Tuesday, February 17, 2009

More on Legalizing Drugs

February 17, 2009

As always, readers know far more than I do about complex issues like drug use-- from alcohol abuse to unintended consequences...

Readers checked in with some thoughtful comments on legalizing drugs. Let's start with a Prosecutor who warned of unintended consequences of legalizing all drugs:

"I have great respect for you and I’ve learned a lot from you (you opened my eyes with your contrarian view on the Chinese economy a year or two ago and you are being proved right). But we often differ, and I certainly disagree about legalization.
I am a prosecutor. I worked for years in a previous drug court assignment. I’ve talked with real addicts. I’ve attended seminars and talked with experts like a doctor who ran the Haight-Ashbury free clinic and worked with Jerry Garcia. I have a brother who is addicted to methamphetamine. And I myself went to college in California in the seventies (I’ll leave it at that). I’m not an expert but I do have some education and practical experience.

The devil is always in the details, and your thesis is no exception. For example, you say “The way to ‘take out’ crack cocaine and crystal meth is to legalize plain old powder cocaine and make it cheap.” But, any novice can easily “rock up” powder cocaine to make “crack.” So if the alkaloid powder is cheap and accessible then the base rock derivative will be too. Some slopes really are slippery. Where is the logical or practical distinction to legalize one form of cocaine but not the other?

I also don’t follow your main exception for methamphetamine. Meth is comparable in every way to cocaine. Abuse of meth by oral or intra-nasal ingestion is virtually identical to intra-nasal abuse of alkaloid cocaine (powder)—in these modes of ingestion the two CNS stimulants create a similar subjective experience (very mild “high”), the same side-effects and a similar addictive process and potential. Likewise, smoking meth and IV injection are comparable in every way to injecting or smoking cocaine (in the alkaloid or base rock forms, respectively).

Addicts who smoke or inject either drug can experience severe psychosis, intense addiction, and extreme side-effects. The subjective experience of smoking or injecting either one is extreme. People who are prone to addiction can be hooked instantaneously upon the first overwhelming “rush” the very first time they smoke or inject either meth or cocaine. If anything, smoking allows an even faster, more direct and intense assault on the blood/brain barrier—a bigger rush—than IV use. Some describe it as an extended orgasm. Severe abusers of cocaine and methamphetamine often add heroin to make “speedballs” –the addict’s holy grail (and Garcia’s drug of choice). You get all the euphoria of the heroin and the meth/cocaine combined, plus you get to stay awake to enjoy it all, and you can take bigger doses without depressing CNS activity down to the point of death. (Similar effects to a lesser degree with alcohol/stimulant combos.)

By way of contrast, the casual abuser ingesting either drug orally or intra-nasally experiences mild stimulation—a “boost.” There is no extreme or overwhelming euphoria. Many abusers of either drug in the milder form experience little more than alertness, agitation, depressed appetite and insomnia, with little or no “high.” Some novice alkaloid cocaine abusers say there is a “learning process” requiring several repeat uses before one can even begin to identify subjectively the “high” of intra-nasal cocaine ingestion. Years ago I read a double blind medical study where most first-time users could not subjectively distinguish the intranasal use of alkaloid cocaine and procaine/novocaine (the latter two are purely local anesthetics without CNS effect).

I don’t see a logical or practical distinction between legalization of meth and cocaine. If anything, methamphetamine produced by thousands of ragtag meth labs is more dangerous than illicit cocaine. Meth labs are smaller and temporary so the quality of the basic product is more ragged with great variability in amounts of red phosphorus and other byproducts remaining in the finished drug. Some batches are “wetter” or “redder” indicating more phosphorus. (I’m not sure. What’s more dangerous to eat or smoke, pure meth or pure phosphorus?)

Imported cocaine at least comes from larger centralized factories overseas with greater economies of scale and investment in production with some quality incentive from repeat sales opportunities. Thousands of fly by night meth labs have no quality incentive whatsoever. The production problems happen before the “pure” drug even gets “stepped on” by illicit retailers.

Bottom line, I understand the appeal for legalization on a grand and idealistic level. It breaks down when you really start to analyze it, but I’m always open to discussion. One thing is certain, addiction in a large scale, poly-substance abusive society is not a simple problem susceptible to easy elegant answers. It is a hard, hard problem with dirty, ugly details.

Even the goal to eliminate enforcement, prosecution and incarceration through legalization is simplistic. Perhaps we can reduce expenditures but we will always have black market production, sales and abuse even if we legalize. If nothing else we’d have to police production like we now police the licit and illicit production of Vicodin and Valium for example here and overseas.

