Missouri's Republican governor rejects a call to include marijuana legalization in an upcoming special session, a DC court reverses the firing of a medical marijuana-using employee accused of being high on the job, and more.

Marijuana Policy

Survey: Most Voters Support Federal Banking Reforms for Licensed Marijuana Retailers. The overwhelming majority of voters believe that federal law should be amended so that state-licensed marijuana businesses can readily utilize banks and other financial services, according to national survey data compiled by Morning Consult and commissioned by the Independent Community Bankers of America. Consistent with prior survey data, 65 percent of respondents “support allowing cannabis-related businesses to have access to banking services in states where cannabis is legal.” Moreover, 63 percent of voters agree that allowing cannabis-related businesses to access the banking system will help improve public safety, and 58 percent say that it is “important” that members of the U.S. Senate vote to establish a safe harbor for licensed cannabis businesses. The SAFE Banking Act (HR 1996), which would do just that, has repeatedly passed in the House only to be blocked in the Senate by Senate Majority Leader Charles Schumer (D-NY) and his allies, who are holding out for passage of a full-fledged marijuana legalization bill.

Missouri Governor Will Not Include Marijuana Legalization in Special Session. Efforts to do a legislative end run around a pending marijuana legalization constitutional amendment (Amendment 3) have come to naught after Gov. Mike Parson's office said Tuesday that he will not expand the scope of his upcoming legislative special session to consider legalizing marijuana. "The call will not be amended to include marijuana legalization," Kelli Jones, spokeswoman for Parson, said. Lawmakers hoping to blunt momentum for the measure had called on the governor to include marijuana legalization, but even though Parsons has called Amendment 3 "a disaster," he demurred.

Medical Marijuana

DC Court Reverses Firing of Government Worker Who Tested Positive for Marijuana. An administrative court in the DC Office of Employee Appeals (OEA) has reversed the firing of medical marijuana patient and city government employee who was accused of being high on the job and later tested positive for marijuana. The employee argued that the city's communications office falsely accused her of being impaired because her eyes were red and she was talking quietly. She pointed out that her eyes were red because she had spent the previous night at a hospital sitting beside a relative who had overdosed. She also presented a valid medical marijuana patient card. The court held that the communications office was negligent in how it handled the process for reasonable suspicion of impairment from drugs. The judge noted that supervisors allowed her to continue working after they accused her of being impaired: "Because Employee was allowed to perform her duties and did in fact adequately do so after being observed by her supervisors, I find that [the supervisors] did not reasonably believe that Employee’s ability to perform her job was impaired. As such, I further conclude that a reasonable suspicion referral was unwarranted," the judge wrote in the ruling. 

Opioids and Opiates

DEA Warning that Colored Fentanyl Pills Are Aimed at Kids is Nonsense, Experts Say. On August 30, the DEA warned the public about fentanyl in colorful pills being sold by "drug cartels" to "made to look like candy to children and young  people," calling it "Rainbow fentanyl" and charging that it is "a deliberate effort by drug traffickers to drive addiction amongst kids and young adults." But drug policy experts said such statements were misleading—and used harsh terms in doing so.

The charge is "typical drug war bullshit," said Dr. Nabarun Dasgupta, a pharmaceutical scientist at the University of Carolina at Chapel Hill. DEA's framing "was so divorced from any reality of what drug markets are actually like, it was almost laughable that our country's top drug enforcement folks are so out of touch.We've been talking about colored dope for years. This is like completely nothing new."

Claire Zagorski, a licensed paramedic, program coordinator and harm reduction instructor for the PhARM Program at The University of Texas at Austin College of Pharmacy, described the DEA announcement as "old recycled drug propaganda" that echoes the perennial myth of dope-laced Halloween candy. "Why would someone give away their expensive drugs to some random person they don't know, just so they might have a bad experience? It doesn't make sense," Zagorski told Salon. "At the end of the day, drug sellers are business people, and they're not going to invest in some kind of change to their supply if they don't think there's some good return on it … Kids don't have a lot of money that their parents don't supervise or give to them. So it just doesn't make sense from a business standpoint."

Colombia's new president says he will not extradite drug traffickers who quit the trade and comply with surrender conditions, a California bill to protect employees who use marijuana off-the-job is moving, and more.

