DRUGS FLOP AT THE BALLOT BOX

THIS PAST ELECTION day, I was visiting in Arizona when the conversation with
my hosts turned to the state's ballot initiative that asked voter approval
to reduce legal penalties for the possession of relatively small amounts of
marijuana, and to create a register of people allowed to use marijuana for
medical purposes.

Our conversation turned to the politicization of psychoactive-substance use
over the history of America, the poor state of knowledge regarding the
medical value of smoking cannabis, and the high emotions that surround
public-policy related to psychoactive substances. The referendum was viewed
as a "crank" -- just one more effort by the fringe to get legal access to an
illegal substance.

Previous issues of The Brown University Digest of Addiction Theory &
Application have chronicled the scientific evidence for the adverse effects
of psychoactive substances. Part of the purpose of this effort is to counter
the overblown hype that often characterizes "drug education" in this
country.

Unfortunately, it seems that compared to other psychoactive substances of
abuse, there is more than the usual amount of overstatement of the dangers
of cannabis use. The problems of pulmonary toxicity, involvement in drug and
marginalized social groups, decrements in reaction time leading to
motor-vehicle accidents, and the deleterious effects on cognition and memory
are plenty enough reasons for why cannabis use is a problem in our society
- -- especially among our youth.

We don't need to demonize cannabis. This common strategy backfires,
especially when young people see through it, generalize all adult/authority
admonishment as hyperbole, and then discard the even more salient advice
about the dangers of tobacco and alcohol use.

In fact, research by Peter Monti's group here at Brown has illustrated that
nonjudgmental techniques, such as motivational enhancement, have potent
positive effects on adolescent alcohol use even when applied in the highly
charged setting of a hospital emergency room.

We may never learn the useful medical purposes for smoked cannabis. Legally
smoking cannabis, even if strongly controlled like other prescription drugs,
is likely too emotional a topic to permit the rational application of the
scientific method.

Is smoked cannabis more useful for the wasting syndromes of HIV and terminal
cancer than currently available medications or even tetrahydrocannabinol
(Marinol), one of the many psychoactive substances present in cannabis? Is
cannabis a useful adjunct to chronic or terminal pain? How about in less
life-threatening conditions such as muscle spasticity? Does smoking cannabis
offer an advantage to currently available medications?

It turns out that in Arizona, as well as in Ohio and Nevada, where other
"decriminalization" referenda were on the ballot, the voters soundly
defeated the measures. It seems as if the social and political fabric of the
United States will plague any dispassionate policy surrounding psychoactive
substances.

Currently, that plays itself out through our society's emphasis on punitive,
criminal-justice approaches to psychoactive substance misuse in the face of
evidence that shows treatment is a more successful and cost-effective
approach to curb psychoactive substance misuse.

I fear that it is our patients who will continue to suffer the consequences
of this moralistic and judgmental stance.