Louisiana doctors could soon treat more medical marijuana patients, black VA patients on opioid therapy are more likely to be drug tested and have their treatment halted for illicit drug use than whites, a Georgia judge throws out a heroin murder conviction, and more.

Medical Marijuana

Louisiana Regulators Weight Raising Limit on Number of Patients Doctors Can Treat. The state Board of Medical Examiners is set to boost the number of medical marijuana patients a single doctor can treat. The board set a limit of 100 patients per doctor in 2016, but Vincent Culotta, the board's executive director, said the limit will be raised at the board's meeting next month. "We realize we're going to have to increase that number," he said.

Oklahoma Judge Rules Implementation of Medical Marijuana Rules Can Proceed. Cleveland County District Court Judge Michael Tupper ruled Tuesday that the Board of Health can proceed with implementing the state's medical marijuana rules and regulations. He ruled against a lawsuit by more than a dozen Oklahoma patients and businesses who challenged the rules. The decision Tuesday does not end the case. The judge could still throw out some or all the challenged rules at a later date or choose to leave them alone again. Another legal challenge is still pending in Oklahoma County District Court.

Heroin and Prescription Opioids

Study Finds African-American VA Patients More Likely to Be Drug Tested, Have Prescriptions Stopped. Black VA patients on long-term opioid therapy are more likely to be drug tested by their doctors and much more likely to have their opioid prescriptions halted if any illegal drug use is found, a new study finds. About 25% of black patients were tested within six months of being prescribed opioids, while only 16% of whites were. Black patients were twice as likely as white ones to have their opioid therapy halted if they tested positive for marijuana and three times as likely if they tested positive for cocaine. The findings were published in the journal Drug and Alcohol Dependence.

Georgia Judge Dismisses Indictment in Heroin Overdose Death. A Georgia judge has dismissed a murder indictment against a man accused of injecting heroin into another man who overdosed and died. In the case, Superior Court Judge John Goger found that the defendant injected the fatal dose at the victim's request and that the victim had purchased the drug himself. Goger held that that didn't amount to heroin distribution by the defendant, and without the underlying drug felony, there is no felony murder.

Harm Reduction

California Senate Passes Bill to Permit Safe Injection Sites in San Francisco. The state Senate Wednesday approved Assembly Bill 186, which would allow San Francisco to implement a safe injection site. AB 186 permits San Francisco to establish facilities where individuals can use controlled substances under the supervision of staff that are trained to treat and prevent drug overdose and link people to drug treatment, housing, healthcare, and other services. Mayor London Breed, the San Francisco Board of Supervisors, as well as a significant majority of the San Francisco electorate, support piloting safe injection sites in San Francisco.

With Ohio beset by a massive public health crisis around opioid use and overdoses -- more than 4,000 Ohioans died of opioid overdoses in 2016 -- the Cleveland Plain Dealer sent travel editor Susan Glaser to Amsterdam in search of innovative approaches to the problem. While there, she rediscovered Holland's longstanding, radical, and highly-effective response to heroin addiction and properly asked whether it might be applied to good effect here.

The difference in drug-related death rates between the two countries is staggering. In the US, the drug overdose death rate is 245 per million, nearly twice the rate of its nearest competitor, Sweden, which came in second with 124 per million. But in Holland, the number is a vanishingly small 11 per million. In other words, Americans are more than 20 times more likely to die of drug overdoses than Dutch.

For Plain Dealer readers, the figures that really hit home are the number of state overdose deaths compared to Holland. Ohio, with just under 12 million people, saw 4,050 drug overdose deaths in 2016; the Netherlands, with 17 million people, saw only 235.

What's the difference? The Dutch government provides free heroin to several score hardcore heroin addicts and has been doing so for the past 20 years. Public health experts there say that in addition to lowering crime rates and improving the quality of life for users, the program is one reason overdose death rates there are so low. And the model could be applied here, said Amsterdam heroin clinic operator Ellen van den Hoogen.

