Current Drug Use Trends

Kevin A. Sabet, Ph.D.

Co-Founder, Project SAM (Smart Approaches to Marijuana)Asst. Professor, UF College of Medicine

www.kevinsabet.comwww.learnaboutsam.org

Overview

• Prescription Drug Abuse• Synthetics• Other Drugs

• (Cocaine, Heroin, Methamphetamine)

• Marijuana

Prescription Drug Abuse

1. Depressants: central nervous system include sedatives (calm and drowsy) and tranquilizers (reduce tension or anxiety). Ex. Zyperxa, Seroquel, Haldol

2. Opioids and Morphine Derivatives: Painkillers. Ex. Codeine, Hydrocodone, Oxycodone, Fentanyl

3. Stimulants: Increase energy, alertness but also blood pressure and heart rate. ADD/ADHD Ex. Ritalin, Concerta, Dexedrine, Adderall

4. Antidepressants: Psychiatric drugs supposed to handle depression.

Ex. Prozac, Celexa, Zoloft, Paxil

Commonly Abused Prescription Drugs

Youth: Prescription Drugs (RX)

• Every day in the US, 2,500 youth (12-17) abuse a prescription pain relievers for the first time.– The average age for first time users is now 13 to 14. – 8% of American 12th graders used narcotics in the past 12

months (MTF, 2012).

• A 2012 study in the US found that 1.7% of 12 and 13-year olds and 2.5% of 14 and 15-year olds had abused a prescription drug in the past month (NSDUH, 2013).

• Almost 50% of teens believe that prescription drugs are much safer than illegal street drugs.

Youth: Prescription Drugs (RX)

• 2.5 million teenagers (12 to 17) in the US have used prescription drugs in their lifetime (NSDUH, 2013).

– Over 2 million used pain killers such as OxyContin

– Nearly half a million used stimulants such as methamphetamine.

• According to the National Center on Addiction and Substance Abuse at Columbia university, teens who abuse prescription drugs are 2x as likely to use alcohol, 5x more likely to use marijuana, and 12-20x more likely to use illegal streets drugs such as heroin, ecstasy, and cocaine.

Prescription Drug Abuse (Rx)

• Of the 1.4 million drug-related emergency room admissions, 598, 542 were associated with abuse of prescription drugs

• Prescription drug abuse causes the largest percentage of deaths from drug overdosing. Of the 22, 400 drug overdose deaths, opioid painkillers were the most commonly found drug, accounting for 38.2% of these deaths.

Prescriptions Dispensed for Select Opioids in U.S. Outpatient Retail Pharmacies, 2000-2009

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

140,000,000

Hydrocodone Oxyocodne methadone buprenorphine tramadol

Num

ber o

f Pre

scrip

tions

Source: SDI, Vector One: National. Extracted June 2010.

Sources of Nonmedical Prescription Drugs1

9

1 2010; Most recent nonmedical pain reliever use among past year users ≥12 years.2 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s

Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

Bought/Took from Friend/Relative16.2%

Drug Dealer/Stranger 4.4%

Bought on Internet0.4% Other 2

4.9%

Free from Friend/Relative7.3%

Bought/Took fromFriend/Relative4.9%

OneDoctor79.4%

Drug Dealer/Stranger2.3%

Other 2

2.2%

Source Where Respondent Obtained:

Source Where Friend/Relative Obtained:

One Doctor17.3%

More than One Doctor1.6%

Free from Friend/Relative55.0%

More than One Doctor3.3%

SAMHSA 2010, 2011

Emergency Department Visits

Persons Classified with Substance Abuse/Dependence on Psychotherapeutics

Results from the 2009-2013 National Surveys on Drug Use and Health (NSDUH)

NSDUH

12

Percent Increase in Admissions for Specific Opioid Analgesics1:2000-2006

1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone. Analysis restricted to 13 States that reported detailed drug codes for 2000 and 2006.

13

% Increase in Admissions for Heroin and Opioid Analgesics1: 2001-2011

1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone.

Total visits Heroin Opioid Analgesics0%

50%

100%

150%

200%

250%

300%

350%

400%

450%

47.66%

0.33%

406.92%

N-SSATS, 2011: TEDS 2001-2011

14

Treatment Admissions Involving Opioid Analgesics1

1 Includes admissions where primary, secondary, or tertiary substance was reported as Other opiates/synthetics. Excludes admissions for non-prescription use of methadone.

SAMHSA 2007

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011300

320

340

360

380

400

420

440

460

480

Nu

mber

of

adm

issi

on

s x1

000

N-SSATS, 2011: TEDS 2001-2011

Drug-Induced Deaths vs. Other Injury Deaths, 1999–2009*

Source: National Center for Health Statistics, Centers for Disease Control and Prevention. National Vital Statistics Reports Deaths: Final Data for the years 1999 to 2007 (2001 to 2009); Deaths: Preliminary Data for the years 2008 and 2009 (2010 and 2011).

*Data for 2008 and 2009 are provisional and subject to change. Causes of death attributable to drugs include accidental or intentional poisonings by drugs and deaths from medical conditions resulting from chronic drug use. Drug-induced causes exclude accidents, homicides, and other causes indirectly related to drug use. Not all injury cause categories are mutually exclusive.

