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The Rosenthal Report - November 2016

Rosenthal Reports
Post-Election Highlights
Victory, Defeat, and Uncertainty for Recreational Marijuana

Pro-pot forces outspent and overwhelmed opponents of recreational marijuana use in California, Massachusetts, Nevada, and Maine, but failed to win in Arizona. Meanwhile, in Alaska, where voters approved recreational use close to two years ago, the first pot shops just opened in Valdez and Fairbanks. These five join Colorado and Washington, states with recreational marijuana already on the books, in the shops, and growing in the fields. This year’s election also saw medical use of marijuana approved by voters in Florida, North Dakota, and Arkansas, making medical use the law in a majority of states.

Legalization champion Ethan Nadelmann, executive director of the Soros-funded Drug Policy Alliance, called the election results “a monumental victory for the marijuana reform movement.”   The Washington Post speculated that adoption of legal marijuana by California, home to roughly 12 percent of nation’s population, might “prompt the federal authorities to rethink their decades-long prohibition on the use of marijuana.” This thought has clearly not escaped President Obama who said, in a recent interview with Bill Mahr, that passage of the legalization proposals could make “untenable” the current federal “hands-off” policy towards legalization efforts at the state level.

It is not likely, however, that the incoming Trump administration, strong for law and order and skeptical of drug reform, would be enthusiastic about keeping their hands off. “The prospect of Rudy Giuliani or Chris Christie as attorney general,” Nadelmann allowed in an interview, “does not bode well. There are various ways in which a hostile White House could trip things up.”

The battle against legalization is clearly not over on the state by state level. “We were outspent greatly in both California and Massachusetts, so this loss is disappointing, but not wholly unexpected,” says Kevin Sabat, president of SAM (Smart Approached to Marijuana), a leader in the fight against legalization. "This is the beginning of the conversation, not the end,” he adds, for SAM will be working with localities within the legalizing states, he says, “to ensure they know their rights and obligations to protect their citizens from pot shops, candies, and advertising."

What Was Lost With Hillary

There was no mention of the nation’s opioid epidemic in the Presidential Debates and Donald Trump’s sole reference to the problem went no farther than the Mexican border where, he declared, “We’re going to build a wall and we’re going to stop that heroin from pouring in.” But Hillary Clinton had a carefully thought out plan to spend ten billion dollars over the next ten years on just about everything other than a wall.

It would have boosted the Substance Abuse Block Grant, (money that regularly goes to the states for drug abuse services), provided blanket provision of naloxone for overdose victims, funded prevention initiatives, promoted prescription monitoring programs, and prioritized treatment over incarceration.

When it came to treatment, Hillary’s plan was committed to comprehensive, ongoing care, and, according to the Associated Press, would promote greater use of medication assisted treatment (MAT).  

 

The Problem with Medication Assisted Treatment (MAT)

Hillary is not alone in promoting medication assisted treatment. President Obama’s plan, authorized by Congress before the summer recess, also increases funding for MAT programs.

But, at what point does “medication assisted” treatment become “the medication alternative” to treatment, for federal regulations define MAT as “the use of medication in combination with counseling and behavioral therapies.”  This is an issue that troubles health care officials in areas hard hit by the opioid addiction, where the priority has been getting buprenorphine step-down medications to patients in new opioid treatment clinics where they are unlikely to be getting much, if anything, in the way of the “whole patient approach” that federal guidelines say should provide, “a range of services to eliminate, reduce, or prevent the use of illicit drugs.”

Prescription by Decree

When it comes to medically assisted treatment for Medicaid patients, no state is more generous than Vermont.  A number of states demand that Medicaid patients “fail first” at a less costly intervention or, as Kelly Clark, M.D., president-elect of the American Society of Addiction Medicine points out, “require patients to wean off their addiction medication” (which she considers akin to telling a heart patient to taper off of his medication after a year). But not Vermont, where the state’s Medicaid program pays for 68 percent of all the retail prescriptions for buprenorphine, more than any other state in the nation. 

Governor Peter Shumlin, who chose not to run for a fourth term this year, has been determined to end the state’s opioid crisis and is proposing to limit the number of painkilling pills a physician can prescribe for a patient. The issue of setting prescription rules was passed on to the governor and the Vermont State Department when legislators approved an omnibus bill designed to curb the opioid crisis.  

“Limits would be based”, says the governor, “on severity and duration of pain, the complication of the procedure, and the particular medication prescribed.” He contends that rationing the number of pills will reduce the incidence of addiction, “We didn’t have a heroin crisis in America before OxyContin was approved and started being handed out like candy.”

According to the state’s health commissioner, Harry Chen, M.D., the proposal would cap prescriptions for some minor procedures at between nine and twelve pills. The plan, he explained would impose consistency on opioid prescription.  “There is a clear pattern of over-prescribing,” he said, and “tremendous disparity between different doctors on how many painkillers are prescribed for the same surgery.”

Critics of the plan warn that limiting access to legal pain medication was most likely to drive patients to seek illicit drugs. It should also be recalled that over-prescription of pain medication in the recent past was not due entirely to aggressive marketing. It reflected as well the under-treatment of pain that preceded today’s concern about patient satisfaction.

Adderall: Not Just for Kids

After last month’s report on A.D.H.D., Casey Schwartz’s article, “Generation Adderall,” appeared in the Sunday Times Magazine.

Casey wasn’t an A.D.H.D. adolescent. She came to Adderall on her own as a young adult, a sophomore student at Brown University.  It was when she was stuck for a five-page report due the next day on a book she’d only just begun to read that Casey took two Adderall pills from a friend. She spent the rest of the night, she recalls, “in a state of peerless ecstasy. The world fell away; it was only me, locked in a passionate embrace with the book I was reading and the thoughts I was having about it, which tumbled out of nowhere and built into what seemed an amazing pile of riches.” 

She was hooked. It was an experience she was going to have and seek to have repeatedly over the years that followed.  Casey was not unique. As she points out, adults made up the fastest growing group of Adderall users in the mid-2000s.  And, once she realized she needn’t buy overpriced pills from A.D.H.D. kids, and conned her own prescription from an easily hoodwinked psychiatrist, she had access to pills for life.

Does Adderall actually enhance cognitive performance?  Is it, as Casey asks “a smart drug?”  She calls the evidence “more than a little ambiguous.”

In time, she came to realize, she writes, that “I lived in a paradox, believing that the drug was indispensible to my very survival while also knowing that it was nothing short of toxic, poisonous to art, love, and life.” Periodically, she tried to get off Adderall and eventually succeeded. But she found the drug infinitely more difficult to relinquish than various experts assured her it was supposed to be. She also found evidence in the message boards of websites devoted to giving up the drug that she was far from alone in her struggles to quit.

1st November 2016
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