By Robin Jay, BHC Editorial Director

During BHC’s monthly interview recently with General Barry McCaffrey (Ret.), former Drug Czar under President Bill Clinton, the General asked to change our scheduled topic and “tiptoe out onto thin ice” by covering a controversial topic that he finds professionally and personally disturbing: medical marijuana. As of this interview, 13 states have enacted laws that legalize medical marijuana (see the accompanying chart, bottom). And in California, the booming growth in the marijuana industry has some state officials hoping it will also medicate the state’s financial woes. The irony of this issue is not subtle in a state that has banned the public use of trans fats in restaurants, yet wants to tax the medical use of a substance that the National Institute on Drug Abuse says causes a 4.8-fold increase in the risk of heart attack in the first hour after smoking the drug. To discuss this controversial issue, BHC spoke in-depth not only with Gen. McCaffrey (pictured, bottom left), but also Drug Czar Gil Kerlikowske (top right), Deputy Drug Czar Dr. Tom McLellan (top left), and President of the National Narcotics Officer’s Association Coalition, Ronald Brooks (bottom right). (To listen to the complete audio recordings of the three interviews conducted in the process of preparing this in-depth special report, scroll to the end of the article.)

“Let me tell you what I’m concerned about,” says Gen. McCaffrey. “I believe that with drug abuse in America, you look back over time, and drugs never go away, but it gets out of control. It creates a huge societal wave of criminal, social, medical, legal, family-related mayhem. Society organizes itself in desperation, but the drugs and alcohol are always there.

“We have dramatically reduced drug abuse from 1979 through today. We actually have done remarkable. The number I carry in my head is 13 percent of the population were past-month drug users and we’ve gotten it down to, I believe, around 6 percent. So here we are now, headed into the next decade, and I worry that we are seeing something that’s surprising to me. Given our enormous reduction in drug abuse in America, the enormous increase in the number of people having access to drug and alcohol treatment, the enormous success we had with public advertising and public service commercials and forming thousands of community anti-drug coalitions.

“The group out there that wants to legalize or normalize or decriminalize, or you pick the ‘-ize’ — there are not very many of them, but they’re sort of well-funded. They’ll say, ‘We fought a failed ‘War on Drugs’, we’ve got hundreds of thousands of people in prison for the possession of a joint. Let’s open the prison gates, let’s get realistic, get mature and by the way, there’s nothing wrong with most of these drugs, they’re far less dangerous than alcohol.’

“The argument about alcohol can seem pretty compelling. But what I worry about is we’re about to enter a period in which we’ll go10 years where we’re going to say to teenagers that binge-drinking beer, smoking pot, experimenting with drugs, [and] using Ecstasy isn’t all that dangerous. This whole medical marijuana thing is a complete farce. We’ve got in the city of Los Angeles 400 or more places selling pot to anybody that walks in off the street. So it’s not decriminalized. It’s been falsely ‘medicalized.’

“I see California kind of leading the way, but all across the country now, states are passing medical marijuana laws, in violation of two generations of building the most safe and effective Food and Drug Administration system in the world. We got this system and they bypassed it with medical pot. So, this farce on medical marijuana, where you can get the THC synthetic Marinol prescribed by your doctor right now in a pharmacy or all sorts of stuff — off-branding included. But that system’s being ignored, and we’re peddling home-grown marijuana all over in large parts of the country. So what I’m worried about is, will this administration, this president, stand up against it? Vice President Joe Biden was my hero who helped me with this issue. But where are the voices now that are going to speak up and say, ‘What are you doing? You’re normalizing the use of these drugs!’

"I go into drug treatment centers all the time, sit in on 12-step meetings, and at the end of it, I’ll say, ‘What should I tell high school kids about pot?’ And never have I talked to somebody struggling to achieve sobriety and maintain sobriety that doesn’t say, ‘Tell them and their parents and their pediatricians to not smoke dope.’

“So where is the voice that’s going to speak up? Is Gil Kerlikowske going to speak up? Tom McLellan? Dr. Westley Clark? Where are the voices that are going to push back against this? Or are we going to go 10 years and suddenly find ourselves with 13-17 percent of the population past-month drug users and another giant wave of addicts? What is going on? There’s the biggest issue I think we’ve got to address. But to do that, people have to have the scientific evidence and the courage to stand up and say, ‘No, we don’t think our kids ought to be smoking dope and binge drinking.’”