9/2011

0

1

2

3

4

5

6

7

8

9

10

'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06

De

ath

rate

pe

r 1

00

,00

0

HeroinCocaine

27,658 unintentional drug overdose deaths

Unintentional Drug Overdose DeathsUnited States, 1970–2007

National Vital Statistics System, http://wonder.cdc.gov

Year

Rx Drugs

Public Health Impact of Opioid Analgesic Use

Mortality figure is for unintentional overdose deaths due to opioid analgesics in 2007, from CDCTreatment admissions are for with a primary cause of synthetic opioid abuse in 2007, from TEDSEmergency department (ED) visits related to opioid analgesics in 2007, from DAWNAbuse/dependence and nonmedical use of pain relievers in the past month are from the 2008 National Survey on Drug Use and Health

Nonmedical users

People with abuse/dependence

ED visits for misuse or abuse

Abuse treatment admissions

450

148

29

7

For every 1 overdose death in 2007, there were…

Economic Costs

• Illicit drug use in the United States is estimated to have cost the U.S. economy more than $193 billion in 20071

• $55.7 billion in costs for prescription drug abuse in 20072

– $24.7 billion in direct healthcare costs

• Opioid abusers generate, on average, annual direct health care costs 8.7 times higher than nonabusers3

1. National Drug Intelligence Center. The Economic Impact of Illicit Drug Use on American Society. 2010. http://www.justice.gov/ndic/pubs44/44731/44731p.pdf 2. Birnbaum HG, White, AG, Schiller M, Waldman T, et al. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. Pain Medicine.

2011;12:657-667. 3. White AG, Birnbaum, HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United States. J Manag Care Pharm. 11(6):469-479. 2005

Prescription Drug Abuse Prevention Plan

• Coordinated effort across the Federal government

• 4 focus areas– Education– Prescription Drug

Monitoring Programs– Proper Medication

Disposal– Enforcement

Education

• Education Goals for youth, parents, and patients

• Increase awareness about prescription drug abuse• Patients and parents understand how to use

medications safely, and how to store and dispose them properly

• Main Actions• Evidence-based public education campaign

partnering with local anti-drug coalitions, and other organizations (chain pharmacies, community pharmacies, boards of pharmacies, boards of medicine)

Education Gaps

• Physicians:• 2000 survey: 56 % of residency programs required

substance use disorder training, median number of curricular hours ranged from 3 to 12 hours1

• 2008 follow-up: “Although the education of physicians on substance use disorders has gained increased attention, and progress has been made to improve medical school, residency, and postresidency substance abuse education since 2000, these efforts have not been uniformly applied.”2

1. Isaacson JH, Fleming M, Kraus M, Kahn R, Mundt M. A National Survey of Training in Substance Use Disorders in Residency Programs. J Stud Alcohol. 61(6):912-915. 2000. 2. Polydorou S, Gunderson EW, Levin FR. Training Physicians to Treat Substance Use Disorders. Curr Psychiatry Rep. 10(5):399-404. 2008.3. Lafferty L. Hunter TS, Marsh WA. Knowledge, attitudes and practices of pharmacists concerning prescription drug abuse. J Psychoactive Drugs. 2006 Sep:38(3):229-232.

Education Gaps• Pharmacists

• 67.5% report receiving two hours or less of addiction or substance abuse education in pharmacy school

• 29.2% reported receiving no addiction education

Pharmacists with greater amounts of addiction-specific education:

• Higher likelihood of correctly answering questions relating to the science of addiction and substance abuse counseling

• Counseled patients more frequently and felt more confident about counseling

Prescription Drug Monitoring Programs

http://www.pmpalliance.org/pdf/pmpstatusmap2010.pdf

Prescription Drug Monitoring Programs

• Develop and implement “interoperability” system (PMIX, NABP, others)

• Link PDMP with State Health Information Exchanges (HIE)

• Liberate PDMP data to healthcare providers as part of provider “work flow” operation

• Ensure Emergency Departments have “real-time” access to RX data

Proper Medication Disposal

• Goals: • Easily accessible, environmentally friendly method of drug

disposal that reduces the amount of prescription drugs available for diversion and abuse

• Main Actions• Publish and implement regulations allowing patients and caregivers

to easily dispose of controlled substance medications

• DEA will continue holding a take-back day at least every 6 months until a Final Rule is implemented

• Once regulations are in place, partner with stakeholders to promote proper medication disposal programs

Pharmacy Based Programs

• Completes the drug distribution loop– Patient/pharmacist relationship already exists

• Potential for clinical intervention– Reasons for unused medication - adverse events, ineffective, cost, etc. – Stronger patient/pharmacist/prescriber relationship– Improved health outcomes

• Reverse distribution and disposal mechanisms already in place

• Security and diversion safe guards already in place for current drug inventory

• Pharmacy based programs have been effectively operating in other countries and in the U.S.

Enforcement

• Goals:• Assist states in addressing “pill mills” and doctor

shopping

• Main Actions• Provide technical assistance to states on model

regulations/laws for pain clinics

• Encourage High-Intensity Drug Trafficking Areas (HIDTAs) to work on prescription drug abuse issues

• Support prescription drug abuse-related training programs for law enforcement

Conclusions

• This is a critical time for the “marriage” merging of Public Health and Public Safety Strategies…

• Striking the right balance of strategies will ensure the critical availability of these medications while preventing/reduce diversion and abuse .

What Can The Rx Problem Teach Us About

Illicit Drug Use?

• Rx Drugs Are “Highly” Controlled

• Available and Abused at Extremely High Rates

• Medical Properties

• Cause Billions in Societal Costs

First Choice Drugs:Youth(Grades 8, 10, 12 Combined)

Substance Past Month Use Past Year Alcohol 25.5% 45.3%

Cigarettes 18.2% 23.7%

Marijuana 15.2% 25%

Monitoring the Future: Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor: Institute for Social Research, The University of Michigan.

Alcohol• Alcoholic beverages have been and are the

most widely used psychoactive substances by American young people.

• Binge drinking (5 > drinks in a row during the prior two-week interval at least once) is probably of greatest concern from a public health perspective.

• In 2011, all measures of alcohol use—lifetime, annual, 30-day, and binge drinking in the prior two weeks—reached historic lows.