I prefer to continue carefully with recent reforms emphasizing treatment (and limiting incarceration of addicts) as California started with Penal Code Section 11357b and Proposition 36. Grand legalization schemes break down when you get into the hard, ugly, difficult details. In your proposed legalization scheme I can’t comprehend the distinction between alkaloid cocaine on the one hand and methamphetamine and base rock cocaine on the other hand. This just makes no logical or practical sense to me at all.

I then asked about legalizing marijuana, and received this cogent response:

Marijuana and hard drugs are different animals. And California is different from some states because possession of less than 1 oz. of marijuana is punished with a maximum $250 fine--no jail. Plus, you have a right to a jury trial before even the de minimus punishment. Under Prop 215 a doctor's "recommendation" is rather easy to obtain for "medical marijuana" (say the ubiquitous "low back pain"). Then it's completely legal and you can even grow your own supply. Yet the gangs continue to import and sell it here. Go figure.

It's also my understanding that counterfeit prescription drugs continue to be big business and they're sold on the street. I haven't personally seen much of that. I do understand the idea of taking away the profit and it's an important goal if we could establish a practical, workable approach that the voters would embrace.

It's also my personal experience after Prop 36 that incarceration of prison inmates for simple possession of hard drugs is overblown in the press and popular imagination. It's very hard to get into state prison for anything, and it almost never happens for simple possession anymore.

I certainly don't have all the answers, I just know these are horrible problems. If we change our policy dramatically there will be unintended and unexpected consequences so we have to be careful. My only specific point is the similarity between cocaine and methamphetamine. The main distinction is the location and scale of the production process. (Bear in mind that without easy access to pseudophedrine there can be no crank labs. That's what they make it with.)

The highly distributed and temporary nature of current methamphetamine labs makes the end product more unreliable. Perhaps if we legalized everything else and cocaine products became very cheap then we could undercut meth. I don't know. I'm very fearful of dramatic changes. I personally would just re-emphasize treatment and continue to de-emphasize criminal custody for addicts."

One of the site's physician-readers, "Ishabaka," M.D., made these observations:

"As an old hand in the E.R., who's seen people on just about every drug, I agree with your legalization article. MAYBE not cocaine, as crack is about as destructive as meth, and is easy to make from powder cocaine at home.

You left out the most horrific act associated with alcohol abuse - child abuse/killing. I've see two babies beaten to death by their parents. Remember when "shaken baby" syndrome was discovered? An astute doctor realized that babies coming in with serious brain injuries didn't suffer them spontaneously - he thought their parents lost control, grabbed the babies and shook them so vigorously their brains riccoched around in their skulls causing bruising and bleeding.

This was a huge advance in the recognition of child abuse, and the doc deserves tons of credit, but he got the mechanism of injury wrong - actually, most parents pick the babies up by the feet and slam their heads repeatedly against a wall. As an old professor of mine who dealt with patients with extreme psychopathology told me: "you and I can't imagine doing such things because we have normal brains".

Here's my problem with your proposal - there are basically two types of recreational drugs - uppers and downers. The classic downers are marijuana and heroin. They don't make anyone violent. It's the uppers that cause violence - "agitated delirium" in the absolute worst case - these people are literally like Tasmanian devils. I've dealt with a lot of them.

Alcohol is unique in that it has a biphasic action in many people - excitatory up to a certain level, after which it becomes a sedative. People commit violent acts in the excitatory phase. Other excitatory drugs are all the amphetamines (meth is just one), cocaine, the "ADHD" drugs ( which are modified amphetamines, and often abused), and Angel Dust (phencyclidine).

Lastly, and this may sound perverse - my daughter was born under near optimal circumstances - a loving married father and mother, a nice house, money in the bank, jobs for the parents, no drug or alcohol abuse, and plenty of nearby family support. She was a single child with no prematurity or health problems (both dramatically increase the likelihood of child abuse), and STILL it was tough going when she was a baby, got colic, and cried all night.

I could UNDERSTAND how some guy with no job, no money, on booze or drugs, with his wife yelling at him and six other kids fighting and crying could lose it and smack his baby too hard. I think a MAJOR problem with our justice system is the failure to distinguish between "human" and "inhuman" criminals. This guy I would classify as human - his actions, while never meeting approval, could be UNDERSTOOD by humans with normal brains. MAYBE with some support, anger management classes, detox or AA, and CLOSE MONITORING, the guy might be able to raise his baby OK - he'd never be father of the year, but he might be able to do a decent job.