Marijuana Policy

California Bill to Protect Marijuana-Using Employees Awaits Senate Floor Vote. A measure that would ban employers from firing or punishing workers who use marijuana outside of work hours has already passed the Assembly and now awaits a Senate floor vote. Assembly Bill 2188, sponsored by Assemblyman Bill Quirk (D-Hayward), would bar the use of hair, urine, and other bodily fluid tests for marijuana for employment purposes, with exemptions for workers subject to federal regulations or in safety-sensitive positions. The bill would, however, allow for saliva testing, which picks up the presence of active THC, not the inactive metabolites detected in hair and urine tests. If the bill passes, it is not clear Gov. Gavin Newsom (D) would sign it; he is subject to competing pressures on the topic, with the Chamber of Commerce and other business and retail groups opposing it.

South Dakota Poll Suggests Marijuana Legalization Could Lose in November. A new poll from Mason-Dixon Polling & Strategy has the IM 27 marijuana legalization initiative with the support of only 43.8 percent of respondents, with 54.4 percent opposed to legalization. But the poll of 500 registered voters is raising some eyebrows, given that just two years ago, voters in the state approved a marijuana legalization initiative with 54 percent of the vote (only to see it overturned by the state Supreme Court).

Matthew Schweich, campaign director for South Dakotans for Better Marijuana Laws, pointed to some anomalous findings, such as support in the Sioux Falls metro area being at only 38.6 percent. But in 2020, the Sioux falls metro area state Senate districts all reported at least 57 percent approval for legalization and one had the highest support of any district in the state at 72.7 percent.

"When I look a little deeper, I found things that do not make sense to me," said Schweich. "Some of the numbers don't really make sense and conflict strongly with previous data that we've seen. I see this as a flawed poll, but one that I still need to keep in the back of my head as motivation to keep working hard," Schweich said. "I'm not going to dismiss this poll entirely, and it's a reminder that we have to work really hard and not take anything for granted because in recent times, it's gotten harder and harder to predict what an electorate will look like."

Psychedelics

DEA Moves to Ban Two Obscure Psychedelics. The DEA is moving to place two obscure psychedelics on Schedule I of the Controlled Substances Act, despite little evidence regarding addiction or other harms. The two substances are DOI (dimethoxy-4-iodoamphetamine) and DOC (2,5-dimethoxy-4-chloroamphetamine), first synthesized by psychedelic researcher Alexander Shulgin. Little research has been done on the hallucinogens, but they are said to have subjective effects similar to LSD but lasting longer. DEA says the two drugs have "potential" for abuse, but also says "To date, there are no reports of distressing responses or death associated with DOI in medical literature" and "The physiological dependence liability of DOI and DOC in animals and humans is not reported in scientific and medical literature. DEA also notes that in the past 17 years there has been one death of someone using DOC, but that was "in combination with other drugs."

International

Colombia's President Says Will Not Extradite Drug Traffickers Who Fulfill Deals with the Government. President Gustavo Petro on Wednesday said that drug traffickers who abandon the trade and comply with government surrender conditions will not be extradited to the United States. He also said his government, which was sworn in this month on a vow to bring "total peace" to the country, was reaching out to various armed groups who want to negotiate an end to the conflict.

The US views extradition as a vital tool against the drug trade, but Petro has questioned its effectiveness, and it has been a sore point for many Colombians. "Drug traffickers who do not negotiate with the state will be extradited, drug traffickers who negotiate with the state and re-offend will be extradited, without any kind of negotiation, to the United States," Petro said after a meeting with Spanish Prime Minister Pedro Sanchez. "Drug traffickers who negotiate legal benefits with the Colombian state and definitively stop being drug traffickers will not be extradited," he said.

American Cartel: Inside the Battle to Bring Down the Opioid Industry, by Scott Higham and Sari Horwitz (2022, Twelve Press, 400 pp., $30.00 HB)

Phillip S. Smith, with contributions from David Borden

Pulitzer Prize-winning Washington Post investigative reporters Scott Higham and Sari Horwitz have been on the opioid beat for years, teaming up (with others) on the Post's "The Opioid Files" series, which was nominated for a Pulitzer in 2020. Now, with American Cartel, the pair provide a deeply-sourced account of how opioid manufacturers, distributors, and pharmacies waged an all-out campaign to fend off DEA efforts to stanch the flow of billions of opioid pain pills, and to evade any culpability, even as the overdose death toll mounted year by year.

The picture Higham and Horwitz paint of corporate and political malfeasance is damning. But the laser sharp focus with which they paint it, omits much of the context in which the opioid crisis has unfolded. And that context is also very important.

An article in yesterday's Guardian shows one of the reasons why. In much of the world, very few pain patients are able to access opioids at all. Much suffering results, sometimes leading to suicide attempts. Dr. MR Rajagopal, chair of Pallium India, told the Guardian, "Pain is not visible. It happens in hospital beds or patients' rooms and is not visible to the world. Addiction, on the other hand, is very visible in headlines which quote the US epidemic and overdose deaths. No one talks about the western European success over decades; all the news is about the opioid crisis in the USA. This means that when we try to have discussions, our work becomes harder because many minds are primed against opioids."