Alcohol Trends

• In 2011, all measures of alcohol use—lifetime, annual, 30-day, and binge drinking in the prior two weeks—reached historic lows.

• In 2011, 40% of 12th graders and 27% of 10th graders reported drinking alcohol in the past month.

• Since 2003, perceived risk as well as disapproval of weekend binge drinking has risen in all grades including in 2011.– Accredited to public service advertising campaigns.

Tobacco

• In 2011, 18.7% of 12th graders and 11.8% of 10th graders reported using cigarettes in the past month.

• Perception: 77% of 12th graders perceive smoking one or more packs of cigarettes a day as harmful.

• For all three grades, the 2011 levels of perceived risk are the highest ever observed.

Synthetic Marijuana (K2, Spice)

• Synthetic marijuana is a new and major concern – it refers to herbal mixtures laced with synthetic cannabinoids, chemicals that act in the brain similarly to THC, the primary psychoactive active ingredient in marijuana.

• These mixtures can be obtained legally as “herbal incense” and are perceived as a safe alternative to marijuana.

• Marketed as a “legal” high.

Synthetic Marijuana • Synthetic marijuana (K2, Spice) was added to

Monitoring the Future, University of Michigan study in 2o11.

• In that year, 11.4% of 12th graders or 1 in 9 reported using the substance in the past year.

• According to data from the American Association of Poison Control Centers, 2,915 calls were received related to synthetic marijuana in 2010, and 5,471 calls were received in 2011.

Synthetic Marijuana• Health warnings have been issued in

numerous State and local health departments describing the adverse health affects associated with its use.

• Hallucinations, Withdrawal, Anxiety, Nausea

• The DEA and state drug control agencies have recognized the need to monitor and, when necessary, control these substances. In March 2011, five synthetic cannabinoids were categorized as Schedule 1 substances.

Cocaine

• According to the 2013 National Survey on Drug Use and Health, the estimated percentage of persons 12 or older who use cocaine in the past month was 0.6%, which were similar to the 2011 and 2008 rates.

• Over the last decade, annual prevalence among 12th graders has been declining and stands at a historical low in 2012 at 2.7%

Heroin• According to the 2013 National Survey on Drug

Use and Health, the number of current (past month) heroin users 12 or older increased from 281,000 in 2011 to 335,000 in 2012.

• In 2012, there were 156,000 persons aged 12 or older who used heroin for the first time within the past year.

• The annual prevalence of heroin users among 12th graders have fluctuated between 0.7% and 0.9% from 2005 through 2011. Use has declined in the past two years.

Methamphetamine• According to the 2013 National Survey on Drug Use

and Health, the number of past-month methamphetamine users aged 12 or older decreased by over 20% between 2010 and 2012 (and even more since 2008).

• 530,000 – 2010• 439,000 – 2011• 440,000 – 2012

• From 2002 to 2008, past-month use of methamphetamine declined significantly among youth aged 12-17, from 0.3 percent to 0.1 percent, and young adults 18-25 also reported a decline from 0.6 percent to 0.2 percent in 2008.

Past Year Methamphetamine Initiates among Persons Aged 12 or Older and Mean Age at First Use of Methamphetamine among Past Year Methamphetamine Initiates Aged 12 to 49: 2002-2012

Marijuana

Marijuana

• The number and percentage of persons aged 12 or older who were current marijuana users in 2012 were 18.9 million or 7.3% - similar to 2010 and 2011 rates, but higher than those in 2002 through 2009.

• After a decline in marijuana use among 12th graders

from 2006-08, an upturn occurred until 2011.

• In 2012, 22.9% of 12th graders used marijuana in the past month – an increase from 18.8% in 2007.– Only 22% of 12th graders perceive smoking marijuana

occasionally as harmful.

19911993

19951997

19992001

20032005

20072009

20110

5

10

15

20

25

30

8th graders10th graders12th graders

Perc

ent r

epor

ting

past

mon

th u

se

Trends in current use of any illicit drugs – Past 30 days

47

What drugs do we use?

0%

10%

20%

30%

40%

50%

60%

52.10%

26.70%

7.30%

Current use among persons 12 and older: 2012

NSDUH, 2013

TobaccoAlcohol Marijuana

48

Myth 1:

Marijuana Is

Harmless and

Non-addictive

49

1 in 6 teens become addicted

• The adolescent brain is especially susceptible to marijuana use.

• When kids use, they have a greater chance of addiction since their brains are being primed.

Wagner, F.A. & Anthony, J.C. , 2002; Giedd. J. N., 2004

1 in 10 adults and 1 in 6 adolescents who try marijuana will become

addicted to it.

50

Addictive Nature of Drugs When Different Drug Use

Starts in Adolescence

Tobacco

24%

15%

8% 9%

Alcohol Marijuana Cocaine Stimulant Analgesics Psychedelics

Source: Anthony JC, Warner LA, Kessler RC (1994): Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology 2: 244 - 268

Heroin

25%

20%17%

14%

Primary Substance: Admissions (Aged 12 -17) 1993 (Orange) and 2008(Purple)

Ad

mis

sion

Nu

mb

ers

in

T

hou

san

ds

Substance(s)

Marijuana Alcohol Stimulants

Opiates Cocaine

Other Drugs

52

Dependence on orAbuse of Specific

IllicitDrugs

Persons 12 or Older, 2008

Substance Abuse and Mental Health Services Administration. (2009). O$ ce of Applied Studies. Treatment Episode Data Set (TEDS): 2009 Discharges from Substance Abuse Treatment Services, DASIS.

1,411Cocaine

4,199

Marijuana 1,716Pain

Relievers

126Sedatives

175Inhalants

282Heroin

351Stimulants 358

Hallucinogens

451Tranquilizer

s

53

Today’s marijuana is not the marijuana of the 1960s.

