful of medical marijuana states have approved its used. According to Americans for Safe Access, only California, Connecticut, Delaware, New Mexico and Massachusetts would allow for its use for PTSD, and as we have seen above, it's still up in the air in the Bay State.

"As we find more and more people, especially veterans, benefiting from its use, we see the unfortunate absence of availability for patients across the country," said ASA's Hermes, "It's only approved in five states; that means well below half the medical marijuana states recognize the need for patients to use it for PTSD."

Americans for Safe Access supports expanded access to medical marijuana for PTSD, according to Hermes. "We wholeheartedly support the efforts to petition where patients can do so to get PTSD added to the list of conditions, and we're also pushing for recognition inside the Veterans Administration, but that's an uphill slog," he said.

And it isn't only PTSD treatment that's at stake for veterans. "I'm not only pushing for chronic pain and PTSD, but other stress-related combat issues, and that language is one of the things I asked [the Massachusetts Department of Public Health] to clarify today," Murphy said in an interview following the hearing. "Does their definition of 'debilitating' include PTSD? If they're going to use a broad definition of 'debilitating' so that it covers the full spectrum of vets' injuries, that would be one thing. But it's unclear if PTSD or other mental conditions will be covered. I think we should leave the wording with "and other" -- that's what the voters voted on. I don't think we should have to wait until someone's PTSD is so bad it's life-limiting to be able to get access."

Massachusetts regulators were supposed to have their draft regulations ready by May 5, but in the wake of the Boston bombings, that is now up in the air.

Part of the problem with winning acceptance of using medical marijuana for treatment of PTSD is the relative paucity of clinical studies on its safety and efficacy. When the state of Arizona considered adding PTSD to its list of qualifying conditions, researchers hired by the Department of Human Services found very little of use in their review of the literature.

But studies do exist. Krawitz and Veterans for Medical Cannabis Access compiled an impressive set of studies suggesting marijuana is safe and effective in treating PTSD and anxiety for Michigan regulators. (They are downloadable as submitted at the following links: Packet 1, part 1 of 3, Packet 1, part 2 of 3, Packet 1, part 3 of 3, Packet 2, Packet 3). That same packet also went out to New Mexico, where an effort to remove PTSD from the list of treatable ailments was foiled, and to Oregon, where the PTSD bill moved forward this week.

"While we don't have a lot of studies titled 'PTSD Response to Cannabis Therapy,' we do have a preponderance of evidence that shows cannabis works in various ways, including for symptoms of PTSD," said Krawitz.

One important reason the hard science officials would like to see on the efficacy and safety of marijuana for PTSD is federal government obstructionism. The Multidisciplinary Association for Psychedelic Studies (MAPS), for instance, has been attempting for years to win approval for its study of PTSD and medical marijuana. But it's still waiting and still patiently trying to satisfy the endless niggling of the National Institute on Drug Abuse and the Department of Health and Human Services. The DEA and the courts haven't helped either -- the agency in 2011 denied a request by UMass scientist Dr. Lyle Craker to grow marijuana for research purposes, disregarding its own administrative law judge's recommendation to approve it, and a court last week sided with DEA.

Nevertheless, anecdotal evidence on marijuana treatment for PTSD is helping to move the issue forward. The site ProCon.org, which features a major section devoted to medical marijuana, has posted several readers' comments on the subject:

"I had severe reservations about 'smoking pot.' It is illegal and I am a health care professional," one anonymous commenter wrote. "Still, I wanted to feel better, to be myself again, and to be the person I was before the PTSD. I smoked the pot. Immediately I felt relaxed and calm. I smiled and laughed. I finally felt at peace for the first time in two years. I slept my first night in three years without the sleep medication. The next day I felt refreshed and renewed. I had hope again. My son told me that he was so happy to see the old me again."

 

"I was shot thru the right sub and supra orbital sections of the right side of my head exiting over my right ear. They rebuilt 1/4 of my skull," wrote another commenter. "Epilepsy, PTSD, and other issues such as severe anxiety, constant pain and depression... I am still alive because I smoke [marijuana] every day. Empirical evidence has proven to me that failure to utilize generally causes a seizure and at minimum I get really aggressive... I will not live on narcotics. Ibuprofen or aspirin all have side effects worse than any temporary pain. Replacement liver from the damage of man-made drugs? No thanks."