Feds 'Looking the Other Way'?

What has General McCaffrey scratching his head is why it seems the federal government chose to look the other way, allowing state laws to sidestep national law. In February, U.S. Attorney General Eric Holder announced an end on raids on marijuana dispensaries in California. Holder told reporters that American policy is now what President Obama said during his presidential campaign: that states should be allowed to make their own rules on medical marijuana. Following the announcement by the Attorney General, Los Angeles officials said applications for retail outlets to dispense marijuana surged.

Marijuana remains a Schedule 1 drug — the most restrictive schedule of the Controlled Substances Act because it has “no currently accepted medical use.” The Drug Enforcement Administration supports maintaining that classification, as does the Food and Drug Administration — which requires new drugs be shown to be safe and effective for their intended use before being marketed in this country. Marijuana received a Schedule 1 classification because it meets three criteria: high potential for abuse, no currently accepted medical use in treatment in the United States and lack of accepted safety for use under medical supervision.

There is also solid evidence that smoking marijuana has additional adverse health risks: NIDA reports that marijuana smoke contains 50—70 percent more carcinogenic hydrocarbons than tobacco smoke does. It also narrows arteries in the brain, not unlike patients with hypertension and dementia.

Perhaps most disturbing is a study published by the US Substance Abuse and Mental Health Services Administration (SAMHSA) that confirmed gateway effects of marijuana on our youth. It said the younger children are when they first use marijuana, the more likely they are to use cocaine and heroin and become dependent on drugs as adults. And people who smoke marijuana at a young age have an increased likelihood of cocaine and heroin drug dependence later in life. According to government studies, 100 million Americans have smoked marijuana in their lifetime, and a quarter of them have done so in the last month. On the other hand, national polls indicate Americans as a rule are against legalization.

The Attorney General’s re-position on medical marijuana and the growth in the number of states vying to legalize it have caused concern and confusion for the law enforcement officers who must decipher how to interpret the laws. Ronald Brooks is the President of National Narcotic Officers Association Coalition (NNOAC). The NNOAC is a coalition of state narcotic officers’ associations and other associations of law enforcement professionals around the country. The Coalition represents about 70,000 members from throughout the United States and is the voice of that profession in Washington, D.C. with the Congress and the Administration and with other associations such as the Drug Court Professionals, the International Association of Chiefs of Police, and the National Sheriffs. It was formed to provide that voice because at the state level, none of them had a good voice in Washington on policy or legislative issues.

“The whole issue with medical marijuana is kind of complex because it has become the wedge issue used by many who advocate legalization or decriminalization of drugs,” says Brooks. “Our position has always been that we believe the studies show that smoked marijuana is not an effective medicine. We’ve always said, ‘Hey, we’re not the docs, and we’re not the scientists. If the FDA, if the AMA, if the medical and scientific community advocated for crude marijuana, we would support that because it’s not in our position as non-scientists to decide that. But until then, we have a process that has been brought about beginning in 1906 with the Pure Food and Drug Act; 1914, with the Harrison Narcotic Control Act; and in a host of legislation since then.’ There’s a process and that is that the medical community asks for a drug; there are FDA trials; [and] it’s clinically approved based on science, not based on emotion at the ballot box, like all our medical marijuana initiatives across the country so far.”

BHC asked Brooks during our interview how the 13 states that have legalized medical marijuana are able to skirt the federal law.

“Well, they’re not. That is the problem. That is the confusing position that they put law enforcement officers and prosecutors and judges in,” says Brooks. “Obviously, federal law supersedes state and local law, but there is a limited number of federal resources — both law enforcement and prosecutorial resources and judges. So the federal government is now in a position of having to oppose state law and also try to decide, what are these resources we can apply to investigating and prosecuting at a federal level? I think the underlying question is how dangerous is marijuana and who’s behind this?

“There is a growing drug legalization movement, but it’s really run by three gentleman, George Soros, one of the richest men in the world who’s primarily a commodities broker living in Connecticut; Peter Lewis the CEO of Progressive Insurance; and John Sperling, the founder and CEO of the for-profit University of Phoenix. They have funded millions of dollars into the whole legalization and decriminalization movement to move toward legalizing drugs, using things like changing from an abstinence-based prevention message to a harm-reduction message, changing from no-drug-use, total abstinence, to medical marijuana. And then moving from there — now in California — with a bill in the legislature to just outright legalize marijuana.

