Naloxone Not Associated With Moral Hazard

Good news, a new study finds that expanding access to naloxone (Narcan), an antidote that reverses opioid overdoses and saves countless lives every day, was NOT associated with increased heroin or other intravenous drug use among adolescents.  This echoes previous research that finds no such "moral hazard" occurring among adults either.  Thus conclusively ends one of the most tired, jaded, cynical, and empathy-lacking arguments against harm reduction.  

In other words, in this day and age, there is absolutely no rational reason to not make naloxone readily available, period.  Ditto for things like fentanyl test kits as well.  Those who oppose doing so are thus basing their self-righteous opposition on a selectively moralistic and ideological foundation, and certainly not a scientific or a humanitarian one.

The same goes for needle exchange programs as well, something even former NYC Mayor Mike Bloomberg openly came out in favor of during his time as mayor. 

The flip side of "live and let live" need not be "live and let die".  Harm reduction is NOT a zero-sum game, since dead people can't recover from addiction. 

NOTE:  Narcan nasal spray is now approved for over the counter (OTC) sale by the FDA.  It should have always been, but better late than never.  Beware that it only reverses opioid overdoses, not overdoses of other, non-opioid drugs such as alcohol, cocaine, crack, meth, Adderall, benzos, or xylazine ("tranq").

The Public Health Crisis That Wasn't

One of our favorite journalists, Annie Lowrey, recently wrote an article titled, "America's Invisible Pot Addicts".  While she is clearly no friend of cannabis prohibition and in fact has repeatedly gone on the record supporting legalization, in this article the author addresses head-on the issue that many (but not all) legalization advocates have heretofore been loath to discuss at all:  cannabis addiction and its apparently growing trend in this country.

As she quotes various self-styled experts on the matter, we seem to get several different answers on the size of the problem and especially how to handle it.  But some facts are undeniable regardless of who says them:

• Some people can indeed become dependent on cannabis, to one degree or another.  And while cannabis is significantly less addictive than alcohol, tobacco, hard drugs, prescription painkillers and sedatives, and even caffeine, it can still become quite habit-forming when used too frequently and heavily.
• While cannabis addiction is usually not as severe as most other addictions, it can be for some people.  Cannabis may be relatively harmless for most of its users, but that does not make it completely safe for everyone.  Some may find that it can have quite a dark side when seriously abused.
• Since the early to mid-1990s and especially since the early 2000s, rates of "cannabis use disorder" (abuse, dependence, or both) as defined by DSM-IV criteria have increased markedly, as have the percentage of daily or near-daily (DND) users of cannabis (about half of whom are dependent).
• While some of those who technically meet DSM-IV criteria for abuse or dependence are pseudoaddicts or an artifact of social stigma and prohibition, others are indeed genuine addicts, and the exact proportion is not entirely clear.
• Likewise, many DND users are truly medical or quasi-medical users, but many are clearly not.
• These trends in heavy and/or dependent use began long before recreational legalization and even before medical legalization in most states, and there is no unambiguously prospective link between legalization and such trends.
• These trends have occurred primarily among adults rather than teenagers.
• Regardless, none of the above facts constitute a real public health crisis at this time, and all of this truly pales in comparison to the opioid epidemic as well as the "pink elephant in the room" that is America's alcohol problem.

So yes, Virginia, there really is a "there", there, but contrary to what some commentators may fear, it is unlikely that legalization is really anything to fear in terms of making it worse.  After all, prohibition clearly couldn't stop it from rising over the past quarter-century.  And us legalization advocates would do wise to stop the denials and face the problem head-on, without fear that it would weaken our movement one bit.  Do not fall into the trap of ceding the moral high ground to the anti- side.  At the same time, we must also tackle head-on the "tyranny of the weaker brother" that really has no place in a free society.

The message really needs to be that spending the majority of one's waking hours under the influence of any psychoactive substance is probably not a wise idea, unless of course one truly needs it for medical reasons.   Saying that cannabis is the safer choice is NOT the same as saying that it is absolutely safe for everyone.  Besides, when you are stoned all the time, it basically loses its fun eventually, and isn't the whole point of recreational use by definition to have fun in the first place?  As Dr. Andrew Weil notes, if it stops being fun or effective, the worst thing one can do is smoke even more weed or seek out stronger strains.  And if you're at the point where you can't even enjoy video games without being stoned, that is definitely a warning sign that you need to at least take a break or cut back significantly, if not quit completely.

It is utterly important to first name and define the problem before discussing it further, to avoid inadvertently reinforcing the lies and half-truths on either side of the debate. We are talking about problematic, chronic, heavy, very heavy, and ultra-heavy use of cannabis here, at ANY age.  We are NOT talking about casual use, use per se by people below some arbitrarily high age limit, or about the roundly debunked "gateway theory" either.   Toking up, say,  once a week (or less) is really NOT the problem here, it's more like toking up every day or nearly so, especially multiple times a day, and/or in very large quantities, that is the real problem.  And while slopes may be slipperier than they appear as one approaches heavier and heavier use, the vast majority of cannabis users still do NOT become chronic heavy users.  And among those who do, it doesn't usually last very long, though for some it unfortunately does.

Likewise, while there currently is no hard scientific evidence (and not for lack of trying to find it) that using cannabis at 18 is really any worse in practice than using it at 21, 25, or even 30 for that matter, there is nevertheless some evidence that using before 18 and especially before 15 may indeed be riskier overall, both in terms of potential harm as well as addiction potential.  It is quite nuanced and the studies still need to be fleshed out, for sure.  But we should note that the aforementioned chronic, heavy users that represent the real problem typically started toking before 15 and/or transitioned to heavy use before 18 as a rule.  And many, if not most, of those users have also used alcohol and/or tobacco at an early age as well, again especially before 15.