In the meanwhile, veterans and others continue to suffer from PTSD and continue to use marijuana for relief. In states that do not have medical marijuana laws, that makes them criminals. In states that do have medical marijuana laws, but don't allow it to be used for PTSD, they are criminals, too -- unless they hide what they're actually using it for.

"These state medical marijuana control boards are willing to allow vets to have it for pain, but not PTSD, so in states like Arizona, vets suffering from PTSD are using a pain diagnosis to be legal under state law, and that's problematic. We're trying to get people suffering from PTSD to actually come in and get help, and it's difficult because there's a lot of stigma around it. What are we telling our soldiers when we tell them 'tell the doc you have pain, don't say you have PTSD'"? Krawitz asked. "What are we saying about the validity of their condition?"

That leads to other problems, too Krawitz said.

"When we can't recommend medical marijuana for PTSD, we're pushing people to use chronic pain as a qualifying condition, and that leads to police and prosecutors seeing all those pain recommendations and saying there must be fraud in the system," he said. "There are a lot of patients who would otherwise have had recommendations for PTSD."

PTSD sufferers are not waiting for peer-reviewed, clinically-controlled studies to tell them what works. PTSD is a real and growing problem, and medical marijuana appears to do some good. The scientific studies that would satisfy legislators and state review boards need to be done, and that is happening, albeit too slowly, but in the meanwhile, people are suffering because the government they served at risk to life and limb is now obstructing the research that would legitimize their treatment.

A bill that would establish a National Commission on Marijuana Policy was introduced in the US Congress last week. Filed by Rep. Steve Cohen (D-TN), House Bill 1635 seeks a commission that would undertake a comprehensive review of the costs and benefits of current federal marijuana prohibition, as well as examining how federal policy should interact with state laws that have either approved medical marijuana or legalized marijuana outright.

Cohen's proposal is inspired by the 1971 Shafer Commission on Marijuana and Drug Abuse, which was commissioned by President Richard Nixon but then shelved when it recommended decriminalizing marijuana. The commission report resulted in decriminalization in a handful of states in the 1970s, before marijuana reform went into the deep freeze during the Reagan era.

"Regardless of your views on marijuana, it's important that we understand the impact of current federal policy and address the conflict with those state laws that allow for medicinal or personal use of marijuana," said Congressman Cohen. "This conflict is only going to continue to grow over the next few years and we must provide certainty to the millions of individuals and businesses that remain caught in a web of incompatible laws. A national commission would provide us with the information we need to create sensible policy going forward."

Joining Cohen in backing the bill are cosponsors Reps. Earl Blumenauer (D-OR), Sam Farr (D-CA), Jim Moran (D-VA), and Jared Polis (D-CO).

"The Obama administration has repeatedly stated that a national conversation is needed when it comes to our country’s marijuana policies, but so far that conversation has been largely one sided," said Erik Altieri, communications director for NORML, which worked with Cohen on drafting the bill. "It is time for federal lawmakers to listen to the voice of the majority of Americans who want to see change to our nation’s marijuana laws and for them to take part in that dialogue."

"We have clearly reached a point where the American people want marijuana prohibition to end," said Steve Fox, national political director for the Marijuana Policy Project. "The states have been taking the lead, but the federal government must catch up. It is no longer a question of whether the federal government should allow states to enact their own marijuana policies. Of course, it should. The question now is how to reconcile state and federal laws. This commission bill proposes a study and a discussion that is long overdue."

The proposed commission would consist of 13 members: five appointed by the president; two appointed by the Speaker of the House; two appointed by the House minority leader; two appointed by the Senate majority leader; and two appointed by the Senate minority leader.

Eighteen states and the District of Columbia allow patients with qualifying conditions to use medical marijuana with recommendations from their physicians. In November, voters in Colorado and Washington State approved measures making marijuana legal for adults 21 and older and directing state regulatory bodies to create regulations for businesses to cultivate and sell marijuana to adults.