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Chronicle Book Review: American Cartel

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

https://stopthedrugwar.org/files/americancartel.jpg
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

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.

Biden Signs Criminal Justice Reform Executive Order, RI Legislature Approves Marijuana Legalization, More... (5/25/22)

Rhode Island is set to become the 19th legal marijuana state, West Virginia announces a big settlement with drug manufacturers over their role in the opioid crisis, and more.

After congressional inaction, President Biden issues an executive order on criminal justice reform. (whitehouse.gov)
Marijuana Policy

Georgia Voters Approve Marijuana Legalization Ballot Question. State voters sent a strong signal to lawmakers Tuesday by overwhelmingly approving a non-binding ballot question on marijuana policy. Voters were asked: "Should marijuana be legalized, taxed and regulated in the same manner as alcohol for adults 21 years of age or older, with proceeds going towards education, infrastructure and health care programs?" A whopping 80 percent of them answered "yes."

Rhode Island Legislature Approves Marijuana Legalization. Both the House and the Senate voted Tuesday to approve a marijuana legalization bill, Senate Bill 2430. Gov. Dan McKee (D) is set to sign it into law today. The law will allow people 21 and over to possess, grow, and purchase limited amounts of marijuana. It also includes expungement and social equity provisions. Once the bill is signed into law, Rhode Island will become the 19th state to free the weed. Look for our feature story on this later today.

Opiates and Opioids

West Virginia Announces Settlement with Opioid Manufacturers. State Attorney General Patrick Morrisey announced Wednesday that the state had reached a $161.5 million settlement with two drug companies over their role in the opioid epidemic. The settlement came as the trial in the state's lawsuit against Allergan and Teva was nearing its end. Morrisey touted the settlement as "record-breaking," saying it was the highest per capita settlement in the country and blasted the two companies as "helping fuel the opioid epidemic in West Virginia by engaging in strategic campaigns to deceive prescribers and misrepresent the risks and benefits of opioid painkillers."

Criminal Justice

President Biden Signs Executive Order to Advance Accountable Policing, Strengthen Public Safety. Marking the second anniversary of the killing of George Floyd at the hands of Minneapolis police, President Biden on Wednesday issued a broad-ranging executive order to advance accountable policing and enhance public safety. The move comes after Congress largely failed to act on policing reform in the wake of the killing and the mass protests it generated. Among other provisions, the order creates a new national database of police misconduct, restricts the use of no-knock search warrants, bans the use of chokeholds and carotid restraints unless deadly force is authorized, requires new standards limiting the use of force for all federal agencies, restores the Obama administration's restrictions on the transfer of military equipment to law enforcement agencies, requires an updated approach to recruitment, hiring, promotion, and retention of law enforcement officers; requires all federal law enforcement agencies to track data on use of force; directs a government-wide strategic plan to propose interventions to reform the criminal justice system; and requires full implementation of the First Step Act.

Federal Pot Busts Continue Decade-Long Decline, VT Governor Vetoes Drug Decrim Study Bill, More... (5/23/22)

Luxembourg is on a path to be the first European Union country to legalize marijuana, Alabama Medicaid is being challenged for blocking access to Hep C treatment for people who use drugs or alcohol, and more.

Vermont Gov. Phil Scott (R) has vetoed a bill that could have led the way to drug decriminalization. (vt.gov)
Marijuana Policy

Federal Pot Busts Continue to Decline. The DEA arrested 2,576 people on federal marijuana charges in Fiscal Year 2020, down dramatically from 2010, when the DEA made 8,215 pot arrests. Arrests have declined on an average of 11 percent a year in the past decade. Some of the decline is because of the coronavirus pandemic, which the Bureau of Justice Statistics said, "drove an 81 percent decline in arrests and 77 percent decline in cases charged from March to April 2020." But the decline also reflects discretionary decisions by the Justice Department as state after state legalizes marijuana.

Drug Policy

Alabama Medicaid Sued for Denying Hep C Treatment for People Who Use Drugs. The Center for Health Law and Policy Innovation and AIDS Alabama have filed an administrative complaint with the Justice Department, charging that Alabama Medicaid is discriminating against people with substance use disorder by denying "[Hep C] treatment to otherwise eligible Medicaid enrollees who cannot prove they did not use drugs or alcohol within the last six months." Prospective enrollees must promise not to use illegal drugs or alcohol, even though only alcohol has an effect on the liver. Alabama Medicaid patients who are found to be using drugs, including alcohol, could see their access to treatment, which otherwise costs tens of thousands of dollars, blocked. "On an individual level, for a single person seeking hep C treatment, it means the difference between being cured of hepatitis C and continuing to live with this very dangerous illness that, in many cases, can lead to liver scarring, liver cancer and even death," said Suzanne Davies, an attorney and CHLPI clinical fellow.

