Marijuana liberalization has proliferated throughout the United States over the past decade. Though still technically illegal under federal law, marijuana is now permitted for medical use in 40 states and recreational use in 24 states and the District of Columbia. Attitudes towards marijuana use have greatly changed throughout the United States over the course of the last twenty years. According to a 2024 Pew Research poll, 88% of Americans now believe that marijuana should be made legal for at least medical use, with 57% of Americans also supporting legalization for recreational use. This sentiment stands in stark contrast to public opinion in 2000, when only 31% of Americans supported recreational legalization.

Additionally, major research organizations have concluded that marijuana can effectively treat a range of medical conditions, including chronic pain, according to a report from the National Academies of Sciences, Engineering, and Medicine (NASEM). Other studies show that marijuana is also effective in treating mental illnesses, such as post-traumatic stress disorder. Amid changing perceptions of recreational use and increased understanding of potential medical applications, the U.S. is now considering an adjustment of marijuana’s current prohibited status under federal law.

Despite these trends towards the general acceptance of marijuana legalization in the U.S., many remain skeptical of marijuana’s alleged benefits and wary of its potential consequences. In his book Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence, journalist Alex Berenson voices concern about the relationship between marijuana use and the increased likelihood of experiencing psychosis and developing schizophrenia. Furthermore, the onset of schizophrenia, he argues, makes one more likely to experience a violent psychotic episode, increasing the risks surrounding marijuana use. He also alleges that medical marijuana use is misguided, given that little medical evidence suggests that the drug has any effectiveness in palliating the medical complications its advocates claim it can treat.

This review examines Berenson’s claims in light of the current literature in epidemiology, public health, and economics by reviewing his research summary and analyzing government data measuring marijuana use, mental illness, and violence. Despite Berenson’s claims, much of the literature he cites concludes that marijuana is effective in treating many conditions, including chronic pain—one of many scientific findings Berenson chooses to omit in his book.

However, there does appear to be an association between mental illness and marijuana use at the individual level, including a rare onset of schizophrenia. Still, the risk of developing mental illness is less associated with marijuana use than other intoxicants, like alcohol, and the risk decreases with lower levels of consumption. Additionally, it is unclear whether marijuana use leads to an increased likelihood of developing mental illness or if people with mental illnesses, like depression, are just more likely to use marijuana. The possibility of self-medication further complicates the understanding of this relationship.

Due to predictive decreases in violence following regulated marijuana access at the state level, we conclude that benefits from further liberalization outweigh public health concerns surrounding mental illness. Additionally, the risk of schizophrenia can be materially eliminated for almost all people with no current mental health issues through reasonable moderation. Furthermore, because marijuana-induced mental illness is so rare, marijuana’s effect on violence through compounding mental illness is not measurable and marijuana legalization appears to reduce the prevalence of violent crime and suicide.

Our analysis finds that at the state level:

• Recreational and medical marijuana legalization are not followed by increases in mental illness.
• Increases in marijuana use are associated with increases in mental illness for all age groups.
• Regulated marijuana access is followed by slight reductions in suicide for young adult men.
• Recreational marijuana access is followed by reductions in homicide.
• Recreational and medical marijuana legalization are associated with reductions in drug crime arrest rates and reductions in racial disparities in drug-sale arrests.
• Recreational marijuana legalization is followed by increases in marijuana use among adults, but stable rates of marijuana use among children.

Berenson’s characterization of the academic literature studying marijuana is limited, periodically inaccurate, and not sufficient to model policy. Despite the claims made in Tell Your Children, marijuana prohibition does not reduce rates of mental illness, while legalization appears to reduce violence by eliminating dangerous illicit markets.

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The Centers for Disease Control and Prevention reported 70,630 drug overdose deaths for 2019 in the United States, 70.5 percent of which were opioid-related. Amid unprecedented drug-related mortality across the entire United States, Prescription Drug Monitoring Programs (PDMPs) are the most popular interventions states enact to address opioid addiction and overdoses. Prescription Drug Monitoring Programs allow health officials and law enforcement to review the prescribing histories among doctors and patients in hopes of reducing inappropriate prescribing that might lead to addiction or death. However, the inception of PDMPs has been followed by increasing rates of opioid overdose and stable rates of drug addiction. With 19 years of mortality data, this analysis assesses whether Prescription Drug Monitoring Programs have significant effects on either opioid prescribing or mortality.

This study finds that, although Prescription Drug Monitoring Programs’ intermediary purpose to reduce prescribing has been achieved by reducing opioid distribution by 7.7 percent, they have had inconsistent effects on prescription opioid overdoses, while increasing total opioid overdoses by 17.5 percent due to increased mortality from the black market varieties by 19.8 percent.