• In the past 15 years, marijuana potency has tripled and since 1960 it grown 5 times stronger.

Increased Potency

54

1960

1965

1970

1974

1975

1978

1980

1983

1984

1985

1986

1992

1993

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

THC

0.2 0.24

0.39

0.47

1 1 1.5 3.3 3.3 3.5 3.5 3.1 3.1 4 4.54

5.16

4.96

4.67

5.4 6.18

7.26

7.18

8.33

8.09

9.08

10.27

10.25

9.91

10.96

11.42

CBD

NaN

NaN

NaN

NaN

NaN

NaN

NaN

NaN

0.28

0.31

0.38

0.36

0.33

0.31

0.42

0.4 0.41

0.43

0.45

0.47

0.42

0.46

0.46

0.46

0.53

0.48

0.41

NaN

NaN

NaN

1

3

5

7

9

11

13

MAR

IJUAN

A PO

TEN

CY CBD:NON-

Psychoactive Ingredient

Average THC and CBD Levels in the US: 1960

- 2011

Mehmedic et al., 2010

THC:Psychoactive Ingredient

55

Cannabis-related emergency hospital admission rates have been

rising sharply in the US

• From an estimated 16,251 in 1991 to over 374,000 in 2008

ER admission rates rising

SAMHSA, 2011

56

Harmful effects on the brain

Marijuana use directly affects the brain• It affects parts of the brain responsible for:

• memory, • learning attention, • and reaction time.

• These affects can last up to 28 days after abstinence from the drug

Giedd. J.N., 2004

57

• Increased risk of mental illness

• Schizophrenia (6 fold)• Psychosis• Depression• Anxiety

Harmful effects on mental health

Andréasson S, Allebeck P, Engström A, Rydberg U. , 1987; Arseneault, L., 2002

58

Research shows that marijuana smoke is an irritant to the lungs.

• Results in greater prevalence of:• bronchitis, • cough, • and phlegm production.

Harmful effects on the lungs

Tetrault, J.M, 2007

59

• It contains 50-70 percent more carcinogenic hydrocarbons than tobacco smoke.

• Evidence linking marijuana and cancer is mixed. However, marijuana smoke contains an enzyme that converts hydrocarbons into a cancer-causing form.

• Evidence on cancer is mixed.

Marijuana smoke is carcinogenic.

Hoffman, D., et al., 1975; Brambilla, C., & Colonna, M., 2008; Bello, D., 2006; Tashkin, D. P., 1999

60

• Persistent and heavy use among adolescents reduces IQ by 6-8 points

• Dunedin study; vigorously defended • According to a government survey, youth

with poor academic results are more than four times likely to have used marijuana in the past year than youth with an average of higher grades.

Marijuana use has significant effects on IQ and learning

Meier, M.H., et al., 2012; MacLeod, J., et al., 2004.

61

• Linked with:• dropping out of school, • unemployment, • social welfare dependence,• and lower self-reported quality of life

Marijuana use is linked to low productivity and job performance

Fergusson, D. M. and Boden, J.M., 2008

62

• Employee marijuana use is linked with increased:• absences, • tardiness,• accidents,• worker’s compensation claims,• and job turnover

Marijuana use is linked to low productivity and job performance

NIDA, 2011

63

Increased use can lead to increased drugged driving

• “Drivers who test positive for marijuana or self-report using marijuana are more than twice as likely as other drivers to be involved in motor vehicle crashes.”

Mu-Chen Li, J.E., et al., 2011

64

Myth 2:

Smoked/Eaten

Marijuana is

Medicine

65

Marijuana has medical properties, BUT we don’t need to smoke or eat it!We don’t smoke opium to derive the benefits of morphine.So we don’t need to smoke marijuana to receive it’s potential benefits.

• A distinction must be made between raw, crude marijuana and marijuana’s components

Is marijuana medicine?

66

Is marijuana medicine?

No: smoked or inhaled raw marijuana is not medicine

Yes: there are marijuana-based pills available and other medications coming

soon

Maybe: research is ongoing

Kevin A. Sabet, Ph.D., www.kevinsabet.com

Marijuana is NOT approved as medicine by:

• The FDA• The American Medical Association• The National Multiple Sclerosis Society• The American Psychiatric Association• The American Glaucoma Society• The American Academy of Ophthalmology

• The American Cancer Society• The American Academy of Pediatrics

68

Studies show that components or constituents within marijuana

have medical value.• For instance, dronabinol (also known as

Marinol®) contains lab-made THC and is widely available at pharmacies as capsules to treat nausea/vomiting from cancer chemotherapy

Marijuana has medicinal properties

69

Marijuana-based medicines are being scientifically developed.

• However this process needs improvement• Research must be done on marijuana’s

components, not the raw, crude plant

Marijuana-based medicines

70

• Sativex® is in the process of being studied in the USA.

• THC:CBD = 1:1• It is administered via an

oral mouth spray• Already approved in

Canada and Europe

Marijuana-based medicines

72

• 87.9% had tried marijuana before age 19

• 75% of Caucasian patients had used cocaine and 50% had used methamphetamine in their lifetime.

Average medical marijuana patients

O’Connell, T.J. & Bou-Matar, C.B., 2007

Profile: 32-year old white male history of alcohol and substance abuse no history of life-threatening illnesses

73

• In Colorado, 2% reported cancer, less than 1% reported HIV/AIDS, and 1% reported glaucoma as their reason for using medical marijuana.

• In Oregon, these numbers are less than 4%, less than 2%, and 1%, respectively.