Vermont Governor Vetoes Drug Decrim Study Bill. Gov. Phil Scott (R) has vetoed House Bill 505, which would have created a Drug Use Standards Advisory Board as a first step toward drug decriminalization. The board would have been charged with determining a way to decriminalize the personal possession of currently illicit drugs, as well as ending the legal distinction between powder and crack cocaine. But in his veto message, Scott complained that the bill "places no limits on which drugs can be contemplated for legalization or the amounts, and while rightly saying we need to view substance abuse as a public health matter -- a point where I agree -- it includes absolutely no recognition of the often-disastrous health and safety impacts of using drugs."

International

Jordanian Armed Forces Kill Four Drug Smugglers from Syria. Four people trying to smuggle a large quantity of drugs from Syria into Jordan have been killed, with an unspecified number of others wounded and others escaping back into Syria, the Jordanian armed forces said. Jordan is both a destination and a transit route for captagon, an amphetamine now manufactured in Syria. The military did not specify who killed the smugglers, but in January, Jordanian soldiers killed 27 armed smugglers as they crossed the border.

Luxembourg Council of Government Set to Review Draft Marijuana Legalization Bill Next Month. The Council of Government will review a draft of a marijuana legalization bill next month. The government has committed to legalization, and in the current draft, would allow for home cultivation and would legalize the possession of up to three grams of marijuana. If the bill passes, Luxembourg would be the first country in the European Union to legalize marijuana, although Germany is now following a similar process.

White House Drug Strategy Embraces Harm Reduction, But Prohibitionist Impulse Remains Strong [FEATURE]

The Biden White House sent its first National Drug Control Strategy to Congress on April 21. It breaks positive new ground by explicitly acknowledging harm reduction measures to prevent overdose and blood-borne diseases among drug users. At at the same time, though, it also relies heavily on the destructive and counterproductive pursuit of failed prohibitionist drug policies -- and funds more law enforcement much more heavily than harm reduction.

The strategy comes out just weeks after the Centers for Disease Control and Prevention (CDC) reported that drug overdose deaths hit an all-time high of 106,000 in the year ending last November. The administration is responding with what it calls a "whole of government" approach to the crisis.

"The strategy focuses on two critical drivers of the epidemic: untreated addiction and drug trafficking," the White House said. "It instructs federal agencies to prioritize actions that will save lives, get people the care they need, go after drug traffickers' profits, and make better use of data to guide all these efforts. Saving lives is our North Star, and the 2022 National Drug Control Strategy calls for immediate actions that will save lives in the short term and outlines long-term solutions to reduce drug use and its associated harms, including overdose."

While the strategy includes long-familiar categories such as drug treatment, prevention, supply reduction, and criminal justice and public safety, it also emphasizes an evidence-based approach, "building a recovery-ready nation," and for the first time, harm reduction.

"The Biden-Harris Administration's efforts focus on meeting people where they are and building trust and engagement with them to provide care and services," the White House said. "Specifically, the strategy calls for greater access to harm reduction interventions including naloxone, drug test strips, and syringe services programs. It directs federal agencies to integrate harm reduction into the US system of care to save lives and increase access to treatment. It also calls for collaboration on harm reduction between public health and public safety officials, and changes in state laws and policies to support the expansion of harm reduction efforts across the country."

The strategy calls for "the coordinated use of federal grant funds for harm reduction," and the administration last year broke new ground with a $30 million grant program for harm reduction providers. But in a sign of continued reliance on traditional law enforcement priorities, the strategy also envisions a $300 million increase for Customs and Border Patrol and another $300 million increase for the DEA. Those figures were released as part of the White House's FY 2023 budget released last month.

"Responding effectively to the illicit production, trafficking, and distribution methods of domestic criminal organizations and Transnational Criminal Organizations (TCOs) is a significant challenge and remains a Biden-Harris Administration priority," the White House said.

That kind of talk suited mainstream Democrats just fine.

"Illicit drugs cause immeasurable pain and loss in our communities. As the Chairman of the Senate Caucus on International Narcotics Control, I've pressed for an updated federal plan to tackle them," said Sen. Sheldon Whitehouse (D-RI). I've been clear that the plan must include a more coordinated approach to cracking down on drug trafficking and transnational criminal organizations, especially the ways in which they launder and protect their ill-gotten gains using US rule of law and financial networks; and more and better cooperation with our international partners to reduce the supply of precursor chemicals used to manufacture illicit drugs and to levy tougher sanctions against transnational drug syndicates. I'm pleased to see my priorities reflected in this new strategy, and I look forward to working with the Biden administration to deliver on those priorities."

