There’s more to drug policy than legal or illegal
In a recent post, I tried to unpack “drug policy” to look beyond legal/illegal and think through the kinds of things that drug policies determine and influence.
Historically, it seems that concerns about the harms associated with drugs have overshadowed the harm associated with policies that seek to prevent those harms.
It seems particularly important at this time to acknowledge the direct and indirect harms associated with drugs, and the direct and indirect harms associated with drug policies.
Several articles published within the last couple of weeks brought that post and the role of policy to mind.
Addicted to Cannabis?
The NY Times recently published an article on cannabis use and addiction. It raises questions about trends in use (also addressed in this recent article), the relationship between those trends its legal status, how differences in harms influence the ways drugs are thought about, and how problems are conceptualized by the public, journalists (the authors equate cannabis use disorder and addiction), and professionals.
Julian (who asked not to use his last name when talking about a sensitive medical condition) didn’t have much of a social life, so he started smoking by himself to pass the time. “Weed became my friend,” he said. “I would get off work and I would smoke because I was bored.”
Soon, Julian’s life began to revolve around cannabis. Smoking never interfered with his work, but it stopped him from doing just about everything else. “Typically, when you move to a new city, you establish new relationships, and I was doing none of that,” he said. “I was living almost like a recluse.”
…Despite the common misconception, people can become addicted to cannabis just as they can with other drugs, like alcohol or cocaine. As more states either decriminalize or legalize cannabis, more people are using it than ever before. According to the National Survey on Drug Use and Health, in 2021, approximately 19 percent of Americans 12 and older used cannabis, and nearly 6 percent of teens and adults qualified as having cannabis use disorder…
…The potential consequences of cannabis use disorder are not as severe as with other drugs like opiates, where overdose deaths are a dire concern. But cannabis addiction can cause “a dramatic decrease in quality of life,” said Dr. Christina Brezing, an assistant professor of psychiatry at Columbia University.
How Do You Know if You’re Addicted to Weed? (2023). The New York Times.
Cannabis Prices Plummet; Cannabis Real Estate?
This Bridge Michigan story raises questions about policy influences price, how price influences use patterns, industry consolidation, and the creation of adjacent business sectors.
…as revenues rose for recreational use, the price of marijuana has plummeted. The average price of an ounce of recreational marijuana was $160.10 in February of last year compared with $86.00 this February.
Experts say one reason the price for marijuana is constantly decreasing is to encourage more consumers to buy it legally, rather than from illegal sellers.
“Even though prices are falling, there’s more people buying in the legal market [and] that’s what’s driving the increase in overall revenue,” said Beau Whitney chief economist for the National Cannabis Industry Association.
Others say oversupply is driving down the price of marijuana.
The Michigan cannabis industry started to become oversaturated with products about a year ago, causing prices to decrease, said Corbin Yaldoo, founder of Corbin Ventures, a commercial real estate development and investment firm in Bloomfield Hills that specializes in cannabis real estate.
“The larger operators have more capability of selling products at a cheaper price,” he said. Because larger operators are able to do this without taking a loss, they ultimately have control over the market.
“Michigan is in its consolidation stage right now, so larger operators are acquiring smaller operators or they’re merging together,” he said.
There isn’t anything that can be done immediately to help suffering businesses, but Yaldoo said lawmakers should limit how much cultivation space they allow growers.
Good times for Michigan marijuana customers, a struggle for the industry | Bridge Michigan. (2023).
Changes in Alcohol Consumption Sharpen Health Inequalities
A recent Lancet article describes the consequences of changes in alcohol consumption patterns, the role the alcohol industry plays in the dominant public health narratives, and how those narratives obscure the inequities associated with those changes in consumption.
Alcohol-specific deaths (encompassing those deaths that are a direct consequence of alcohol, such as alcohol-related liver disease) in the UK have taken an extremely concerning turn, with the Office for National Statistics reporting 9641 such deaths in 2021—the highest on record and a 27·4% increase since 2019 (n=7565).1 This number of deaths reflects alcohol consumption trends since the pandemic, during which drinking patterns became more polarised, with people who were drinking lower amounts before the pandemic on average, drinking less, and people who were drinking higher amounts before the pandemic drinking more.2 This change represents a substantial sharpening of health inequalities, driven by changing consumption patterns of a harmful product.