As for public policy within the framework of legalization, Lowrey notes that probably one of the best--if not the best--measures that policymakers can take is to raise the taxes on cannabis.  That would, by definition, hit the heaviest users the hardest, while casual users would barely even notice the resulting price hike.  Of course, it would be best to keep the taxes very low at first in order to destroy the black market, and then gradually but sharply raise them beginning a year or two after legal recreational sales begin in a given state.  Lowrey also notes other ideas as well, such as capping THC levels in products, dispensing public health information, and restricting advertising, which are likely good ideas.  But excise taxes, especially if they are proportional to THC content (and perhaps inversely proportional to CBD content as well), would probably have the largest effect size of all in terms of reducing cannabis-related problems.  As for the fear that higher cannabis taxes would drive users back to alcohol, well, we all know by now how to prevent that hypothetical from happening:  simply raise the taxes on alcohol as well.

In other words, freedom has nothing to fear from the truth.  That, and don't fear the reefer--but DO treat it with the respect it deserves nonetheless.

Of Death And Taxes, Part Deux

While the opioid epidemic has recently been declared a public health emergency, what if we were to tell you that there is another drug epidemic that kills even more people (a whopping 88,000 per year vs. 65,000 per year for opioid and all other drug overdoses combined), a number that has actually been increasing in recent years?  And that number, though staggering in itself, is merely the tip of a very large iceberg of injury, illness, crime, violence, motor vehicle crashes, family breakdown, addiction, and other social costs linked to this deadly yet ubiquitous substance.  Meanwhile, the powers that be are responding to this epidemic with a collective shrug for the most part.  I think the reader would figure out by now that we are talking about alcohol.

And aside from its overall banality, what is particularly notable about the alcohol epidemic is how ageist our response has been.  While the epidemic clearly affects all ages, the powers that be have been focusing in laser-like fashion on people under 21 while largely ignoring people over 21, despite the fact that people over 21 make up the vast majority of this epidemic.  Not only does this scapegoat young people for largely adult problems, but it also hinders any real solutions to such problems as well.  It's basically the "pink elephant in the room".

Fortunately, we know now after decades of reams of research evidence that there is in fact a very simple solution for reducing the death rates and other harms of excessive drinking.  And that solution is raising alcohol taxes.   The higher the price of alcoholic beverages, the fewer deaths and other alcohol-related problems occur, all else being equal.  Even modest increases seem to have a significant impact.   We know this, yet not only have the powers that be generally let the alcohol taxes lag behind inflation, but have actually moved to lower such taxes as a lesser-known part of the new Republican tax bill.  

So what should the ideal alcohol tax be?  According to researchers, the externality costs of alcohol are estimated to be around $45-58 per proof-gallon, yet the federal tax on distilled spirits is $13.50 per proof-gallon, and for wine and beer it varies but tends to hover between $4 and $5 per proof-gallon.  And while state and local alcohol taxes vary, they are also generally very modest in most states, especially for beer.  So there is a very wide range by which such taxes can be raised while still being socially efficient.

Of course, those figures are now effectively even lower now that the Republican tax bill has lowered such rates even further for roughly the first 100,000 proof-gallons of all alcoholic beverage categories across the board.  But the aforementioned rates still remain the top rates above the respective thresholds in the now-tiered system.  Beer was always tiered with a reduced rate for the first 60,000 barrels, but now that reduced rate is even lower still, and for the first time ever distilled spirits now enjoy a reduced rate for the first 100,000 proof-gallons.  The rate structure is not inherently bad in itself, of course, but both the new and old rates are simply too low.

Twenty-One Debunked believes that, along with lowering the drinking age to 18, that alcohol taxes should be raised significantly.  Specifically, we support raising and equalizing the federal tax on all alcoholic beverages to the inflation-adjusted 1991 level for distilled spirits, which would be $24 per proof-gallon in 2016 dollars.  It should also be simplified by getting rid of all credits and lower tax rates, with perhaps the exception of ones for the first X number of proof-gallons produced by very small domestic producers.  At the state level, it would also be good to equalize alcohol taxes across all beverage types, while allowing localities to levy their own alcohol taxes (including sales and gross excise taxes) as they see fit.  The latter is especially important for college towns.

Even a smaller hike, such as to $16 per proof-gallon across the board, would likely save thousands of lives per year according to researchers.  And of course it would also raise more revenue.  As for job losses, the best research suggests that the net effect is actually neutral or even positive with respect to jobs overall.  So it should be a no-brainer.  A win-win-win situation for everyone but the alcohol industry, basically.

Oh, and by the way:  craft breweries (both macro and micro) not only exist in high-tax Canada, but actually appear to be thriving over there.  Ditto for even higher-tax Iceland as well.   Keep in mind that the tax hikes we propose would still leave American beverages cheaper than Canadian beverages.  So even if we raise such taxes dramatically without reduced rates or credits for small producers, they will likely continue to thrive here as well (at least if such tax hikes are phased in somewhat gradually).

Don't get us wrong, Twenty-One Debunked does not believe that alcohol is inherently evil or anything like that.   We are certainly not in league with the neo-dry lobby!  But when we as a society fail to appreciate that alcohol has a very real dark side for all ages, there are very serious consequences to doing so.  History speaks for itself.  So what are we waiting for?