Whitehouse also lauded the strategy's "tearing down barriers to treatment, including expanding access to life-saving naloxone and medication-assisted treatment; improving our data collection systems to better understand the effects of our intervention efforts."

Reform advocates offered praise -- sometimes lukewarm -- for the administration's tentative embrace of harm reduction, but blasted its reliance on tired, failed drug war paradigms.

In its analysis of the strategy, the Washington Office on Latin America (WOLA) called it "a major step forward" and lauded the administration for "focusing on ensuring access to treatment for substance use disorders and highlighting the crucial role of harm reduction services." But WOLA also noted that, "when measured against the scale of the nation's overdose problems and the urgency of the needs, Biden's new plan appears quite timid."

WOLA also warned that the strategy's "positive innovations regarding investment in treatment and harm reduction strategies risk being undermined by a continued commitment to the kinds of policies that have exacerbated the present crisis and that continue to absorb the lion's share of resources, namely, drug criminalization at home and wildly exaggerated expectations for what can be achieved through supply control efforts abroad."

Similarly, the libertarian-leaning Cato Institute called the attention to harm reduction a "positive," but noted steps that it did not take, such as making the opioid overdose reversal drug naloxone available over-the-counter and repealing the so-called Crack House Statute that stands in the way of federal approval of safe injection sites.

"On a negative note," Cato observed, "the remainder of the new report calls for doubling down on interdiction, border control, and other law enforcement measures aimed at curtailing the supply of illicit drugs -- as if repeating the same failed strategies of the past half century, only with more gusto, will somehow work."

So there it is: The Biden administration's first crack at a national drug strategy deserves kudos for its embrace of harm reduction and evidence-based approaches, but beyond that, it is pretty much more of the same old same old.

CA Psilocybin Legalization Initiative Falls Short on Signatures, Ukraine War Deepens Suffering of Drug Users, More... (3/18/22)

Medical marijuana bills advance in Georgia and Kentucky, Honduras' former "narcopresidente" is a step closer to being extradited to the United States on drug charges, and more. 

Fomer Honduran President Juan Orlando Hernandez can be extradited to face US drug charges, a court there ruled. (CC)
Marijuana Policy

Rhode Island Governor Has "Concerns" About Marijuana Legalization Bill's Cannabis Control Commission. Gov. Dan McKee (D) has "significant constitutional concerns" with Senate Bill 2430, the marijuana legalization bill backed by House and Senate leadership. The concerns are around the proposed three-member cannabis control commission's members are to be appointed—and removed if necessary. The governor's office argues that the bill would give the Senate "unfettered discretion" on whether to remove a commissioner, which is says is a violation of the separation of powers. But one of the key sponsors of the bill, which was crafted after long deliberation, Sen. Joshua Miller (D-Cranston), said the governor's objection is not an insurmountable obstacle. "It’s not a big impediment," said Miller. "It’s solvable." 

Medical Marijuana

Georgia House, Senate Pass Separate Medical Marijuana Bills. The House approved a bill to revamp the state's dysfunctional medical marijuana system, House Bill 1425 on Tuesday. The bill would allow the provision of low-THC cannabis oil "from any available legal source" by August 1 and begin providing it to patients now on the state registry by August 15. The state had passed a low-THC cannabis oil law in 2015, but legal challenges have left Georgians without any legal supply. The Senate, meanwhile, approved its own medical marijuana bill, Senate Bill 609, which would require the medical cannabis commission to issue its initial licenses by May 31. Tuesday was the last day for bills to pass their original chamber, so both bills remain alive.

Kentucky House Approves Medical Marijuana Bill. The House on Thursday approved House Bill 136, which would legalize medical marijuana in the state. The legislation now heads to the Senate. This is the third try for bill sponsor Rep. Jason Nemes (R), who got a similar bill through the House in 2020 only to see in die in the Senate and whose 2021 effort got nowhere in the midst of the pandemic. The bill now heads to the Senate, where Senate Judiciary Chairman Whitney Westerfield (R) says he will back it despite personal reservations.

Psychedelics

California Psilocybin Legalization Initiative Falls Short on Signatures. Decriminalize California, the group behind a psilocybin legalization initiative campaign, announced Wednesday that it had failed to gather enough valid voter signatures to qualify for the November ballot. The all-volunteer effort faltered during the winter outbreak of the omicron variant of the coronavirus. "We were doing great there collecting and then in mid-December just about everyone of our core volunteers got COVID and most of the events we were scheduled at either closed, postponed or had an extremely weak turnout," campaign manager Ryan Munevar said in an email to supporters. The group will now do fundraising in coming months to determine whether it is feasible to start a second effort in either June or October of next year for 2024.