"It's been an enormous success. I think it would work elsewhere," she told Glaser.

It already has. The Dutch program was modeled on a similar effort in Switzerland, which has also proven successful. Germany and Canada are among the several other countries with similar programs.

The Dutch approach is an example of the country's policy of gedogen (pragmatic tolerance), the same principle that led the Dutch to pioneer quasi-legal access to marijuana in the 1980s. It is also rooted in the notion that, for some, drug addiction is a chronic disorder, not a condition to be "cured," and one that can be treated with supervised drug use under clinical supervision. And the complete cessation of drug use need not be the ultimate goal; rather, the Dutch look for reductions in criminal activity and increases in the health and well-being of the drug users.

"It's not a program that is meant to help you stop," acknowledged van den Hoogen. "It keeps you addicted."

That's not a sentiment sits well with American moralizers, such as George W. Bush's drug czar, John Walters, whom Glaser consulted for the story. He suggested that providing addicts with drugs was immoral and not "real treatment," but he also resorted to lies about what the Dutch are doing.

He claimed the Dutch are "keeping people addicted for the purpose of controlling them" and that the Dutch have created "a colony of state-supported, locked-up addicts."

Actually, the Dutch are dealing with older, hardcore addicts who have repeatedly failed to quit after repeated stints in treatment, including methadone maintenance therapy, and they are neither "controlling them" or locking them up. Instead, the people in the program show up at the clinic twice a day, get their fix, then go about their business. This heroin-assisted treatment (HAT) allows those hardcore users to live less chaotic and more productive lives.

And heroin-assisted treatment is "real treatment," said Peter Blanken, a senior researcher with the Parnassia Addiction Research Centre in Rotterdam. He pointed out that one-quarter of program participants make a "complete recovery," including better health and quitting illegal drugs and excessive drinking. Many others continue to use heroin, but do so with better outcomes, he said.

There is also a real safety benefit to using state-supplied pharmaceutical heroin. It's potent, but it's a known quantity. Users face no risk of adulteration with more dangerous drugs, such as fentanyl, which is deeply implicated in the current US overdose crisis.

In the current political atmosphere in the United States, providing heroin to hardcore addicts is a hard sell indeed. Other, lesser, harm reduction interventions, such as needle exchanges remain controversial, and the country has yet to see its first officially sanctioned safe injection site. And drug decriminalization, which has led to a dramatic reduction in heroin addiction and overdose deaths in Portugal, remains off the table here, too. But with an annual drug overdose death toll of more than 50,000 people a year, it may time to start asking how many more Americans we are willing to sacrifice on the altar of moralistic drug prohibition.

The US Surgeon General has some surprisingly frank words about harm reduction and evidence-based drug policy, Cory Booker's Marijuana Justice Act picks up another sponsor, Arizona's Supreme Court throws out a state law criminalizing the use and possession of medical marijuana on campus and more.

The section on the Surgeon General's comments has an update, including a statement from the Department of Health and Human Services on the safe injection sites mention.

Marijuana Policy

Jeff Merkley Signs on to Federal Marijuana Justice Act. And then there were five. Sen. Jeff Merkley (D-OR) has become the fifth cosponsor of Sen. Cory Booker's Marijuana Justice Act (S. 1689). The other cosponsors are Sens. Kirsten Gillibrand (D-NY), Kamala Harris (D-CA), Bernie Sanders (I-VT), and Ron Wyden (D-OR). Representatives Barbara Lee (D-CA) and Ro Khanna (D-CA) introduced a companion measure, H.R. 4815, in the House of Representatives earlier this year that has 35 cosponsors.

New York Democratic Party Officially Endorses Marijuana Legalization. Delegates to the state Democratic convention Wednesday adopted a resolution supporting marijuana legalization: "The New York State Democratic Committee supports the legalization of marijuana which should be regulated and taxed in a manner similar to alcohol," reads a resolution. The resolution adds that legalization is "an important social justice issue."