Marijuana Not a 'Safe Drug'

“So that has been the ongoing movement: ignoring the fact that marijuana is a proven dangerous drug. I mean 65 percent of all teens in drug treatment today according to ONDCP are in treatment because of marijuana, not because of alcohol, cocaine heroin or meth. According to the Drug Abuse Warning Network study of targeted cities, ER admissions have tripled since 2004, and now ER admissions marijuana exceed heroin. It’s clearly dangerous. They ignore the fact that drugged driving, according to the former director of NIDA, now kills at least 8,000 Americans a year, and in Maine, another half a million, and those are under-reported because our cops and troopers on the highways are not as well trained to recognize drug intoxication symptoms as they are alcohol. So it’s under-reported, but still a large problem. And now, the CDC released just recently in the news, I think, 16 states where drugged fatalities — which are primarily sudden overdose, so not marijuana but certainly part of that drug culture — where drug overdoses are killing more people than traffic fatalities.”

Brooks is based in California and well aware of state’s push for taxing medical marijuana. BHC asked him why a state so health conscious as to pass a ban on certain types of fats in restaurants would entertain legalizing such an unhealthy carcinogen as smoked marijuana for medical purposes. Could it be that the real impetus for the legalization is a political fundraising effort to create a revenue source to help get the state out of budgetary mayhem?

Brooks replies, “Well, I actually think that’s a smokescreen. I mean the state is in the worst budget crisis of any state in the union, and the worst in the history of our state, at least in my lifetime. But if you look at it, the amount of revenue that would be generated from that bill [can’t compare to the costs] when you consider the amount of money it would cost to set up, develop a regulatory agency [and] to regulate the industry. When you look at the chronic healthcare costs that would surely happen as marijuana use was increased, and if you look at the highway safety cost and the increase in insurance, both worker’s comp, because of the increase in workplace accidents, and then highway insurance — motor vehicle insurance — because of the insurance in drunk driving accidents, there’s no way that they could raise enough revenue that they could even break even. And that doesn’t factor all of the lost opportunities, the people that then make the wrong choice.

“The SAMHSA studies show that the kids that choose not to use drugs, including marijuana, consider strongly in their decision the fact that it’s illegal, there’s a negative social stigma there. They’re afraid of disappointing family and going to jail and getting in trouble. So we know. I mean, we saw Alaska decriminalize marijuana for adults [for a few years], not even for kids, but during that time period, teen marijuana use was double that of anywhere else in the nation.

“We know there is a cause and effect to decriminalization and increased marijuana use, and even though they try to regulate and keep kids from using marijuana, clearly once the flood gate is open, they can’t keep kids from using marijuana. So we know that in California, were we to legalize it, first of all there would still always be a black market because people would want to avoid the tax. They would want to buy without regulation. But even if we could regulate it, it’s going to open this up to teen drug use. I always try to remind people that since 9/11, no kid has been hurt on American soil due to terrorism, but every year, kids have to make a choice, whether to use drugs or not. Every kid — whether you’re in a big town or a small town, whether you’re affluent or not, regardless of race or gender or social standing — kids are faced with a tough choice. And when they make a wrong choice, they drop into this abyss of drug-taking. They lose their opportunities. They don’t have a chance to be a cop, or a firefighter, or a teacher, or the president. They have lost that opportunity, and that is the real tragedy of this political debate, that we’re using the health and well being of kids as pawns in a political game.”

Those in favor of legalizing marijuana take a fiscally prudent stance, saying it’s a “commonsense” effort for a “victimless crime” that would reduce the tide of violence against law enforcement, could reduce overcrowded prisons, would end the violation of human rights (similar, they say, to ending prohibition of alcohol). Legalizers theorize that an increase in the drug supply wouldn’t increase the rate of addiction. Physicians who prescribe medical marijuana say it reduces nausea, eases glaucoma, and improves appetite and sleep in AIDS patients, among other things.