FIGURE ES1: STATE-LEVEL DEATH RATES FROM LICIT AND ILLICIT OPIOID OVERDOSES FOLLOWING PDMP IMPLEMENTATION BY STATE

Since Prescription Drug Monitoring Programs fail to achieve their ultimate goal of reducing opioid overdoses, their funding should be re-appropriated to more effective mechanisms to reduce addiction and overdose rates, such as providing access to prescription-quality opioids for medication-assisted treatment (MAT).

Introduction and History

Prescription Drug Monitoring Programs (PDMPs) have been used in the United States since the early 20th century. Prior to 1914, natural opiates—the predecessors to modern synthetic or semi-synthetic “opioids”—were unregulated by the federal government and widely available for purchase without prescription in most of the United States.¹ Use among the American public was quite commonplace. According to one article published in The New York Times, one in every 400 United States citizens had some type of opiate addiction by 1911, reportedly due to “the sudden emergence of street heroin abuse as well as iatrogenic [induced by medical treatment] morphine dependence.”²

In response to rising levels of Chinese immigration to the U.S., which was blamed for rising rates of opium use, states like California began outlawing the recreational consumption of various narcotics. San Francisco became the first U.S. municipality to enforce an anti-narcotics law in 1875, outlawing the operation of opium dens, which became state law in 1881. By 1907, California’s State Board of Pharmacy quietly lobbied for an amendment to the state’s poison laws, which prohibited the sale of opium, morphine, and cocaine except by a doctor’s prescription.³

Eventually, the U.S. Congress passed the Harrison Narcotics Tax Act in 1914, the first federal statute regulating the production and sale of opiates and cocaine, which was enforced as a ban on the recreational sale of both products. Under this law, physicians across the U.S. were also restricted from prescribing opiates to addiction patients, and all proprietors of opium products needed to be registered with the federal government, creating the ancestor to the modern PDMP databases.

In an effort to further combat overprescribing, states slowly began to develop their own monitoring programs, the first of which was created in New York in 1918. However, these early PDMPs were rather slow in their collection speeds and used inefficient paper reports to monitor the prescription history of patients. ⁴

These programs developed throughout the mid-20th century and were rather ineffective, as “[p]rescribers were required to report to databases within 30 days, too long a time to reasonably be useful in preventing real-time ‘doctor shopping’ or over-prescribing.”⁵ Additionally, there were no electronic databases tracking which patients had recently filled opioid prescriptions for doctors to reference.

Given the weaknesses of these early PDMPs, few states adopted any type of monitoring program over the course of the first half of the 20th century. However, the proliferation of PDMPs was greatly enabled by the ruling of Whalen v. Roe in 1977, a case that upheld the constitutionality of New York’s precursor of the PDMP under the broad police power given to the states by the Tenth Amendment. The plaintiffs of this case argued that the monitoring program constituted an invasion of patient privacy, due to its collection and storing of prescribing records. Writing for the majority, Justice John Paul Stevens held that, “[n]either the immediate nor the threatened impact of the patient identification requirement on either the reputation or the independence of patients…suffices to constitute an invasion of any right or liberty protected by the Fourteenth Amendment.”⁶ With the constitutionality of patient prescription monitoring upheld, states were able to pursue data collection on prescribing history more thoroughly. Empowered by this ruling, many more states began to operate some form of a PDMP.

By 1990, states such as Oklahoma and Nevada began to adopt electronic reporting systems, greatly expanding the capabilities of these programs. These improvements reduced operations costs and increased the accuracy of the databases, leading other states to consider them as a viable means to monitor opioid prescribing.⁷

In 2003, the PDMP seemed to be an effective way to combat opioid overdose deaths. Given that the majority of opioid deaths in 2003 were due to prescription drugs, the program’s intended purpose of limiting opioid prescribing seemed logical. In that year, Congress further increased funding for state PDMPs through the Harold Rogers Prescription Drug Monitoring Programs Grant, a competitive federal program that allows states to receive funding to “enhance the capacity of regulatory and law enforcement agencies and public health officials to collect and analyze controlled substance prescription data…through a centralized database administered by an authorized state agency.”⁸

Although PDMPs are implemented at the state level, federal law enforcement such as the Drug Enforcement Administration (DEA) has unfettered access to the prescribing records states collect. States such as Oregon and Utah have challenged this power on Fourth Amendment grounds, but federal courts ruled in favor of the DEA saying state law provides a “positive conflict…so that the two cannot consistently stand together” against Oregon in 2014 and “physicians and patients have no reasonable expectation of privacy from the DEA” against Utah in 2017.⁹