Only a small proportion of medical marijuana users report any serious

illness

Colorado Department of Public Health and Environment, 2011; Oregon Public Health Authority, 2011

74

Majority of medical marijuana users report using marijuana to treat

‘chronic or severe pain’• 96% in Colorado• 91% in Oregon• 93% in Montana

Chronic pain

Colorado Department of Public Health and Environment, 2011; Oregon Public Health Authority, 2011; Montana Department of Public Health and Human Services, 2011

75

“We will use [medical marijuana] as a red-herring to give marijuana a good

name.” —Keith Stroup, head of NORML to the Emory Wheel, 1979

• Advocates have pushed their agenda through “medicine by popular vote” rather than the rigorous scientific testing system devised by the FDA.

Legalization behind the smokescreen

Emory Wheel Entertainment Staff, 6 February 1979

76

After the Compassionate Use Act passed in California in 1996, Allen St. Pierre, the

director of NORML admitted in a TV interview that

“in California, marijuana has also been de facto legalized under the

guise of medical marijuana”

Behind the smokescreen

CNN Newsroom 9 May 2009

77

Residents of states with medical marijuana laws have abuse/dependence rates almost twice as high as states with no such laws.

Pacula et al (RAND) found that two characteristics of medical marijuana states

– (1) Dispensaries and (2) Home Cultivation – were positively associated

with marijuana use

Medical marijuana has led to increased use

Cerda, M., et al., 2012; Wall, M., et al., 2011; Pacula et al. 2013.

• Dispensaries – Are these serving the sick and dying??

79

Bypassing the FDA Process

Before FDA approves a drug as medicine, testing is done to:

Determine the benefits and

risks of the drug

Determine how it may interact

with other drugs

Assure standardization

of the drug

Determine the

appropriate dosage levels

Identify and

monitor side effects

Identify safe drug

administration

Marijuana-Based Medications

• NIH is responsible for research into marijuana-derived medications.

• 288 NIH-supported projects on cannabinoids.

• Scheduling less relevant– Cocaine is Schedule II, no “Dispensaries”

allowed– But it Would Be A Symbolic Victory for

Advocates– Need an individual FDA-approved product

for medical use

A Compassionate Access Proposal

• Before marijuana-based medications become more widely available, offer non-smoked marijuana components, regulated in strength, purity, and composition, to:

• Cancer patients

• Terminally ill

• Those with MS, ALS, and AIDS whose bona fide physicians have recommended marijuana because other medications have not worked

Bottom Line

We don’t smoke opium to get the effects of morphine.

So why would we smoke marijuana to get its potential

medical effects?

83

Myth 3:

Countless People Are Behind Bars

for Smoking Marijuana

84

0%

2%

4%

6%6.00%

1.40%0.40% 0.30% 0.10%

Drug Possession Of-fenders in State PrisonsPercent of State Prison-

ers, 2004

Offense

Bureau of Justice Statistics, 2004

85

• Only 0.4% of prisoners with no prior offenses are in prison for marijuana possession

• 99.8% of Federal prisoners sentenced for drug offenses were incarcerated for drug trafficking

• The risk of arrest for each join smoked is 1 for every 12,000 joints

Countless people are NOT behind bars for smoking marijuana

Bureau of Justice Statistics, 2004 and 2012; Kilmer, B., et al., 2010

86

Num

ber o

f Sen

tenc

ed P

rison

ers

38,900148,600

224,900 263,800 251,400

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Estimated Number of Sentenced Prisoners and Drug Offenders Under State Jurisdiction, 1985 to 2009

Source: Bureau of Justice Statistics, Prisoners in 2009 (December 2010); Prisoners in 1996 (June 1997).

6/2011

All Offenses

Drug Offenses

87Bureau of Justice Statistics, 2010

18%

82%

99.80%

0.20%

Among sentenced prisoners under state jurisdiction in 2008, 18% were

sentenced for drug offenses.

Of those 18%, 99.8% were sentenced for drug

trafficking

Only 0.2% are for drug possession

88

Myth 4:

The Legality of Alcohol and

Tobacco Strengthen the Case for Marijuana

Legalization

Alcohol and Tobacco: A Model?

• Use levels for alcohol and tobacco are much higher than marijuana

• Industries promote addiction and target kids

89

Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat 10(256). 2012.

Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010. Morbidity and Mortality Weekly Report 2011;60(33):1207–12

90

Alcohol and tobacco use among teens

• 50% and 44% of youth report that they can obtain alcohol and cigarettes, respectively, within a day.

• Youth are least likely to report that they can get marijuana within a day (31%); 45% report that they would be unable to get marijuana at all

The National Center on Addiction and Substance Abuse at ColumbiaUniversity (CASA), 2012

91

What incentives do legal corporations have to keep price

low and consumption high?

• “Enjoy Responsibly”

• Taxes today for alcohol are 1/5 of what they were during the Korean War (adjusted for inflation)

Cook, P. J. (2007). Paying the tab: The economics of alcohol policy. Princeton, NJ: Princeton University Press.

92

Will legalization diminish the power of cartels and the black

market?

• Marijuana accounts for 15-25% of revenues gained from drug trafficking groups

• More money is found in human trafficking, kidnapping, and other illicit drugs

Kilmer, B., et al., 2010

93

Will legalization diminish the power of cartels and the black

market?• In a legal market, where drugs are taxed and

regulated (for instance to keep THC potency below a certain level or to prevent sale to minors), the black market has every incentive to remain

• Legalizing marijuana would not deter these groups from continuing to operate

Kilmer, B., et al., 2010

94

Can we trust companies and Big Corporations not to target youth and the

vulnerable?