International

At Urging of US, CND Acts Against Precursor Chemical Used to Produce Illicit Fentanyl. The UN Commission on Narcotic Drugs (CND) voted Friday to control three chemicals used by drug traffickers to produce illicit fentanyl, a powerful synthetic opioid that is driving overdose deaths in the United States. At the request of the United States, and with the recommendation of the International Narcotics Control Board, the Commission’s Member States voted unanimously to take international action and control the acquisition, production, and export of three precursors used to manufacture illicit fentanyl and its analogues. "President Biden has made clear that ending the overdose epidemic is a top priority. As part of the Administration’s efforts to reduce the supply of illicit fentanyl driving overdose deaths, the United States called on the global community to regulate three chemicals commonly used to produce it, and today that call was answered," said Dr. Rahul Gupta, Director of the White House Office of National Drug Control Policy (ONDCP). "This new action makes it more difficult for drug traffickers to obtain and use these chemicals for illicit purposes. It will also help disrupt synthetic drug trafficking that not only leads to deaths caused by overdose, but also corruption, drug-related violence, and insecurity. The collective work of the international community to address global drug-related challenges has never been more important. The Biden-Harris Administration is committed to building on today’s progress."

Honduran Judge Okays Extradition of Former President to Face US Drug Charges. A judge in Honduras has ruled the former President Juan Orlando Hernandez can be extradited to the United States to face drug charges. Hernandez was president from 2014 until last month, after he lost an election, and was considered a US ally even though federal prosecutors alleged he was involved in drug trafficking throughout his presidency. He was detained last month by the new government at the request of the US. The "narcopresidente" has until Saturday to appeal the Wednesday ruling, after which he could be extradited. Meanwhile, he remains in prison in Honduras.

War Deepens Suffering for Ukraine's Drug Users. Drug users in the country are facing shortages of methadone and street drugs as the Russian military campaign in the country disrupts daily life. "Today, I went around five pharmacies where I used to get methadone on prescription. None were open. Another place was open today, but there was a queue of at least 200 people and I didn’t want to go into withdrawal right there, and so I went home," one drug user said. In the city of Kyiv, there were 45 fee-based centers serving opioid-dependent patients each; now they are all closed after the doctors evacuated. Similar clinics in the Crimean Peninsula were shut down when Russian forces took over in 2014; since then, of approximately 800 Crimean methadone patients, at least 80 have killed themselves, died of fatal overdoes, or died of other narcotic causes. 

US Prison, Parole, Probation Population Continues Slow Decline; $26 Billion Opioid Settlement, More... (7/22/21)

Florida's Republican establishment may not be ready for marijuana legalization but the public is, the Justice Department drops an effort to send some First Step Act releasees back to prison, and more.

Drug distributors agree to pay out big-time for their role in the opioid crisis. (Pixabay)
Marijuana Policy

Florida Poll Shows Strong Support for Marijuana Legalization. A new poll from Public Policy Polling has support for marijuana legalization at 59%. Two different efforts to get an initiative before the voters last year were quashed by the state Supreme Court, and the Republican-led state legislature this year passed a bill making it more difficult to finance initiatives, which Republican Gov. Ron DeSantis signed into law. Translating public support into marijuana reform is going to be more difficult than ever now.

Opioids

Major Drug Distributors Reach Agreement on $26 Billion Opioid Settlement. The three largest US pharmaceutical drug distributors -- McKesson, Cardinal Health, and AmerisourceBergen -- and drugmaker Johnson & Johnson have reached an agreement with a group of state attorneys general to pay out $26 billion to settle lawsuits related to their roles in the widespread prescribing of prescription opioids and the subsequent wave of addiction and overdose deaths. "The numerous companies that manufactured and distributed opioids across the nation did so without regard to life or even the national crisis they were helping to fuel," said New York Attorney General Letitia James, one of the attorneys general from 15 states involved in the deal. "Today, we are holding these companies accountable and infusing tens of billions of dollars into communities across the nation." Responding to that wave of addiction and overdoses, the states and the federal government have moved to restrict opioid prescribing, even though chronic pain patients have found their access to their medications more difficult.

Sentencing

US Correctional Population Drops for 12th Straight Year. The Bureau of Justice Statistics (BJS) reports that in 2019, the number of people in the US in jail or prison or on probation or parole was 6,344,000, down 65,200, or 1%, over the previous year and marking the 12th year in a row that that figure has declined. At the end of 2019, 4,357,700 people were under community supervision (probation or parole), while there were 2,086,000 people behind bars in jails or prisons. The BJS report did not discuss the types of offenses for which people were under correctional supervision, but a 2020 Prison Policy Initiative report found 190,000 doing time for drug offenses in state prisons, 157,000 in local jails, and 78,000 in the federal prison system, meaning drug prisoners account for about one-fifth of the US incarcerated population.