In other words, by speaking too solely to one side of an issue, one risks adversely impacting the other sides. Whether "opiophobia" is real or significant in the US is another question. Higham and Horwitz don't venture a view on this, at least not in American Cartel.

One entity that has warned about opiophobia (without using the term) is the US Centers for Disease Control. In a 2019 memo, CDC writes that a 2016 guidance the agency issued on prescribing opioids for chronic pain had seen "misapplication[s]" by some physicians that put patients at risk. The memo cites a New England Journal of Medicine commentary by the authors of the 2016 guidance. It warns against "hard limits" on opioid dosages or cutting patients off; abrupt tapering of prescriptions; applying the guidance to acute pain situations patients face in situations like active treatment for cancer or sickle cell anemia or post-operative care; and applying it to medication-assisted treatment prescriptions for addiction.

Technically the CDC memo addressed a period of a few years beginning in 2016. But the dynamics it describes are inherent risks in a situation where providers are charged with supplying a substance that's useful but also addictive and potentially deadly if misused, and for which they can be sanctioned professionally or even prosecuted and imprisoned if things go wrong or someone disagrees. Pharma-driven promotion of their new opioid products was a factor in driving up prescribing rates to where they reached. But a part of the increase was also the medical community reacting to a real problem of under-treatment or non-treatment of pain for some patients, a problem that coexists with over-prescribing to some other patients. That increase in turn came with a learning curve.

The authors also give short shrift to the impact of today's woes and inequalities in driving the so-called deaths of despair -- a concept coined by Princeton professors Anne Case and Angus Deaton -- alienation and anomie, helplessness and hopelessness afflicting many Americans who have been left behind in the modern economy, especially in the opioid use heartlands of the Midwest and Appalachia. The Midwest deindustrialized beginning in the 1970s, and both regions largely missed out on the tech boom of the '90s and '00s. Then came even more pain with the Great Recession, followed by COVID and more economic and social disruption. People there (and elsewhere) are dying not just of opioids, but of smoking, drinking, and suicide. Big Pharma is easily (and oh so deservingly) demonized, but the laser focus on the companies allows us not to have to look in the mirror about the pain our society produces.

That factors like these should play a role in the opioid crisis, though, doesn't exonerate Big Pharma. Rather, the misleading promotions of their products carried out by pharma, took an even greater toll due to the vulnerabilities those other factors had brought to the fore.

Meanwhile, the death toll continues to mount -- over 100,000 per year, and with a new record high every year. Prescription opioids still figure prominently in overdoses. But the greatest part of the problem by far is black-market fentanyl, used deliberately by some high tolerance heavy users of opioids, but primariy causing overdose as an adulterant in heroin, counterfeit prescription pills, and other street drugs, essentially a poisoning crisis. But as Higham and Horwitz note, that is part of a wave of opioid use that began with pharmaceutical companies such as Purdue Pharma taking Oxycontin onto the market in the late 1990s. The first decade of this century also saw other prescription opioids -- oxycodone, hydrocodone, Vicodin, Percocet, Opana, et al. -- hit the market.

Higham and Horwitz are fond of tossing around astounding numbers of pills produced by manufacturers or sold by certain pharmacies, such as Mallinckrodt producing 3.5 billion 30 milligram hydrocodone pills in one year, and critics could protest that those numbers need context, too. A prescription for a medication doesn't just have a number of pills to take. It specifies how large a dosage there is inside each pill. A smaller number of pills that each contain a higher dose might mean more than a larger number that each contain a smaller dose. And a higher dose prescription sometimes reflects a patient's tolerance to opioids built up through past medical (or non-medical) use. Maybe West Virginia didn't really need 81 million pain pills during a five-year span. But maybe it did. Without more information, it's just not clear what these numbers mean.

They do provide some context, though, for example by comparing pain pill sales across all drug stores in a region and pointing out anomalies not easily explainable by, say, differing rates of cancer or other serious illness. And they demonstrate that plenty of businesses -- from Big Pharma to the drug store chains and individual pharmacies -- were either in it for the money or at best screwed up, both through detailed analysis and telling anecdote. For example, there was the guileless Florida pharmacist who explains to investigators that she fills pain pill prescriptions all day long, but always keeps a certain number of pills on reserve "for my real pain patients."