‘Big marijuana’

95

96

The “Yale MBAs Are Here”

Steve DeAngelo Troy Dayton

97

ArcViewwith investors at the

Washington Athletic Club

“Business is driving the change. Business is the most powerful

platform for political change that’s existed, when there is money for government, money for investors,

money for entrepreneurs, and benefits to communities, that’s a powerful incentive for change”

ArcView Co-Founder Troy Dayton

99

“The use of marijuana ... has important implications for the tobacco industry in terms of an alternative product line. [We] have the land to grow it, the machines to roll it and package it, the distribution to market it. In fact, some firms have registered trademarks, which are taken directly from marijuana street jargon. These trade names are used currently on little-known legal products, but could be switched if and when marijuana is legalized. Estimates indicate that the market in legalized marijuana might be as high as $10 billion annually.” From a report commissioned by cigarette manufacturer Brown and Williamson (now merged with R.J. Reynolds) in the 1970s.

‘Big marijuana’

100R.J.Reynolds, 1984 est.: http://legacy.library.ucsf.edu/tid/eyn18c00

101Tobacco Institute, 1989: http://legacy.library.ucsf.edu/tid/pvt37b00

102

Brown and Williamson, 1972: http://legacy.library.ucsf.edu/tid/wwq54a99

103

‘The 2nd Annual National Marijuana Business Conference And Expo’ – Nov.

6-8, 2013 in Seattle• Expecting nearly 600 people including:

• Dispensary owners and license holders• Professional cultivators• Edibles and infused product makers• Ancillary goods and services firms, from

attorneys to security technology• Investors and angel investing group leaders

• Conference registration costs $600

‘Big marijuana’

104

Will Big Marijuana become the new Big

Tobacco?

105

Several vending machines and billboards have already emerged

throughout the country

106

A variety of medical marijuana products and ‘edibles’ can be found at

dispensaries:

• Brownies, cake, cookies, peanut butter, granola bars, ice cream

• Many such as ‘Ring Pots’ and ‘Pot Tarts’ are marketed with cartoons and characters appealing to children:

107

Alcohol and Tobacco

legalization teach us there is no

money in this for anyone other than

Big Marijuana

108

Myth 5:

Legal Marijuana Will Solve the Government’s

Budgetary Problems

109

Will legalization solve budgetary problems?

• Few people are currently in jail for smoking marijuana

• Arrests and regulatory costs will increase with legal marijuana

110

2.7 million

Arrests for alcohol-related crimes in 2008

847,000Marijuana-related

arrests in 2008

(Does NOT include violence;Includes violations of liquor laws

anddriving under the influence)

“If Only We Treated It Like Alcohol…”

111

Alcohol & Tobacco:Money Makers or Dollar Drainers?

• For every $1 gained from alcohol and tobacco tax revenues, $10 is lost in legal, health, social, and regulatory costs

$$$$$$$$$$$

Urban Institute and Brookings Institute, 2012; Tax Policy Center, 2008

112

Alcohol & Tobacco:Money Makers or Dollar

Drainers?

Alcohol Costs

T obacco Costs

$14 billion

Costs

Revenues

$25 billion

$200billion$185

billion

Revenues

State estimates found at http://www.nytimes.com/2008/08/31/weekinreview/31saul.html?em; Federal estimates found at https://www.policyarchive.org/bitstream/handle/10207/3314/RS20343_20020110.pdf; Also see http://www.tobaccofreekids.org/research/factsheets/pdf/0072.pdf; Campaign for Tobacco Free Kids, see “Smoking-caused costs,” on p.2.

There are 8x as many alcohol outlets in

poorer, communities of color than in upper-class

white communities.

New Message

A new Big Marijuana industry will target the most vulnerable, just like Big

Tobacco and the Liquor Lobby have.

We don’t need more arrests in these communities, BUT we also don’t need

more drugs -- we need job opportunities, health screening, and proper education – all things that are

compromised when more people smoke marijuana.

115

Myth 6:

Portugal and Holland Provide

Successful Examples of Legalization

116

Neither Holland nor Portugal have legalized

ANY drug

117

In 2001, Portugal changed policy to send users with small amounts of drugs to

“dissuasion panels” – social worker panels who refer individuals to treatment,

administer fine, etc.

Portugal also implemented robust treatment plan

Portuguese policy

118

• Youth use has increased since 2001 • Deaths have gone down • The impact of is policy unclear, despite

extreme rhetoric

Results are mixed

119

The Dutch established the Non-enforcement Policy in 1976 and saw the birth of “Coffee Shops”

Dutch policy

120

• Experienced a three-fold increase in marijuana use among young adults

• Before Non-Enforcement, the Dutch always had lower rates of drug use than the US.• Holland is now #1 country in Europe with marijuana

treatment need

• Scaling back policy• Coffee Shops Closing• Cannot sell to non-residents

Results

What about Jolly Ole’ England?

122

Myth 7:

Prevention, Intervention, and

Treatment are Doomed to Fail – So

Why Try?

123

Policy Implications

The groups pushing for marijuana legalization

have found a way to make their issue resonate with

everyday people.

124

They have reframed the issue so it is about:

• Voting for compassion for the sick and dying

• Reducing our prison population

• Stimulating the economy125

Advocates have organized across US states and around the world

to push their initiatives.

126

They have major donors who fund their work and

messages.

127

Spent over $250 Million on Legalization

The National Organization for the Reform of Marijuana Laws estimates that Peter Lewis has spent between $40 million and $60 million funding legalization of marijuana campaigns since the 1980s.

John SperlingOver $50 Million

They’ve secured legislative champions at all levels – local, state, federal, international.

131

They’ve gotten the attention of editorial boards and media –

including print, television and social media.

132

Case of Sanjay Gupta: “Gupta Changes His Mind

On Weed”

133

They’ve mobilized major grassroots and student

supporters.

134

They are present and active in every single

academic, think-tank, UN, and other international and domestic discussion

on drug policy.

135

Most of all: They have captured the “sensible” ground, boxing us in as

extremists, old fashioned, and moralistic.