Due to increased access to funding and resources under the Harold Rogers Program, by 2016, every state with the exception of Missouri had enacted some form of a PDMP (see Table 1). States vary on the extent to which types of participation in these databases are mandatory and on what types of drugs are monitored. All states with PDMPs monitor at least Schedule II-IV opioids, and the majority of states also monitor prescriptions for Schedule V opioid products, such as codeine cough syrup. PDMPs are administered by state government agencies and compile accessible information on prescribing histories, which is entered into the database by health care providers. These systems are updated on a daily or weekly basis, depending on the state.“¹⁰

The PDMP is now widely regarded as an effective policy mechanism that states can use to combat the opioid crisis. Given the crisis’s wide-reaching effect across the United States, policies such as this aimed at curbing opioid overdoses are now considered a priority by politicians across the political spectrum. Legislators with ideologies as differing as Senators Bernie Sanders (D-VT) and Rob Portman (R-OH) have rallied in unison to support legislation aimed at lowering overdose deaths. In a time of unprecedented political divide and gridlock, it is exceptional for any policy to garner such universal support.

For example, in October of 2018, the U.S. Senate passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act—a bill that strengthened state PDMPs by encouraging interstate sharing of data through nationwide databases such as PMPi Hub and RxCheck Hub and mandated PDMP use for all Medicaid providers—by a margin of 98-1 in the Senate, indicating the unified nature of mainstream political thought surrounding this crisis. Though all PDMPs are administered by the states, this legislation enhanced funding for state PDMPs and created a mechanism by which a patient’s prescription history could be accessed across state lines.¹¹

The dire magnitude of the opioid crisis has created an imperative for legislators, forcing them to act quickly in order to stem the rising level of overdose deaths. As Senator Ted Cruz (R-TX) stated in 2018 while endorsing the SUPPORT for Patients and Communities Act: “[t]oo many lives have been lost to the opioid crisis….I am proud of Congress’s actions today to take a stand in efforts to save millions from the ravages of drug addiction.”¹²

It is this sense of urgency—legislating in response to tens of thousands of overdose deaths every year—that has created almost universal support for these interventions, with little, if any, public debate or criticism of them. The only abstention in the Senate to the SUPPORT Act was Sen. Mike Lee (R-UT), who originally publicly endorsed congressional intervention at the American Enterprise Institute, but later expressed worry that the bill would be ineffective despite its good intentions:¹³

There are some very good elements in this opioid response bill, including strengthening U.S. Customs and Border Protection authority to discover and destroy packages containing illegal controlled substances. Unfortunately, the bill also includes dozens of new grant programs with little accountability for how the dollars will be spent and minimal measurement or analysis on their effectiveness. Good intentions are not enough. In the face of a crisis such as this, we cannot afford to waste precious funds on programs which likely won’t work.¹⁴

This study finds that Prescription Drug Monitoring Programs fail at their major goal to reduce opioid overdoses. Although Prescription Drug Monitoring Programs successfully decrease prescription rates, they also increase the use of black market opioids. Consequently, as Prescription Drug Monitoring Programs cut off users from legal channels of prescribing and force them to switch to more dangerous illicit drugs, this unforeseen substitution to illegally purchased heroin and fentanyl is the principal reason why Prescription Drug Monitoring Programs ultimately lead to more drug overdose deaths.

Full Policy Study— Prescription Drug Monitoring Programs: Effects on Opioid Prescribing and Drug Overdose Mortality

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In October, Juul suspended in-store sales of its fruit-flavored pods, such as mango, fruit punch, and cucumber, in response to pressure from the Food and Drug Administration (FDA), which claimed that fruit flavors were attracting teens to vaping.

According to a recent study, mint is now the most popular flavor among 10th and 12th graders and accounts for 70 percent of Juul’s total sales. Just as discontinuing fruit flavors pushed users to mint, the discontinuation of the mint flavor, undertaken in the wake of continuing pressure on Juul from the FDA, is likely to drive teens to try the remaining flavors. They may substitute their mint pods with tobacco pods, menthol pods, or, worryingly, may even switch to traditional cigarettes.

As Thomas Ylioja, a tobacco cessation doctor at Denver’s National Jewish Health Hospital, noted, “Rather than giving up when they [teens] can’t get their particular flavor, they’re switching to a flavor that is more available.”

Juul and the entire vaping industry have been under increasing pressure due to the recent series of vaping-related illnesses and deaths in the United States. However, the Centers for Disease Control and Prevention (CDC) recently announced that its research into the causes of the illnesses experienced a “breakthrough”— finding that Vitamin E acetate was in all 29 lung injury cases the CDC sampled and calling it “a very strong culprit of concern.”