When the DEA cracked down first on Wild West internet sales of opioids and then on the "pill mills," medical practices with perfunctory examinations and huge numbers of opioid prescriptions whose entire business model seemed to be writing opioid prescriptions, it succeeded in reducing access to those drugs. But the people using opioids didn't stop; they went to black market drugs, fueling first a resurgence in heroin use and now an opioid crisis driven by fentanyl.

A key figure in the tale is Joe Rannazzisi, who as head of DEA's Office of Diversion Control from 2006 to 2015 oversaw the agency's endless effort to ensure that prescribed opioids are only prescribed for legitimate medical purposes and not leaking into the black market. We are inclined to think of the DEA as a prohibitionist agency, but in this case, it is acting as a regulatory agency. And what Higham and Horwitz uncover is a case of regulatory capture -- when the industry being regulated manages to set the terms under which it is regulated, for its own benefit, not that of the public.

Rannazzisi and his team of DEA lawyers spent years going after opioid manufacturers, distributors, and pharmacy chains who were repeatedly (administratively) busted for failing to do due diligence about just who was buying their products. The companies would pay huge fines, promise not to do it again, and then continue to pump massive amounts of opioids through the supply chain.

The companies mobilized against Rannazzissi and his campaign, forming industry front groups, undertaking lobbying efforts, hiring legions of high-priced law firms, and crafting legislation that would rein in what they saw as an out-of-control agency. As Higham and Horwitz document in great detail, it worked.

Sponsored by Rep. Tom Marino (R-PA) and Sen. Marsha Blackburn (R-TN), both of whom received substantial contributions from the industry, but written by industry lobbyists, the nicely named Ensuring Patient Access and Effective Drug Enforcement Act removed from the DEA tools that Ranizzisi had been using to try to force drug distributors to monitor and report suspicious orders, such as the 1.2 million oxycodone tablets one distributor bought from Mallinckrodt in one day, only to order another 1.2 million the next day.

The bill passed, only to be drastically revised amidst scandal after an earlier Post report on the opioid bill derailed then-President Trump's effort to name Marino drug czar. But Higham and Horwitz also detail rot inside the DEA, where the industry managed to get to high-ranking officials who sidelined Rannazzisi, forcing him into retirement and forcing many of his team members into bureaucratic Siberia. It's an ugly little story of money and power, the sort that is all too common in Washington.

If the first part of American Cartel reads like a detective novel, the second part is more like a legal thriller, It covers the massive wave of civil lawsuits filed against the drug companies, and it is not particularly edifying reading. You see hundreds of high-powered attorneys from the country's top litigating firms -- including dozens of former DEA attorneys working now working for the industry they regulated -- facing off against armies of lawyers for the thousands of states, cities, and counties. You see massive settlements from the companies and massive damages wrested from companies that went to court and lost. While it is unclear just how the moneys won or negotiated by the various plaintiffs is actually being used to help people who suffered from the opioid crisis, what is clear is that it has been a bonanza for the legal profession, with winnings -- excuse me, earnings -- by attorneys reaching well over a billion dollars.

They weren't all in it for the money, though. Some, like West Virginia attorney Paul Farrell, whose state was one of the epicenters of the pain pill epidemic, were sickened by the toll of addiction they saw all around them. Not willing to settle for the pittance the town and county he represented would receive under a massive settlement agreed to by most of the suing entities, he gambled on going it alone against the drug distributors. As this book went to print in April, he was still waiting for a decision. Earlier this month, he lost, with a federal judge ruling that drug distributors were not responsible for the area's opioid crisis.

The litigation goes on, and the dying goes on. Sometimes the drug companies settle, sometimes they lose and have to pay even more. But sometimes they win.

The profit-driven wave of opioids that engulfed the country in the last couple of decades is not an anomaly. The pharmaceutical companies have a historical pattern of creating and marketing drugs that later wreak havoc. That's what they did with amphetamines, that's what they did with barbiturates, that's what they did with benzodiazepines. It's almost enough to make one wonder if profit-driven capitalist enterprises should be in charge of the nation's drug supply.

Read Higham and Horwitz's book. But read Case and Deaton's too. And when you see the next "pill mill" story, don't assume that it is, or isn't, what it seems.