Justice Department Drops Appeal of First Step Act Releases. The Justice Department has dropped an effort to re-imprison four New Jersey men who were released from prison under the First Step Act's retroactive crack cocaine sentencing provision. The men had been released in November 2019 after serving more than 20 years on crack charges, but the Trump Justice Department then sought to send them back to prison. The Biden Justice Department had been under pressure from groups such as Families Against Mandatory Minimums (FAMM), which applauded the decision, saying: "We raised this case among others with the Biden transition team as an appeal that should be dropped right away. It would have been cruel and unjust it would be to send these guys back."

Federal Appeals Court Taps the Brakes on Drug Induced Homicide Prosecutions of Drug Users [FEATURE]

A woman who bought heroin with a pair of friends, one of whom shortly afterward suffered a fatal overdose on the drug, is not a murderer, at least according to the US 3rd Circuit Court of Appeals. That was the June 1 ruling in US v. Semler, a case that may not set binding precedent, but does send a signal to the prosecutors and the judiciary that the federal courts do not want to see a federal law aimed at so-called drug kingpins applied to mere drug users.

As described in the decision, the case began when two heroin-addicted Philadelphia women, Emma Semler and her old drug rehab buddy Jennifer Werstler, went to score heroin together at Wertsler's request. They were joined by Semler's sister Sarah, who drove them to the West Philadelphia locale where they bought their heroin. It is unclear who actually purchased and then shared the heroin. The trio then shot up in the restroom of a nearby KFC restaurant. Werstler began to show signs of overdosing, and the Semler sisters "attempted to revive Werstler by splashing cold water on her, then left the bathroom and called their mother for a ride home. They did not call 911 or alert anyone to Werstler's condition."

Werstler was later discovered by a KFC employee, who called 911, but EMTs arrived too late to save her and she was pronounced dead. Her official cause of death was "adverse reaction to heroin."

Semler was then indicted by a federal grand jury in the Eastern District of Pennsylvania with "distribution of heroin resulting in death," punishable by a 20-year mandatory minimum prison sentence. As an added bonus, she was also charged with doing so within 1,000 feet of a school, as well as aiding and abetting on both counts. She was found guilty at trial and sentenced to 21 years in prison.

Semler appealed, arguing that friends sharing jointly procured drugs did not qualify as drug distribution and that the district court had erred in refusing to allow a jury instruction to that effect, as well as erring in failing to instruct the jury that there had to be a "proximate cause" for it to convict.

Scott Burris, JD, is a professor of both law and public health at Temple University and directs Temple's Center for Public Health Law Research. He is also Semler's appellate counsel and coauthor of an amicus curiae brief supporting Semler, which nicely laid out the issues at play.

"This case presents the Court with an opportunity to determine the proper scope of the Drug Distribution Resulting in Death (DDRD) sentencing enhancement provision," the abstract explains. "The provision, its parent statute, and the totality of modern federal law and policy to stem the overdose crisis are intended to target major drug traffickers. Research suggests that DDRD prosecutions routinely pervert this intent, indiscriminately deploying DDRD and similar provisions to target end consumers of illicit drugs affected by addiction. Rather than deterring drug trafficking, such prosecutions deter help-seeking during overdose events and interfere with overdose prevention measures. This cuts at cross purposes to overdose crisis response, leading to more, not fewer deaths."

The 3rd District Court of Appeals agreed, vacating Semler's conviction and sending her case back for retrial using proper legal instructions for jurors. "We hold that the definition of 'distribute' under the Controlled Substances Act does not cover individuals who jointly and simultaneously acquire the possession of a small amount of a controlled substance solely for their personal use," wrote Judge Jane Richard Roth.

It was a victory, if not a complete exoneration, for Emma Semler and any other drug user federal prosecutors in the 3rd Circuit might have been thinking about charging under that statute. Hopefully it also serves as a distant early warning signal for states that have passed drug induced homicide laws, as well as for state-level prosecutors, who are zealously embracing them to convict low-level drug users as murderers.

The Health in Justice Action Lab at Northeastern University School of Law reported that the number of states with such laws jumped from 15 to 25 in from 2009 to 2019, while the number of drug induced homicide prosecutions hovered at near zero from the 1970s until the early 2000s. Then, as overdose deaths jumped, so did prosecutions, rising to 100 per year by 2011 before skyrocketing to nearly 700 per year by 2018.