The 'Dynamic Duo' of Drug Policy Weigh In

To discuss the law-enforcement concerns and the question about scientific benefit versus scientific dangers of smoked marijuana, BHC next interviewed the Director and the Deputy Director of the Office of National Drug Control Policy (ONDCP), R. Gil Kerlikowske and A. Thomas McLellan, Ph.D. Both were appointed this year by the new administration, and their backgrounds make them especially dynamic as a partnership. (And, with tongue-and-cheek humor during our interview, they called themselves the ‘dynamic duo’ of drug policy).

Drug Czar Kerlikowske has a 37-year law enforcement and drug policy background. He most recently served nine years as the Chief of Police for Seattle, Washington. When he left, crime was at its lowest point in 40 years. Previously, he was Deputy Director for the U.S. Department of Justice, Office of Community Oriented Policing Services. For his part, Dr. McLellan is one of the nation's leading drug and alcohol scientists who co-founded the non-profit Treatment Research Institute (TRI) in Pennsylvania as a translational center that would adapt and engineer promising scientific findings into useful products and services that could be broadly used throughout the field.

BHC asked Director Kerlikowske and Dr. McLellen what issues since their appointment they felt were the hottest topics they’ve faced. Director Kerlikowske responded, “I think for hot topics, one that’s been around but actually hasn’t gotten as much attention or publicity (at least not national attention until maybe within the last six months) is the overdose deaths. The fact that more people are dying from an overdose than a gunshot wound; the fact that 16 states have said that more people are dying from drugs than from car crashes — and that’s based upon 2007 data. So my guess would be that it may be the number-one cause of accidental death in the country right now.”

ONDCP Deputy Director Dr. Tom McLellan added, “Something also that I thought about is the issue of drugged driving, which is not getting the kind of attention it needs. I think generally, the things people don’t realize is the availability of far better prevention and treatment interventions.”

The new ONDCP Directors have shifted the focus on the drug issue in America away from President Nixon’s “War on Drugs” to one Director Kerlikowske calls a “balanced approach.” BHC asked him to clarify what he meant by this.

“The balanced approach is our position, because we wanted to end the ‘War on Drugs’ — it hasn’t been a successful metaphor for what we’re dealing with, which is not just a public safety problem, but also a public health problem. [The War on Drugs approach] really limits the tools that you can use when you’re dealing with it. So you’re thinking about educating and informing the public about a disease — addiction is a disease. And dealing with it requires a variety of tools. The ‘War on Drugs’ metaphor just is not good, and actually, it’s caused probably a great deal of difficulty, particularly with minority communities.”

Dr. McLellan added, “I would just like to say that we don’t want this balanced approach that Gil’s talked about to mean we’re reducing our commitment to preventing the availability of drugs. That’s not the case. We want to just increase other tools that are now ready to go.”

Our discussion then switched to the issue of medical marijuana. Dr. Kerlikowske recently spoke at the International Association of Chiefs of Police Annual Conference and addressed the issue of medical marijuana. We asked him to talk with us about the ONDCP’s position on the issue. Considering that the FDA has not approved marijuana as a medication, we asked why physicians in states that have legalized medical marijuana don’t just prescribe Marinol, a cannabinoid that’s FDA-approved. And how is it that states are able to have a law that overrides the federal position?

“I’m going to turn some of this over to Tom when it comes to the Marinol, but here is where we are. One is we don’t believe that people should vote on what drugs to take. Two, that medical science should answer the question of what parts of the marijuana plant would in fact have some value in treatment,” says Director Kerlikowske. “We know that the raw marijuana plant is not medicine. States in our federalist society are certainly allowed to pass individual laws, but that doesn’t mean that it still is not against federal law. The Attorney General issued some guidelines, which were, we think, proper and needed, to the various U.S. attorneys who operate within those states that have passed medical marijuana laws. When it comes to the Marinol issue, I’ll turn that over to Tom.

Letting Science and Research, Not Public Opinion, Drive Policy

“I think it’s useful to think by analogy here,” said Dr. McLellan. “We know that nicotine is a perfectly good drug, but I don’t hear anybody advocating for medical tobacco. Opioid medications have proven medical value. I don’t hear anybody arguing for smoked poppies as a new medical advance, and there are reasons for that. It simply would never pass FDA approval, and nor should it. We are completely for the treatment of conditions that would benefit from cannabinoid medications, and we’re urging pharmaceutical companies, as they already are, to extract cannabinoids and cannabinols and refine them into preparations with known potency, known purity and delivery mechanism that are consistent. It is the case that for people that have nausea, it’s tough to take orally. That’s absolutely right, so we do need inhaled medications, but smoked marijuana cigarettes ain’t no medication, and never will be.”