Chronicle Book Review: Opium's Orphans: The 200-Year History of the War on Drugs by P.E. Caquet (2022, Reaktion Books, 400 pp., $35.00 HB)

The history of drug prohibition is increasingly well-trodden territory, but with Opium's Orphans, British historian P.E. Caquet brings a fascinating new perspective embedded in a sweeping narrative and fortified with an erudite grasp of the broad global historical context. Although Asian bans on opium pre-dated 19th Century China (the Thai monarchy announced a ban in the 1400s), for Caquet, the critical moment in what became a linear trajectory toward global drug prohibition a century later came when the Qing emperor banned opium in 1813 and imposed severe penalties on anything to do with it, including possessing it. Precisely 100 years later, after two Opium Wars imposed opium on the empire followed by decades of diplomatic wrangling over how to suppress the trade (and for moralizing Americans, how to win favor with China), the 1913 Hague Opium Convention ushered in the modern war on drugs with its targeting not just of opium (and coca) producers or sellers but also of mere users for criminal prosecution. It urged countries to enact such laws, and they did.

What began at the Hague would eventually grow into an international anti-drug bureaucracy, first in the League of Nations and then in United Nations bodies such as the Commission on Narcotic Drugs and the International Narcotics Control Board. But it is a global prohibition regime that has, Caquet writes, straight-jacketed itself with an opium-based perspective that has proven unable or unwilling to recognize the differences among the substances over which it seeks dominion, reflexively resorting to opium and its addiction model. Drugs such as amphetamines, psychedelics, and marijuana don't really fit that model -- they are the orphans of the book's title -- and in a different world would be differently regulated.

But Opium's Orphans isn't just dry diplomatic history. Caquet delves deep into the social, cultural, and political forces driving drug use and drug policies. His description of the spread of opium smoking among Chinese elites before it spread into the masses and became declasse is both finely detailed and strangely evocative of the trajectory of cocaine use in the United States in the 1970s, when it was the stuff of rock musicians and Hollywood stars before going middle class and then spreading among the urban poor in the form of crack.

Along the way, we encounter opium merchants and colonial opium monopolies, crusading missionary moralists, and early Western proponents of recreational drug use, such as Confessions of an English Opium Eater author Thomas De Quincey and the French habitues of mid-19th Century hashish clubs. More contemporaneously, we also meet the men who achieved international notoriety in the trade in prohibited drugs, "drug lords" such as Khun Sa in the Golden Triangle, Pablo Escobar in Colombia and El Chapo Guzman in Mexico, as well as the people whose job it is to hunt them down. Caquet notes that no matter how often a drug lord is removed -- jailed or killed, in most cases -- the impact on the trade is negligible.

For Caquet, drug prohibition as a global phenomenon peaked with the adoption of the 1961 Single Convention on Narcotic Drugs. Coming as it did amidst a post-World War II decline in drug use around the world, the treaty criminalizing coca, cocaine, opium and opioids, and marijuana seemed to ratify a successful global prohibitionist effort. (In the US, in the 1950s, when domestic drug use was at low ebb, Congress passed tough new drug laws.) But before the decade was over, drug prohibition was under flamboyant challenge from the likes of LSD guru Timothy Leary and a horde of hippie pot smokers. The prohibitionist consensus was seeing its first cracks.

And the prohibitionist response was to crack down even harder, which in turn begat its own backlash. Drug use of all sorts began rising around the world in the 1960s and hasn't let up yet, and the increasingly omnivorous drug war machine grew right along with it, as did the wealth and power of the illicit groups that provided the drugs the world demanded. As the negative impacts of the global drug war -- from the current opioid overdose crisis in the US to the prisons filled with drug offenders to the bloody killing fields of Colombia and Mexico -- grew ever more undeniable, the critiques grew ever sharper.

In recent years, the UN anti-drug bureaucrats have been forced to grudgingly accept the notion of harm reduction, although they protest bitterly over such interventions as safe injection sites. For them, harm reduction is less of an erosion of the drug war consensus than all that talk of drug legalization. As Caquet notes, perhaps a tad unfairly, harm reduction doesn't seek to confront drug prohibition head-on, but to mitigate its harms.

The man is a historian, not a policymaker, and his response to questions about what to do now is "I wouldn't start from here." Still, at the end of it all, he has a trio of observations: First, supply reduction ("suppression" is his word) does not work. Sure, you can successfully wipe out poppies in Thailand or Turkey, but they just pop up somewhere else, like the Golden Triangle or Afghanistan. That's the infamous balloon effect. Second, "criminalization of the drug user has been a huge historical blunder." It has no impact on drug use levels, is cruel and inhumane, and it didn't have to be that way. A century ago, countries could have agreed to regulate the drug trade; instead, they tried to eradicate it in an ever-escalating, never-ending crusade. Third, illicit drugs as a group should be seen "as a historical category, not a scientific one." Different substances demand different approaches.

Opium's Orphans is a fascinating, provocative, and nuanced account of the mess we've gotten ourselves into. Now, we continue the work of trying to get out of that mess.