Medical Marijuana

Arizona Supreme Court Okays Medical Marijuana on College Campuses. The court ruled Wednesday that the state can't criminally charge card-carrying medical marijuana patients for possessing and using their medicine on campus. In Arizona v. Maestas, the court held that a 2012 law banning medical marijuana on campus violated the state's protections for voter-approved laws. The Supreme Court ruling upholds an appellate court ruling that also found in Maestas' favor.

Ohio Dispensary License Announcement Delayed. The state Board of Pharmacy announced Tuesday that its planned announcement of dispensary license awards Wednesday has been postponed and that provisional licenses will instead be issued in June. Legal medical marijuana sales are supposed to begin on September 8. Stay tuned.

Pennsylvania Judge Halts Medical Marijuana Research Program. A Commonwealth Court judge has granted a temporary injunction sought by numerous dispensaries and growers and processors to halt the state's medical marijuana research program. The plaintiffs worry that the regulations for the clinical research programs would give an unfair advantage to clinical research partners and growers. The Health Department is now pondering next steps.

Hemp

Illinois Governor Gets Bill Legalizing Industrial Hemp. With a 106-3 House vote Wednesday, the legislature has approved a bill legalizing industrial hemp, Senate Bill 2298. Now it's up to Gov. Bruce Rauner (R) to sign it.

Heroin and Prescription Opioids

US Surgeon General Urges ER Docs to Advocate for Evidence-Based Opioid Treatment. US Surgeon General Dr. Jerome Adams called Wednesday on emergency room physicians to advocate more vigorously for evidence-based opioid treatment, including harm reduction measures. Adams supported such harm reduction interventions as needle exchanges and safe injection sites. [The Department of Health and Human Services has issued a statement claiming that Dr. Adams does not support safe injection sites, and contesting the evidence on them. See update below.] He urged doctors to reach out to and educate stakeholders in their communities. "We have to understand that these policy interventions look different in different parts of the country," Adams said. "We have to understand that public policy means public and that we have to be able to go there and show them that we care before we can share what we know."

Update: A Department of Health and Human Services officer contacted us on Saturday, March 26th, claiming that the report news outlets relied on, including the one we linked to, was inaccurate in stating that Dr. Adams supports safe injection sites. We do not have other reports on his speech at this time to go on. The article linked above has been updated to include a copy of the HHS statement:

"The Administration and the Surgeon General do not support so-called 'safe' injection sites as a means to combat the opioid epidemic and its consequences. In addition, there is no evidence to demonstrate that these illegal sites reduce drug use or significantly improve health outcomes for those with opioid use disorder. So-called 'safe' injection sites lack the necessary scientific support to be considered a standardized evidence-based practice in the U.S."

Another article states that Adams mentioned safe injection sites as being "part of the conversation" in some communities.

Ed: We are in a position to address the administration's characterization of the evidence on safe injection sites, and it is false to the point of absurdity. There is significant evidence that safe injection sites improve health outcomes for persons with opioid use disorders. In fact, multiple journal articles to this effect are available on the website of the National Institutes of Health, a division of Health and Human Services. Here are a few of them:

• A 2017 study in Canadian Family Physician found that "SISs are associated with lower overdose mortality (88 fewer overdose deaths per 100 000 person-years [PYs]), 67% fewer ambulance calls for treating overdoses, and a decrease in HIV infections."
• A 2017 article in Harm Reduction Journal notes with citations that evaluation of Vancouver's Insite program showed it was "meeting its objectives of reducing public disorder, infectious disease transmission, and overdose and was successfully referring individuals to a range of external programs, including detoxification and addiction treatment programs.". The article further states that "over 40 peer-reviewed studies have been published which speak to the many benefits and lack of negative impacts of this site."
• A 2008 article in the American Journal of Public Health reported that the supervised injection facilities in Sydney and Vancouver were "negatively associated with needle sharing... and positively associated with less-frequent reuse of syringes... less outdoor injecting... using clean water for injection... cooking or filtering drugs prior to injecting... and injecting in a clean location," that "[b]oth... were effective gateways for addiction treatment, counseling, and other services," and that there were no "reported overdose deaths in a SIF."
• A 2014 article in Drug and Alcohol Dependence found that "[s]eventy-five relevant articles... converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency" and that "SISs were found to be associated with reduced levels of public drug injections and dropped syringes."
• A 2008 article in the Canadian Medical Association Journal found "Vancouver's supervised injection site is associated with improved health and cost savings."
• A 2010 article in Addiction found that if Vancouver's supervised injection facility "were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in lifetime HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year."