Communications from the UK’s alcohol industry via their responsibility body, the Portman Group, present a different situation. In 2022, communications from the Portman Group published infographics that drew attention to declines in overall average alcohol consumption, emphasising that “the majority of UK drinkers consume alcohol responsibly”.3 The industry also explicitly links its activities to declines in average alcohol consumption. In an evidence submission to the Scottish government on minimum unit pricing,4 the Portman Group stated that it, along with others, has “played a role in supporting these falls in consumption and harm”, citing corporate social responsibility initiatives like the UK Responsibility Deal (which an independent evaluation found to not be effective5), funding DrinkAware (which independent research has shown communicates misinformation on alcohol-related harms6); and supporting community alcohol partnerships (for which there is little evidence of effectiveness).
The responsible drinking language used in these statements has been found to be overwhelmingly used by industry, rather than other stakeholders like government health departments or independent alcohol charities.8 Such language has been described9 as strategically ambiguous, designed to build positive impressions of an industry that appears to foster responsible use of its product, but with little evidence of effectiveness for responsible drinking campaigns. Crucially, talk of a responsible majority implies that people who drink large amounts of alcohol are somehow irresponsible, and that it is their apparent susceptibility which is to blame. This framing also implies that alcohol harm is a problem only for people drinking the most amount of alcohol, whereas the evidence is clear that alcohol causes substantial harm beyond this group.10
Maani, N., van Schalkwyk, M. C., & Petticrew, M. (2023). Trends in alcohol-specific deaths in the UK and industry responses. The lancet. Gastroenterology & hepatology, 8(5), 398–400.
Minimum Unit Pricing Associated with Reduced Alcohol Deaths
This Lancet study examines the impact of Minimum Unit Pricing (MPU) for alcohol on deaths and hospitalizations in Scotland.
Across 32 months of implementation, we found a significant 13% reduction in deaths wholly attributable to alcohol consumption compared with our best estimate of what would have been expected had the legislation not been implemented. This is equivalent to avoiding 156 deaths per year, on average. There was a corresponding estimated reduction of 4% in hospitalisations for conditions wholly attributable to alcohol consumption, equivalent to avoiding 411 hospitalisations per year, on average. The use of a controlled interrupted time series study design allowed us to infer that the estimated impacts were plausible causal effects attributable to MUP legislation.
Exploratory analyses indicated that the largest reductions were estimated in the 40% most socioeconomically deprived areas in Scotland, indicating that the implementation of MUP has had a positive impact in tackling deprivation-based health inequalities in alcohol health harms. The implementation of MUP legislation was associated with reductions in deaths wholly attributable to alcohol consumption for males and females. Furthermore, we found associated reductions in the age groups of 35–64 years and 65 years and older, but were unable to evaluate change in the 16–34 years age group due to the relatively small number of deaths for this group. The positive impact of MUP legislation by population subgroup was generally similar for hospitalisations, although to a lesser degree.
Wyper, G. M. A., Mackay, D. F., Fraser, C., Lewsey, J., Robinson, M., Beeston, C., & Giles, L. (2023). Evaluating the impact of alcohol minimum unit pricing on deaths and hospitalisations in Scotland: a controlled interrupted time series study. Lancet (London, England), S0140-6736(23)00497-X.
Alcohol Outlet Density and Crime
Drug and Alcohol Review published a study on the relationship between alcohol outlet density and DUI, assaults, robberies, and interpersonal violence. This raises questions about public safety costs associated with the number of outlets and their geographic placement.
In this study, we assessed effects of outlet densities on six alcohol-related crimes during weekday, weeknight, weekend day and weekend night hours… we measured relationships between crime outcomes and outlet densities for different days and times. Strong evidence supported differences in DUI, assaults and robberies by day and time. DUIs and assaults occurred more often in areas with more bars or pubs on weekend nights. …Moderate evidence supported differences in IPV (interpersonal violence) by day and time.
Gruenewald, P. J., Sumetsky, N., Mair, C., Lee, J. P., & Ponicki, W. R. (2023). Micro-temporal analyses of crime related to alcohol outlets: A comparison of outcomes over weekday, weekend, daytime and nighttime hours. Drug and alcohol review, 10.1111/dar.13644.
Drug Policy and Voting Rights?
This snippet from an email newsletter from the Detroit News raised questions about the influence of drug industries on public policy only tangentially related to drugs.
If you were going to the polls on this morning 110 years ago, you saw this in your Detroit News:
Women were voting, too, but only if they owned or shared property with their husbands. On April 7, 1913, full women’s suffrage was on the statewide ballot − and Michigan voters rejected it. (Influenced by a liquor lobby that feared Prohibition would follow, a reminder of the perpetual influence of money in politics.)
