MIKURIYA TO CSAM: "I QUIT!"

To: California Society of Addiction Medicine 74 New Montgomery
Street, Suite 230 San Francisco, CA 94105

American Society of Addiction Medicine 4601 North Park Avenue Suite
101 Chevy Chase, MD 20815

Colleagues,

As I contemplated whether or not to renew this year with the not
unsubstantial dues, I asked myself "Why should I?" Over the years
since I joined the organization I have tried to raise the possibility
of a harm-reduction option for the treatment of alcoholism.
Notwithstanding my repeated and persistent entreaties, I have been
repeatedly denied any opportunity for a collegial and professional
forum. I have even offered to make my patients available for
questioning and review. Nothing. Lame excuses -not ready yet.

Forays into spiritualism with self-styled practitioners responding to
the "spiritual needs" of addicts was particularly disturbing. Somehow
I don't remember any training in medical school in theological
studies. The blurring of boundaries and confusion of identity
diminishes, attenuates medical leadership, and reduces professional
credibility to cultism. Medical Review Officers conducting forensic
examinations are not engaged in a medical activity. Preoccupation
with urinary metabolites instead of actual fitness for duty further
diminishes medical leadership and reduces ASAM/CSAM to corporate
shills and trough feeders. Donald Ian MacDonald of ASAM drug czar< promoted piss testing along with Robert DuPont of
Paraquat fame. The societies support the federal government's
irrational drug-war policy while prominent addiction specialists seek
to maximize their share of court referrals.

I officially give up on ASAM/CSAM and any possibility of a magical
ethical transformation. I have been denied the opportunity to present
a viable, effective, and medically appropriate intervention: cannabis
as a substitute for alcohol and other addictive substances.

Retrospectively, I wonder why I waited so long to quit. I can no
longer maintain my wishful thinking that somehow ASAM/CSAM could be
fair, objective, professionally and medically correct.

I shall not be renewing my membership.

Tod H. Mikuriya, M.D.

Member since 1974 Certified by ASAM 1986 MRO Certified by ASAM 1992

Dr, Mikuriya is feeling a lot better since a stent in his liver
restored the flow of bile and proper digestion last week. Also, he
has been released from "medical house arrest" (his term) imposed
after a bacillus associated with TB was detected in a washing from
his lungs. He is working on several papers based on his clinical
findings and observations and his hypotheses re mechanism of action;
an electronic (and augmented) re-issue of his 1971 anthology,
Marijuana Medical Papers; and a second volume focusing on what
California doctors have learned in 10 years of seeing patients...
Dennis Peron is throwing a party for Dr. Tod this Sunday, April 2,
1-6 p.m., at his house in the Castro. Told it was to honor his work,
Mikuriya said, "To continue my work... a chance to pontificate!"

The Myth of "Amotivational Syndrome"

"There is no such thing as laziness. Laziness is only lack of
incentive." -Norman Reider, MD

A graduate student in the psychology department at the University of
Southern California, Sara Smucker Barnwell, has conducted a survey to
assess whether or not cannabis use undermines motivation. She emailed
a questionnaire to 200 undergraduates who had taken a course on drugs
and human behavior, and to 100 acquaintances of a co-author, Mitch
Earleywine, PhD, who were asked to forward it to others. She got
responses from some 1,300 people. She then analyzed the responses of
everyday users (244) and those who had never used (243).

Barnwell's questionnaire comprised an "Apathy Evaluation Scale" and a
"Satisfaction with Life Scale." Apathy was measured by 12 statements
such as "I don't follow through on my plans" to which respondents
gave their level of agreement ("Not At All, Slightly, Somewhat, Very
Much"). Satisfaction was measured by agreement to five statements,
including "If I could live my life over, I would change almost
nothing." The mean age of the participants was 33. They were mostly
Caucasian (79%), with a preponderance of students. One in three
frequent cannabis users described their use as medical.

Much of Barnwell's paper consists of statistical methodology
involving "T-distribution," "heteroscedasticity," "controlling for
unequal variances," "outliers (e.g. data points above/below three
standard deviations)," "standard transformations (e.g. square
roots)," "trimmed means," "alternative measures of effect size (the
estimated measure of the degree of separations between two
distributions)," "Cohen's delta calculations," "Pearson's
correlations," "Welch's heteroscedastic means comparison," "Yuen's
comparison of 20% trimmed means," etc. etc... The jargon is almost
impenetrable, but it appears that statisticians allow themselves to
discount "outlier" responses that don't jibe with the "central
tendency" of their data. In any case, Barnwell et al's "robust
statistical analysis" makes their simple, fuzzy survey study seem
supremely precise and worthy of publication in a peer-review journal.

But why quibble when they're "good on our issue?" Barnwell et al
conclude: "Participants who used cannabis seven days a week
demonstrated no difference from non-cannabis users on indices of
motivation. These findings refute hypothesized associations between
heavy cannabis use and low motivation... Daily users reported
slightly lower median subjective well-being scores (2 points less on
a 28-point scale)... Post-hoc tests find that some portion of the
differences in subjective wellbeing arose from medical users, whose
illnesses may contribute to low subjective wellbeing more than their
cannabis use."

The authors acknowledge that their results may have been skewed by
not taking into account use of alcohol and other drugs, and list some
other realistic caveats and counter-caveats: "Participant reactivity
to questions of motivation may pose an additional confound. Despite a
lack of empirical evidence supporting amotivational syndrome, the
popular concept is well known among cannabis users. Perhaps cannabis
users demonstrate sensitivity to questions regarding motivation,
exaggerating their own motivation in an effort to defy stereotypes.
In contrast, users tend to attribute low energy and motivation to
cannabis even when they use alcohol problematically, so there may
also be a bias for cannabis users to report lower motivation.
Further, collecting data via the internet may prevent some low
education or low income individuals from participating. Others may
feel uncomfortable reporting drug use online. Simultaneously,
individuals experiencing low motivation may be more likely to
participate in internet-based research rather than traveling to a laboratory."

Barnwell's paper, "Cannabis, motivation, and life satisfaction in an
internet sample," co-authored by Rand Wilcox of USC and Mitch
Earleywine, PhD, of the State University of New York, was published
in the online journal Substance Abuse Treatment, Prevention, and
Policy Jan. 12. It was funded by the Marijuana Policy Project.