In a 2019 Utah Law Review article, Northeastern law professor and faculty director of the Health in Justice Action lab faculty adviser Leo Beletsky found while the laws are ostensibly aimed at drug dealers, "half of those charged with drug induced homicide were not, in fact, 'dealers' in the traditional sense, but friends and relatives of the deceased." He also found that in cases that involved a traditional "drug dealer," half of those prosecuted were black or brown people who sold drugs to whites -- a fact he noted does not fit the demographics of the United States or of drug dealers.

"In view of that context," he wrote, "these findings suggest that drug-induced homicide charges are being selectively and disproportionately deployed to target people of color. This disparate application can further reinforce already dire racial disparities, particularly in the enforcement of drug laws and the length of sentencing for drug-related crimes."

And, as the Drug Policy Alliance (DPA) pointed out in its 2017 report, An Overdose Death is Not a Murder: Why Drug Induced Homicide Laws Are Ineffective and Inhumane, those laws don't work to reduce overdoses: "Prosecutors and legislators who champion renewed drug induced homicide enforcement couch the use of this punitive measure, either naively or disingenuously, as necessary to curb increasing rates of drug overdose deaths. But there is not a shred of evidence that these laws are effective at reducing overdose fatalities. In fact, death tolls continue to climb across the country, even in the states and counties most aggressively prosecuting drug-induced homicide cases."

"The Semler case is one more example of how the Drug War has warped our legal system and led to mass incarceration," DPA senior staff attorney Grey Gardner told the Chronicle in an email exchange. "Prosecutors twisted the law to criminalize this young woman and subject her to a more than 20-year sentence after several friends bought drugs to use together and one suffered a tragic fatal overdose. Urging the jury to convict one of them of drug distribution when each of these users were suffering from substance use disorder and using together was not only overreaching, it highlights the arbitrary nature of our drug laws."

It is also counterproductive, he added: "This prosecution and those like it do nothing to make people safer, but instead put people in greater danger. By elevating the threat of prosecution, they make it less likely that people close to an overdose victim will call for help," he pointed out.

"Thankfully in this case the Court of Appeals rejected the prosecution's overbroad definition of distribution, but what's clear is that we need an entirely new approach," said DPA's Gardner. "Instead of the failed War on Drugs, we need to stop turning to the criminal legal system and spending billions on these ineffective policing strategies. Instead we need better approaches -- such as investments in drug checking, overdose prevention centers, and expanded access to naloxone -- to protect those who are experiencing addiction and are at the greatest risk."

"The court seemed sympathetic to the view that criminal law is not the best way to get at substance use disorder and the behavior of people coping with it," Burris told the Chronicle in an email exchange.

The appeals court labeled its decision as non-precedential, meaning it is not binding on federal district courts in its region, but it still may have a broader impact in the federal courts, Burris explained.

"I think her lawyers are going to ask the court to reconsider that," he said. "It is at least what we call 'persuasive authority' in that its reasoning may be adopted voluntarily by other courts."

As for impact on state and local prosecutions, not so much, he added.

"It has no impact other than as persuasive authority," Burris said. "The state attorney general and local district attorneys pursuing these cases seem to think they are sensible and just, and they are hard to shake," he confessed.

"The overdose crisis is just one symptom of the fundamental disease of inequality and inequity in our country," was Burris's bottom line. "Getting at that root cause requires a sea change in policy such that government at all levels -- and the people who elect the government -- commit to ensuring the basics of decent life to everyone: good work, good housing, good education, good transportation, and a place of respect in the community. In this the 'deaths of despair' idea seems to be to get the problem just right. Of course, short of that, there are many things to do: stop criminalizing drug use; create safe injection sites everywhere they are needed; eliminate regulations that make methadone and buprenorphine harder to get than the drugs whose use they are meant to reduce."

Biden's Drug Policy Priorities Are a Small Step in the Right Direction, But Old Attitudes Linger [FEATURE]

On April 1, the Biden administration gave us the first big hint of what its drug policy will look like as it released the congressionally-mandated Statement of Drug Policy Priorities for Year One. The result is a definite mixed bag: a heavy dose of drug prevention, treatment, and recovery, along with an acknowledgement of harm reduction and a nod in the direction of racially-sensitive criminal justice reform, but also a reflexive reliance on prohibitionist drug war policies both at home and abroad.

And nothing about the most widely used illicit drug by far: marijuana. The word "marijuana" appears not once in the heavily annotated 11-page document, and the word "cannabis" only once, in the title of an academic research paper about the onset of teen drug use in the footnotes. That's perhaps not so surprising, given that, in response to a reporter's question, Vice President Harris said last week the administration was too busy dealing with other crises to worry about making good its campaign pledges about marijuana reform.