The "inhumans" fall into the Jeffrey Dahmer type - people with normal brains can never understand their crimes. I have a great book by the British Medical Association called "The ABC's of Child Abuse". It is full of photos. One shows a toddler with branding marks all over him, and the wire his mother carefully bent, and would heat up red hot to torture and brand him. Such parents, in my opinion, should have their children PERMANENTLY taken away from them, and be sterilized - PERIOD. Unfortunately, far too often our system considers such parents rehabilitation candidates, and after a period, returns their children to them.

Here's a little fact I learned from a junkie friend of mine - go into a 7-11 or similar store and look at the aisle that stocks bread and such - you'll see little boxes of Arm and Hammer baking soda. As my friend told me: "You think anyone decides to bake biscuits at 2:00 am?". Baking soda is used for converting powder cocaine to crack at home. You will also notice, up near the cash register, those long butane lighters used for lighting fires in fireplaces - these are for vaporizing crack (crack is not "smoked" - it doesn't burn, rather the crystals are vaporized by flame). Poor crack addicts use regular butane lighters held upside down, and burn their hands, especially their thumb - a chronically burnt dominant thumb is called a "tweaker's thumb" and is a sign of crack or meth abuse."

Correspondent Kevin M. made a connection between the "war on drugs" and larger social catalysts:

"You hit another home run today. As you note, "follow the money" is undoubtedly the main driver in the war on drugs from the perspective of the politicians and law enforcement, but there may be a secondary catalyst running a close second and keeping the public on board.
Our society has taken bad turns on a wide number of fronts since the 1960s, some examples being the steady decline in public education, widespread divorce and the attendant fracturing of families, industry and community dislocation, and a self-perpetuating debt trap, which covers only a small slice of the possibilities. The root causes of these troubles are poorly understood by the masses, not the least of which since politicians and the media do such a poor job of articulating them--which assumes they actually know any better. The public, desperate for solutions, seeks what appear to be the simplest solutions, and usually finds them in a system of top down rules and regulations.

We are undoubtedly in the time of greatest public control going clean back to the British occupation. We have rules, regulations, laws and punative taxes connected with any and every behavior that occurs within the borders of this country. Your foam surfboard friend in California was an excellent example of this in a different direction. Desperate to control the uncontrollable, the public demands that "something be done about Problem X", which invariably is another battery of restrictions they believe will actually subdue the problem at hand. And so it is with the war on drugs; millions of people--especially in the middle classes--believe the "drug problem" will be alleviated if we just a) continue to tighten the screws, and b) stay the course.

Now human nature being what it is, the more the authorities push against the drug problem, the more distributors and users push back. The drug war will not work, any more than it has up to this point, but people will continue to believe it will."

Thank you, correspondents, for these informed, thoughtful responses. I would plead guilty to hatching my usual reductionist, simplistic proposals--but it seems that decriminalization is a necessary debate for all sorts of reasons.

I would agree with the prosecutor's conclusion to "re-emphasize treatment and continue to de-emphasize criminal custody for addicts." I still would like to see marijuana not just decriminalized but actively legalized to the point that R.J. Reynolds packaged it for sale alongside the far more addictive and deadly tobacco products in retail outlets.

I would also like to see cocaine and heroin, as awful and addictive as they are, treated more like alcohol, which flat-out kills 15,000 people a year via vehicular accidents and thousands more from "accidental" shootings, beatings and alcohol-abuse-related chronic disorders (liver disease, etc.) and less like violent crime. (Try telling the families of the 15,000 innocents killed by a drunk drivers how "safe" legal alcohol is compared to illegal cocaine. It seems the person most likely to die of cocaine addiction is the user.)

All addiction to destructive drugs is tragic--even "plain old tobacco" is tragic when the smoker is dying before your eyes, unable to breathe. And nicotine addiction flat-out kills tens of thousands of people every year.

So exactly how can we justify this distinction between "legal" addictive drugs which demonstrably kill tens of thousands of people and "illegal" addictive drugs? Am I suggesting these "other addictive drugs" should be as available as tobacco and alcohol? No, but we clearly need to rationalize what deserves treatment and suppression via control and persuasion as opposed to criminalization.

I would wager than getting R.J. Reynolds in the legal pot-growing and marketing business would quickly extinguish much of the profits being raked in by the Mexican Mafia, which is growing pot in our national forests on a massive scale.

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