Recently on an email listserve hosted by the Office of National Drug Control Policy, the topic buzzing around the electronic water cooler was an article titled “Stiletto Stoners” that appeared in an issue of Marie Claire magazine. The article reported on a study that revealed one in five women who admitted to using marijuana in the last 30 days lived in a household with an income of $75,000 or higher. It said many successful women choose cannabis over alcohol because of lower intoxication levels, lower addiction levels, more pleasurable effects, impossibility of overdose and non-existent hangovers. We asked Dr. McLellan to comment on these statements.

“It’s simply factually inaccurate,” said Dr. McLellan. “There’s a known and well-characterized marijuana withdrawal symptom. It isn’t of the same magnitude as heroine or opiate or alcohol, but nonetheless, there are cannabinoid receptors that have been well characterized. It’s the same kinds of phenomena that we’ve seen in other addictions, and this all meets DSM-4 and ICD-9 diagnostic criteria. There just seems to be wished belief that marijuana is benign. It is debatable how bad marijuana is for you — that’s a debate — and for whom it’s the worst. There’s no debate that marijuana is good for you, because it’s not good for you. If you inhale the fumes of burning carbon-based things, it’s not good for you. And so cigarettes, marijuana, anything that you would inhale like that — super-heated carbons with lots of toxic gases in them — aren’t good for you.”

We next asked the ONDCP directors to comment on the confusion in law enforcement regarding the mixed messages of state laws and federal law. We presented this scenario: If someone who lives in a state where medical marijuana is legal had a physician recommendation for medical marijuana, and if that same person traveled to New York where smoking is banned in public, what should a law enforcement official do if the Californian smokes his medical marijuana in public?

Director Kerlikowske responds with a touch of humor. “You know, I think you’re asking the question to the wrong folks on the individual state laws and how they should be interpreted. Neither Tom nor I are attorneys, we just play them on TV, so we probably can’t help you with that one.”

Dr. McLellan adds, “I will say this. But would you be allowed to smoke marijuana in a place where you’re not allowed to smoke cigarettes? That’s hard for me to imagine.”

BHC told the ONDCP Directors about our discussion with Ronald Brooks and the confusion he says narcotics officers face when trying to answer the question of whether someone should be arrested for the possession of a Schedule 1 drug. We asked Director Kerlikowske to figuratively put his law enforcement hat back on for a moment and offer advice for officers trying to figure out this dilemma.

“Well, I think there are two things [to consider,]” said Director Kerlikowske. “One is that — I think rightly so and appropriately — the Attorney General has issued some guidelines, because you have a variety of United States attorneys dealing with a variety of state laws and you have finite prosecutorial and law enforcement resources. The Attorney General issues guidelines on a routine basis to United States attorneys. So I think one that’s particularly helpful. But here’s the other part, and I’ve talked to a number of my colleagues in different states, including Washington state, that have medical marijuana, and the states passed these laws. It really is up to the officials in these states to deal with this. Now, we’ve seen well over 150 communities in California alone that are through planning land use, zoning, licensing, etc., and moratoriums dealing with the dispensaries. I don’t think that the concern has really ever been, or focus has ever been, on those that have a doctor’s recommendation.

“The concern is over the dispensaries and whether or not they operate within own state laws. I think you’re also seeing this in a number of articles in Colorado also, where, through a variety of mechanisms, you’ve got to go back and look. States and cities and counties have dealt with similar issues — not exactly analogous, but similar issues — when it comes to adult clubs or so-called strip clubs. Liquor establishments are licensed premises when they’ve developed zoning restrictions and land-use licensing, and I think that you’re seeing them deal with the dispensaries now in a similar way.”

“If I may,” adds Dr. McLellan, “You used the expression marijuana ‘prescriptions’ a couple of times. It is really not possible to get a prescription for marijuana, because you need a known dose and you need known potency, so it’s not possible. So in the case of marijuana, some doctors write recommendations and that’s what you bring to the dispensary. It seems pedantic, but it actually bears some thought.”