What is on the administration's mind is "the overdose and addiction crisis." Citing ever-increasing drug overdose deaths, the statement says "addressing the overdose and addiction epidemic is an urgent priority for [the] administration." But the solution is not to imprison drug users, with the statement noting that "President Biden has also said that people should not be incarcerated for drug use but should be offered treatment instead." (Underlying that seemingly humane approach is the errant presumption that all or most drug users are addicts in need of treatment when, depending on the drug, only between one in five and one in 10 drug users fit that dependent or problematic drug user description.)

Here are the Biden administration's drug policy priorities, all of which are gone into in detail in the statement:

  • Expanding access to evidence-based treatment;
  • Advancing racial equity issues in our approach to drug policy;
  • Enhancing evidence-based harm reduction efforts;
  • Supporting evidence-based prevention efforts to reduce youth substance use;
  • Reducing the supply of illicit substances;
  • Advancing recovery-ready workplaces and expanding the addiction workforce; and
  • Expanding access to recovery support services.

Prioritizing treatment, prevention, and recovery is bound to be music to the ears of advocacy groups such as Faces and Voices in Recovery (FAVOR), whose own federal policy and advocacy priorities, while focusing on specific legislation, lean in the same direction. But the group also advocates for harm reduction practices the administration omits, particularly supervised consumption sites. FAVOR noted the administration's statement without comment.

As with the failure to even mention marijuana, the Biden administration's failure to include supervised consumption sites in its embrace of harm reduction -- it is wholeheartedly behind needle exchanges, for example -- is another indication that the administration is in no hurry no rush down a progressive drug reform path. And its prioritizing of supply reduction implies continued drug war in Latin America ("working with key partners like Mexico and Colombia") and at home, via support of High Intensity Drug Trafficking Areas (HIDTA) and "multi-jurisdictional task forces and other law enforcement efforts to disrupt and dismantle transnational drug trafficking and money laundering organizations." Prohibition is a hard drug to kick.

Still, naming advancing racial equity issues as a key priority is evidence that the Biden administration is serious about getting at some of the most perverse and corrosive outcomes of the war on drugs and is in line with its broader push for racial justice, as exemplified by Executive Order 13985, "Advancing Racial Equity and Support for Underserved Communities Through the Federal Government," issued on Biden's first day in office. And it is in this context that criminal justice system reform gets prioritized, although somewhat vaguely, with the promise of the creation of an "interagency working group to agree on specific policy priorities for criminal justice reform."

The Drug Policy Alliance (DPA) has some specific policy priorities for criminal justice reform, too, and they go far beyond where the administration is at. In its 2020 Roadmap for the incoming administration released in November, the group calls for federal marijuana legalization, drug decriminalization, and a slew of other criminal justice and policing reforms ranging from ending mandatory minimum sentencing and the deportation of non-citizens for drug possession to barring no-knock police raids, ending the transfer of military surplus equipment for counter-narcotics law enforcement, and dismantling the DEA. And the federal government should get out of the way of supervised consumption sites, or in DPA's politically attuned language "overdose prevention centers."

"We're glad the administration is taking important steps to address the overdose crisis -- by increasing access and funding to harm reduction services and reducing barriers to life-saving medications -- especially as people are dying at an alarming rate. We also appreciate their commitment to studying how to advance racial equity in our drug policies and best implement innovative practices on the ground. But it's clearly not enough. We need action," DPA Director of the Office of National Affairs Maritza Perez said in a statement responding to the administration's statement. "Black, Latinx and Indigenous people continue to lose their lives at the hands of law enforcement in the name of the drug war, and yet, the administration has chosen to prioritize increased funding for law enforcement. We need supervised consumption sites, not more money for police."

"And while we commend the Administration for taking steps to reduce employment discrimination, unless we address the biggest barrier for people trying to get a job -- past drug convictions and arrests -- we will still be left with significant inequities and racial disparities in the workplace," Perez continued. "It's time we get serious about saving lives and repairing the damage that has been caused by the drug war, particularly on Black, Latinx and Indigenous communities. We can start by passing federal marijuana reform and ending the criminalization of people for drugs in all forms."

Young drug reformers also had a few bones to pick with the administration's priorities. In their own statement in response to the administration, Students for Sensible Drug Policy applauded priorities such as more access to treatment and more research on racial equity, it complained that the administration priorities "fail to provide adequate support to Young People Who Use Drugs (YPWUD) in this country" -- especially those who use drugs non-problematically.

"There are no steps being taken to support YPWUD that do not want to and will not stop using drugs," SSDP said. "Young people have feared and faced the consequences of punitive drug policies and shouldered the burden of caring for their peers who use drugs for far too long. Young leaders calling for drug policy reform recognize that simply using drugs is not problematic and that we can support the safe and prosperous futures of People Who Use Drugs (PWUD) without forcing them to stop as a pre-condition for compassion, care, and opportunity."