136

What has been the result of their framing of this

issue?

137

138Sources: Gallup http://bit.ly/olrSEQ and GSS

Support for Marijuana Legalization in the United States Has Reached

Unprecedented Levels

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Do not support legalization Support Legalization

139

National Policy

After 50 years of a movement to legalize marijuana, 2 states have now done it – Colorado and Washington

Marijuana Still Illegal Under Federal Law and Laws of 48 states

140

DOJ Guidance from Holder

Holder did not endorse legalization

He said that the government would defer its right to challenge states in court “right now”

141

DOJ Guidance from Holder

He laid out major areas of importance, including:

- youth use increases- drugged driving/health

consequences - advertising for youth

142

But has this already

happened?

143

• Passed medical marijuana in 2001• But no dispensaries until the mid-

2000s

• Between 2006 and 2012, medical marijuana cardholders rose from 1,000 to over 108,000

• The number of dispensaries rose from 0 to 532

Colorado post-2009

144

Marijuana use among Colorado teens is currently:

• Fifth highest in the nation• 50% above national average

Increased teen use

NSDUH, 2013

10.7%

7.6%

Colorado

National average

145

Average 5.6% of students per year between 2007 and 2009

Distribution to minors

Rocky Mountain HIDTA, 20132007-2009 2010-2012

Chart TitleDrug-related referrals for high school students testing positive for marijuana increased

Average of 17.3% per year between 2010 to 2012

Rose by over 150%

146

In 2007, tests positive for marijuana made up 33% of the total drug screenings, by 2012 that number increased to 57%

Distribution to Minors

Rocky Mountain HIDTA, 2013

147

• Teens who know somebody with a medical marijuana license are more like than those who don’t to report ‘fairly’ or ‘very’ easy access to marijuana

• 74% of Denver-area teens in treatment said they used somebody else’s medical marijuana an average of 50 times

Medical marijuana is easily diverted to youth

Thurstone, 2013; Salomonsen-Sautel et al., 2012

148

• 29% of Denver high school students used marijuana in the last month

• If Denver were an American state, it would have the HIGHEST public high school current use rates in the country

Denver high schools

Healthy Kids Colorado, 2012

149

Percent difference between national and Colorado past-month teen marijuana usage

averages – 2006 and 2011

2006 20110.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

9.41%

28.73%

Rocky Mountain HIDTA, 2013

150

In Colorado, fatalities involving drivers testing positive for marijuana

rose by 112%.

Increased traffic fatalities

Mu-Chen Li, J.E., et al., 2011; Colorado Department of Transportation, 2006

While the total number of car crashes declined from 2007 to 2011, the number of fatal car crashes with drivers testing

positive for marijuana rose sharply.

Colorado Dept of Transportation

2007 2008 2009 2010 2011500

550

600

650

700

750

800

850

Total car crashes

2007 2008 2009 2010 201115

20

25

30

35

40

45

50

55 Crashes with high drivers

151

152

In 2011, marijuana-related incidents accounted for 26

percent of the total ER visits, compared to 21 percent nationally

Increased ER admissions

Rocky Mountain HIDTA, 2013

153Under 5 6 to 12 13 to 14

200%

60%

92%

Chart Title

• 200% for kids under 5

• 60% for kids 6-12

• 92% for kids 13-14

Increased ER admissions

Rise in marijuana-related ER visits from 2006 and 2012:

Rocky Mountain HIDTA, 2013

154

As the price for marijuana plummets in legalization states, we can expect cheap marijuana to be sold in non-legalization states for a handsome

profit.

• According to the El Paso Intelligence Center (EPIC) National Seizure System, in 2012, there were 274 Colorado marijuana interdiction seizures destined for other states compared to 54 in 2005.

Diversion of marijuana

Rocky Mountain HIDTA, 2013

155

Two independent reports released in August 2013 document how Colorado’s supposedly regulated system is

not well regulated at all

Poor regulation

156

The Colorado State Auditor concluded that:

• The state had not “established a process for caregivers to indicate the significant responsibilities they are assuming for managing the well-being of their patients,” and that the state “cash fund” was out of compliance.

Poor regulation

Colorado Office of the State Auditor, 2013

157

The Colorado State Auditor concluded that:

• 50% of ALL recommendations made by only TWELVE physicians

Poor regulation

Colorado Office of the State Auditor, 2013

158

The city of Denver Office of the Auditor concluded that:

• The city of Denver “does not have a basic control framework in place for effective governance of the…medical marijuana program.”

• The medical marijuana records are “incomplete, inaccurate, inaccessible.”

• And that many dispensaries are operating without licenses.

Poor regulation

City of Denver Office of the Auditor, 2013

159

4/20 Rally in Denver

160

4/20 Rally in San Francisco

Responsible Regulations?

161

• Heavily influenced by CO’s massive medical marijuana industry

• Allowing character packaging, edibles, candies

• Can grow much more than you sell

• Advertising allowed in “Adult Periodicals”

162

With the DOJ’s announcement that it will not enforce the CSA, the reform group, Marijuana Policy Project (MPP), announced its plan to get legalization on the ballot in 10 states by 2017

Legalization on the horizon

163

Arizona

California

Maine

Nevada

New HampshireVermont

Maryland

Rhode Island

Hawaii

Alaska

These states include:

Massachusetts

Oregon

164

• MPP is currently supporting a petition – the “Campaign to Regulate Marijuana” – to place legalization on the 2014 ballot

• If passed: • The manufacture, sale, and possession of up

to one ounce of marijuana becomes legal for adults over 21.