'Drugged Driving' a Sleeping Giant

“I think the concern that Tom brought up — and we are really having trouble getting traction with this — is the Department of Transportation’s national roadside survey report about drugged driving. One of the drugged driving points has been marijuana use behind the wheel,” says Director Kerlikowske. “I think this report is one of these sleeping giants. On Oprah recently, they had the family of that horrible accident on the Taconic Parkway in New York. The woman and the children were killed, including the vehicle she struck, and the reports in the newspaper cited both marijuana and alcohol. I don’t think people are paying anywhere the level of attention to the drugged driving issue that they’re paying to text driving.

“This was the first time in 40 years that the Department of Transportation actually studied or checked for drugged driving, and the numbers are very high, significantly higher then alcohol driving. But if you look at the progress that’s been made over 40 years on alcohol because of education and enforcement, I think we need a full-court press when it comes to drugged driving.”

To add to this from a medical and scientific point-of-view, we asked Dr. McLellan to discuss the feelings of control people have who are driving while high on marijuana, compared to intoxicated on alcohol.

“There have been a number of controlled driving experiments and driver simulation studies, and summarizing perhaps too generally, what you can say about alcohol-impaired driving is that people drive way too fast and they think they’re in control. Relative to that, people who are under the influence of marijuana drive way too slowly and are anxious about making mistakes. You might think that’s a recipe for safety but it’s not, if you’re a guy driving 35 miles an hour in a 60-mile-an hour highway. And the other thing is, as Gil said, when the National Highway Traffic Safety Administration did these studies, the majority of people had both alcohol and another drug, usually marijuana, on board. It is unknown what that combination does to your ability to drive. But just guessing here, I can’t imagine it’s improving it.”

In closing, BHC asked the Directors, “If you today could wave a magic wand and have the policies be your way nationwide, if you had that control, what would you say to California and some of the other states who feel that part of the reason that they’re legalizing marijuana, or taking steps in that direction, could be beneficial because of financial reasons — to legalize medical marijuana in order to tax it for a revenue stream and perhaps get out of the rut that they’re in financially?”

Director Kerlikowske responded, “I think that’s an easy one for both of us to answer, and we’ve discussed it a little bit. Right now, you see medical marijuana being advertised as the cure for violence in Mexico, as healthcare [and] as a salvation to the state tax woes. I think when you see something advertised like that, you’d be very suspicious of the product. We tax alcohol and we tax tobacco, but the studies and the research — I’ve seen economic reports show that the amount of taxes collected doesn’t even begin to equate to the health costs and the social cost as a result of tobacco and as a result of alcohol, and I’ll let Tom add to that.”

“Well, first of all, I completely agree with everything that was just said, but wait there’s more,” says Dr. McLellan. “Let’s take a further look at some of our legal drugs. Let’s suppose we had the ideal policy, and let’s imagine that there was medical benefit to marijuana, and let’s imagine that we had it available in a controlled way under doctors’ supervision, under optimized circumstances. Well, you don’t have to imagine. Let’s talk about another drug for which there’s absolutely clear medical benefit, and it’s under the control of doctors and regulated by the FDA, but it’s more available: oxycodone. Now, just because it is indeed legal, and because it’s made more available, you now have whole areas of this country under the scourge of oxycodone abuse. And there’s a drug where it is absolutely the case that it has a clear medical benefit and doctors prescribe it rigorously and still, when you have a drug that has abuse potential, you’re risking the development of far broader problems. Last point: A lot of this is under the view that there’s a fixed number of people that would be negatively affected by any drug — let’s say 10 percent. ‘Let’s get it out of the way. We’ll tax. We’ll offer treatment, but for everybody else, it will be a benefit.’ That is incorrect. The harms and the abuse and dependence liability are a direct function of the availability of any drug, and so it’s no reason to think it’s any less with marijuana.”

Listen to the audio interviews

Click here to listen to the audio interview with General Barry McCaffrey (Ret.).

Click here to listen to the audio interview with Drug Czar Gil Kerlikowske and Deputy Drug Czar Dr. Tom McLellan.

Click here to listen to the audio interview with President of the National Narcotics Officer’s Association Coalition, Ronald Brooks.

Legal Medical Marijuana States: Laws, Fees and Possession Limits

 Table Source: http://medicalmarijuana.procon.org.

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