Although only time will tell, for drug reformers, the Biden administration is looking like a step in the right direction, but only a step, and its policy prescriptions are limited by a vision of drug use rooted in the last century. Perhaps they can be pressured and prodded to plot a more progressive drug policy path.

Book Review: Drug Use for Grown-Ups

Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, by Carl Hart (2021, Penguin Press, 290 pp., $28.00 HB)

Dr. Carl Hart is a one-man drug and drug user destigmatization machine. In his new book, Drug Use for Grown-Ups, the Columbia University psychology professor blasts drug prohibition as both an affront to the American dream of the pursuit of happiness and as a tool of racial oppression. And he makes a strong, informed argument that recreational drug use can be, and usually is, a good thing.

You could hardly find someone more qualified to make the case. Hart has spent years in the trenches of neuropsychopharmacology research, handed out drugs (or placebos) to thousands of research subjects, published numerous scientific papers and popular articles in the field, and risen to the top of his profession along the way. And here is his bottom line:

"[O]ver my more than 25-year career, I have discovered that most drug-use scenarios cause little or no harm and that some responsible drug-scenarios are actually beneficial for human health and functioning. Even 'recreational' drugs can and do improve day-to-day living... From my own experience -- the combination of my scientific work and my personal drug use, I have learned that recreational drugs can be used safely to enhance many vital human activities."

Hart is refreshingly -- and deliberately -- open about his own recreational drug use. Given the stigmatization and persecution of people identified as "drug users," he feels that justice demands privileged partakers come out of the closet and give voice to their own, non-destructive drug use histories as a necessary remedy for that demonization. He certainly does so himself, revealing a disciplined yet curious mind most definitely not averse to sampling various substances.

Those substances include heroin, which he describes as his current favorite drug, one that he's been using episodically for years now: "There aren't many things in life that I enjoy more than a few lines by the fireplace at the end of the day... Heroin allows me to suspend the perpetual preparation for battle that goes on in my head... The world is alright with me. I'm good. I'm refreshed. I'm prepared to face another day, another faculty meeting, another obligatory function. All parties benefit."

But Hart is not quite so mellow when it comes to people and institutions he sees as helping to perpetuate overly negative depictions of various drugs or the persecution of drug users. He rips into Dr. Nora Volkow, head of the National Institutes on Drug Abuse (NIDA) over her "addiction is a brain disease" mantra and the rigid ideological control she has over research funding. He rips into journalists for uncritically and sensationally reporting salacious scientific findings about the evils of drugs that he argues are not supported by the evidence they are supposedly based on. He even calls Bernie Sanders "ignorant" (that word shows up more than a few times) for complaining that marijuana shouldn't be in the same drug schedule as "killer drugs like heroin."

Dr. Carl Hart (Columbia University)
Hart doesn't deny the potential dangers of drug use but makes the case that they are dramatically overstated. In that sense, Drug Use for Grown-Ups is a corrective to more than a century of anti-drug propaganda. In a deep dive into opioids, for instance, he notes that most opioid overdose deaths are actually opioid/benzodiazepines/alcohol deaths, and that a large number of them are due to ignorance (there's that word again) -- in that, in the black market that currently exists, drug users do not and cannot know what exactly is in that pill or powder they purchased.

As long as we are in a prohibition regime, the least we can do is widespread drug testing for quality control, as is done at some European music festivals, Hart argues. But that's the only kind of drug testing he's down with; he calls the urine drug testing industry "parasitic," a sobriquet he also applies to the drug treatment industry.

But hang on, he's not done yet. Although he is an advocate for harm reduction practices, he has a bone to pick with the term itself: It's too damned negative! Drug use doesn't typically involve harm, he argues, but pleasure-seeking. As I pondered this, I came up with "benefit enhancement" as an upbeat alternative to harm reduction, but Hart went with "health and happiness."

And he's got a bone to pick with "psychedelic exceptionalism," the notion, dear to folks like Decriminalize Nature, that psychedelics, or better yet, "plant entheogens," are somehow "better" than dirty old drugs like meth or heroin and thus deserve to be treated differently, more gently. He also snarks at the notion that taking drugs for spiritual or religious purposes is of a higher order than taking them for fun and rebels at the notion of having a shaman or guide during a tripping session: "Some people find this comforting. I find it creepy and have never done so myself."

Drug Use for Grown-Ups is bracing, informative, and provocative contribution to the literature. Even the most ardent drug reformers and defenders would benefit from reading it and reexamining their own assumptions. Maybe Carl Hart is onto something.

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