• Creates establishments such as: marijuana retail stores and marijuana infused-product manufacturers

Alaska

165

• Arizona • California • Maine• Nevada

• Hawaii • Maryland• New Hampshire• Rhode Island• Vermont

Initiatives supported by MPP are in place to put legalization on the ballot by 2016 and 2017

in:

Also on the horizon…

Massachusetts

Oregon Montana

166

In all of these states, if the proposed amendments are passed,

the retail sale and production, and possession of marijuana will

become legal

If passed…

167

So What Are Our Choices?

All or nothing?

Legalization (“Regulation”) vs. Incarceration (“Prohibition”)

168

Not about legalization vs. incarceration

We can be against legalization but also for health, education,

and common-sense

Smart approach

169

Chair, Patrick J. Kennedy

Launched January 10th 2013

Over 15,000 press mentions

Public Health Board of Trustees

10 state-wide affiliates

1. To inform public policy with the science of today’s marijuana.

2. To have honest conversations about reducing the unintended consequences of current marijuana policies, such as lifelong stigma due to arrest.

3. To prevent the establishment of Big Marijuana that would market marijuana to children — and to prevent Big Tobacco from taking over Big Marijuana. Those are the very likely results of legalization.

4. To promote research of marijuana’s medical properties and produce pharmacy-attainable medications.

Project SAM

170

SAM is a national group with state and

local partners

Kevin A. Sabet, Ph.D., www.kevinsabet.com

SAMIA (SAM Interstate Alliance)

State partners who work on state/local issues

Can be separate 501 (c) (4) or PAC or simply an informal entity

173

174

175

176

Addressing current policy:

• People should not be stigmatized for their past use

• No sense in incarcerating users• People need job and economic

opportunities; by being blocked from them they will re-enter the illicit market

Smart Approach

177

• Robust community-based prevention programs • community coalitions

• Criminal justice intervention programs• Probation reforms• Drug treatment courts

• Non-drug interventions• Housing• Education• Healthcare

Non-legalization reforms

Recruit Champions

178

• Legislators at every level of government

• Executive branch leaders, at every level of government

• Media luminaries in every medium

• Business leaders

• Other key influentials (faith leaders, civic leaders, foundation leaders, other) 179

• Figure out how the marijuana legalization issues affect them and their constituents/members.

• Discuss these issues in a way that will appeal to them, their mission and their members.

180

How To Interest Grasstops Leaders:

Frames Win Debates

181

How to Frame Our Messages to Win Back The Public

182

Changing the Frame:

• From negative to positive• From “old” to “new”

183

Old Message

Marijuana legalization will increase drug use and workplace

related consequences.

184

According to the American Council for Drug Education in New York, employees who abuse drugs are:

• 10 times more likely to miss work• 3.6 times more likely to be involved in

on-the-job incidents • 5 times more likely to file a workers’

compensation claim.

185

Facts:

6.5% of high school seniors smoke

marijuana every day1, rendering them

virtually unemployable.186

1 Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. Monitoring the Future national survey results on drug use, 2012. Volume I:

Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan. Available: http://www.monitoringthefuture.org/data/10data.html#2011data-drugs

Fact:

New Frame:

If your community cares about jobs and employability, you need to care about reducing marijuana use.

187

Old Message

Marijuana use is bad for memory, motivation and learning

188

If you care about academic performance, you need to care about youth marijuana

use.

189

The New Frame

Connecting the dots for elected officials is crucial if we want results!

190

191

Kevin A. Sabet, Ph.D., www.kevinsabet.com

There are alternatives…

Smart InternationalPrevention Treatment Recovery Enforcement Efforts

Parental Involvement in Preventing Substance Abuse

• In 2012, most youths aged 12 to 17 believed that their parents would strongly disapprove of their having:– Alcoholic Beverage (one or two every day) – 90.5%– Smoking Cigarettes (one or more packs a day) – 93.1%– Marijuana or Hashish Use (once of twice) – 89.3%

Effect:

– In 2012, past month use of illicit drugs, cigarettes, and alcohol use were all lower among youths 12-17 who reported parental involvement.

• 7.6% - Rate of past month illicit drug use with parental involvement.

• 18.1% - Rate of past month illicit drug use without parental involvement.

Kevin A. Sabet, Ph.D., www.kevinsabet.com

Kevin A. Sabet, Ph.D., www.kevinsabet.com

Prevention:Community-based

■ Planning ■ Multi-Sector approach ■ Reduction in use of …

Alcohol Tobacco Marijuana

12% 28% 24%

Kevin A. Sabet, Ph.D., www.kevinsabet.com

Recovery

Enforcement:An untapped opportunity for progress

7 millionAmericans in the Criminal Justice System

Nearly a … and a quarter of Federalthird of State prisoners committed their crimesprisoners … under the influence of drugs

5 millionOn Probation or

Parole

2 millionIncarcerated

1/3 1/4

Kevin A. Sabet, Ph.D., www.kevinsabet.com

Enforcement and TreatmentCan Work Together

For every $1.00 invested in Drug Court, taxpayers saveas much as $3.36 in avoided criminal justice costs alone.

Project Hope

Reduction in missedappointments

85%

Reduction in positive urinalyses

91%

47%

Arrested Used Drugs

Skipped Appointments

Probation Revoked

46%

23%

15%

21%

13%

9%7%

Control

Project Hope

Drug Market Interventions (DMI)

In Rockford, Illinois, property crime declined by 24 percent.

In Nashville, Tennessee, drug crime declined by 39.5 percent.

In High Point, North Carolina, the first site, indicated that the target area experienced a substantial decline in violent (30.6%) and drug-related crime (32.2%).

In all three communities, interviews with local residents revealed a perceived decline in crime and disorder, reported improvement in the quality of neighborhood life, and appreciation for the police.

Kevin A. Sabet, Ph.D., www.kevinsabet.com

Re-entry

Thank You!

Questions? Email

kevin@learnaboutsam.orgwww.learnaboutsam.org