Drug policies shape the influence that drug manufacturers and purveyors have. Are they permitted to lobby? Are there any restrictions on their donations? Does tax revenue associated with their industry create incentives to protect them?
Too Few Options for Families Dealing with Addiction
The NY Times recently published an essay on the limited options families face when a loved one is addicted.
…substance use disorders, if untreated, can lead to criminal behavior, debilitation and — all too often — death. The number of overdose deaths in the United States is higher than ever.
Ideally, people with addiction would seek care. But waiting for a person to choose treatment for a disease that affects rational thought can be catastrophic, now more than ever.
Opinion | My Son Was Addicted and Refused Treatment. We Needed More Options. (2023). The New York Times.
The writer goes on to discuss the policies and interventions that would help, he points to some gaps that make it difficult for patients and families to find and access quality treatment, and the absence of involuntary treatment processes to protect loved ones at high risk for death due to their addiction.
A couple more papers just came to my attention.
Alcohol Use Disorder Stigma and Responsibility
This Addiction article concludes that alcohol problems are more stigmatized than other mental health problems. This appears to be related to the perceived risk they pose to others and the responsibility ascribed to them.
This fits nicely with some of the references above. The study on alcohol outlet density demonstrates that there are real negative externalities associated with alcohol consumption, and the paper on changes in alcohol consumption patterns speaks to the influence of industry public education efforts emphasizing responsible consumption frame alcohol problems as a failure of personal responsibility.
Our systematic literature search identified 24 publications since 2010, analyzing aspects of stigma toward people with AUD and other mental disorders. The synthesis of findings revealed that stigmatizing beliefs and behaviors toward people with AUD were pervasive in the general population and usually more pronounced than toward persons with depression or schizophrenia. More specifically, people with AUD tend to be perceived as more dangerous and more responsible for their condition, as well as being faced with a greater desire for social distance and a higher degree of acceptance of structural discrimination than people with substance-unrelated disorders.
Kilian, C., Manthey, J., Carr, S., Hanschmidt, F., Rehm, J., Speerforck, S., & Schomerus, G. (2021). Stigmatization of people with alcohol use disorders: An updated systematic review of population studies. Alcoholism, clinical and experimental research, 45(5), 899–911. https://doi.org/10.1111/acer.14598
Alcohol-Related Harms Have Disparate Impact
This Addiction paper looks at the prevalence of alcohol-related harms to others and their distribution among various groups.
Almost half (48.1%) of respondents in this Australia-wide survey reported experiencing one or more harms from others’ drinking in the last year, with 7.5% reporting that they had been negatively affected“a lot” by others’ drinking, and another 26.8% reporting they had been harmed “a little”. Analysing the likelihood of any harm from others’ drinking (including specific harms from known drinkers’ or strangers’ drinking), women, young people, Australian-born (vs. participants born in non-English-speaking countries) and occasionally reported HED (heavy episodic drinking) were more likely to report AHTO (alcohol’s harm to others).Women were more likely than men to be negatively affected both by the drinking of people they lived with and were related to, as well as by the drinking of strangers. In line with previous research, women and young people were at greater risk of AHTO.
More women than men have reported a range of harms from others’ drinking, including arms from intimate partners (24) and financial harm (26) from others’ drinking. This is consistent with previous findings from many countries, including the previous Australian survey (3, 27, 28). Young people are the group of adults that have consistently reported more harms from strangers’ drinking and from drinking of their friends and co-workers (3, 4, 27, 29). In our study, harm from strangers’ drinking was considerably lower for those aged 65 or more than for younger participants, and significantly higher for women aged 18-34 than for middle-aged women. Results in our study are broadly consistent with findings in previous studies that young people report more harms than older adults from strangers’ drinking and from drinking of their friends and co-workers(3, 4, 27, 29).
…women reported substantially more harm than men, particularly from people they knew but also from strangers. This suggests that attention needs tobe paid to reducing harm particularly to women (and particularly younger women) from others’ drinking. Data focusing on differences by this and other social inequalities can provide guidance and benchmarking for policy discussions and interventions.
Laslett, A-M, Room, R, Kuntsche, S, et al. Alcohol’s harm to others in 2021: who bears the burden?. Addiction. 2023: 000– 000. https://doi-org.ezproxy.emich.edu/10.1111/add.16205.