Mitch McConnell just says no, a House committee advances a VA medical marijuana bill, Pennsylvania's governor and attorney general aren't down with a Philadelphia safe injection site, and more.

Marijuana Policy

Mitch McConnell Confirms GOP Still the Party of "No" on Legal Marijuana. Senate Majority Leader Mitch McConnell (R-KY) said he was not interested in legalizing marijuana, even though his Democratic counterpart, Minority Leader Chuck Schumer (D-NY) has endorsed it. "I do not have any plans to endorse legalization of marijuana," McConnell said. McConnell is pushing for the legalization of hemp, though: "These are two entirely separate plants," McConnell said. "I hope everybody understands that. It is a different plant. It has an illicit cousin which I choose not to embrace."

Medical Marijuana

House Committee Advances Veterans Affairs Medical Marijuana Research Bill. The House Veterans' Affairs Committee Tuesday unanimously approved a measure that aims to increase VA research on medical marijuana. The bill would specify that the agency has the ability to research the herb for conditions including PTSD. The measure is part of a package of bills lawmakers hope to pass this month.

Missouri Senate Gives Initial Approval to Medical Marijuana Bill. The Senate Tuesday gave initial approval to House Bill 1554, which would allow people suffering from specified serious illnesses to use non-smokeable medical marijuana. The bill has already passed the House and now goes to the Senate Committee on Health and Pensions for a second reading. If it survives that, it then goes to the full Senate for a floor vote.

Utah "Right To Try" CBD Medical Marijuana Law Now in Effect. A limited medical marijuana law is now in effect. Under House Bill 195, which passed in March, terminally ill patients will be able to access CBD cannabis oil under a provision that expands the state's 2015 Right to Try Act. Also now in effect is House Bill 197, which establishes a medical marijuana cultivation program in the state. Both of these laws could soon be irrelevant, though: A much broader medical marijuana initiative will be on the ballot in November.

Heroin and Prescription Opioids

Study: Prescription Drug Monitoring Programs Have Little Effect on Overdose Deaths. A new study from Columbia University's Mailman School of Public Health finds that prescription drug monitoring programs may be only "marginally effective" in reducing drug overdose deaths. "What it really offers is this cautionary tale that says a few things. One, the amount of money and resources that are going into these programs need to be evaluated to understand what their ultimate costs are," social epidemiologist David Fink said. "Studies have come out in the past looking at reduced prescribing behavior, but we're taking it to the next level -- looking at fatal or nonfatal overdoses. And what we're seeing is that when you actually look at the literature, it isn't that strong to support" the programs. The study also found that half the studies looking at heroin overdose rates found a significant increase after prescription drug monitoring programs were implemented.

Walmart Tightens Opioid Prescription Policies. The nation's largest pharmacy chain announced Monday that beginning within 60 days, it will only fill first-time acute opioid prescriptions for a week or less nationwide. It will also limit dosages to 50 morphine milligram units per day. Walmart didn't say what it would do about patients who require greater dosages than that.

Harm Reduction

Officials in Philadelphia want a safe injection site in a bid to reduce drug overdoses that killed more than 1,200 people in the city last year, but the Democratic governor and attorney general aren't on board. A spokesman for Gov. Tom Wolf said the idea "presents a number of serious public health and legal concerns, while a spokesman for Attorney General Josh Shapiro said changes in federal law would have to come before he could support a safe injection site.