Vitamin E acetate is not an ingredient found in any Juul pods. Instead, this compound is most prominently used as a “thickener” in black market vaping cartridges.

Thus, making it more difficult for users to buy Juul, or the other legal e-cigarette products they prefer, may only make public health matters worse by pushing people to black market products. Because Juul is currently sold legally, consumers are able to know the contents of its vaping solutions—they are listed right on the package. Users of legal Juul don’t have to worry about Vitamin E acetate adulteration.

In contrast, buyers of the black market vaping cartridges don’t know what they’re getting. Black market suppliers obviously do not have to report the true contents of their products and don’t face any of the legal obligations or reputational pressures legal e-cigarette companies face. It is unsurprising that a majority of vaping-related lung injuries have been due to people in places where marijuana is illegal seeking out black market THC cartridges. In purchasing these products illicitly, consumers have no way of knowing whether their vaping solutions contain the culpable Vitamin E acetate.

Juul’s decision and the government-pushed e-cigarette bans could also ultimately harm smokers, many of whom use Juul as a pathway towards quitting smoking. A study published in the Harm Reduction Journal concludes that “restricting access to non-tobacco e-cigarette flavors may discourage smokers from attempting to switch to e-cigarettes.”

With the CDC estimating that over 480,000 people die from smoking and 41,000 people die from conditions related to second-hand smoke each year, discouraging smokers from using a cessation method that clinical trials show is over 81 percent more successful than nicotine-replacement therapy in getting people to quit cigarettes could have drastic public health consequences that are far worse than any of the potential harms of using Juul.

This recent decision by Juul, catalyzed by misguided political pressure from misinformed politicians and public health officials, is ill-conceived and potentially dangerous. Ending the sale of mint Juul pods will likely have a minuscule effect on reducing teen use and may very well only exacerbate lung injuries by pushing users to purchase more dangerous, unverified substances on the black market. The restrictions could also likely lead to more cigarette smoking among all ages. If unfounded decisions persist in this market, many of the public health achievements from e-cigarettes might go up in smoke.

The post E-Cigarette Flavor Bans and Juul’s Decision to Pull Mint Pods Won’t Produce Intended Results appeared first on Reason Foundation.

On January 15, 2019, Massachusetts Attorney General Maura Healey filed a 274-page pre-hearing memorandum alleging the Sackler family and their company Purdue Pharma “created the [opioid] epidemic and profited from it through a web of illegal deceit” by enticing doctors to prescribe their medication and peddling “falsehoods to keep patients away from safer alternatives.”

“We are confident the court will look past the inflammatory media coverage generated by the misleading complaint and apply the law fairly by dismissing all of these claims,” the Sackler’s attorneys said in a statement.

This is no small accusation from Massachusetts. If the state is going take this action against Purdue Pharma, one would hope that their case rests on solid evidence. But, unfortunately, the facts do not seem to support the commonwealth’s claims.

Evaluating the Massachusetts Attorney General’s Accusations

Massachusetts’ accusation that Purdue Pharma “created” the opioid epidemic by intentionally getting pain patients addicted to their products is not supported by the relevant academic literature on the subject. An abundance of evidence suggests that long-term opioid management for chronic pain does not lead to high rates of addiction. A comprehensive literature review of 26 studies found that addiction occurred in only .27 percent of patients treated with opioid painkillers for chronic pain. Another study found that for opioid pain patients with “no previous or current history of abuse/addiction, the percentage of abuse/addiction was calculated at 0.19 percent.”

Purdue Pharma advertised that the addiction rate for OxyContin was one percent, and studies continually agree or suggest that claim was conservative.

Contrary to the commonwealth’s narrative, prescription opioid addiction rates have not been on the rise. While prescribing rates have fluctuated over the past 15 years, nonmedical prescription opioid use has remained constant since 2002. Furthermore, the most recent spike in opioid overdose deaths reflects not prescription opioid deaths, but those of illicit opioids such as heroin and fentanyl—street narcotics that are not manufactured or sold by Purdue. In fact, the Journal of the American Medical Association has documented that opioid overdoses related to fentanyl “account for nearly all the increase in drug overdose deaths from 2015 to 2016” and after.

Additionally, the introduction of “safer alternatives” to OxyContin has only increased overdoses. Facing public pressure, Purdue Pharma introduced an “abuse-deterrent” reformulation of OxyContin on August 9, 2010. According to Evans et al. (2018), “[w]hen the new pills were crushed, they did not turn into a fine powder, but instead a gummy substance that was much more difficult to snort or inject.” But the reformulation of OxyContin only exacerbated the problem. The authors concluded “[t]he new abuse-deterrent formulation led many consumers to substitute to an inexpensive alternative, heroin” and to a quadrupling in heroin deaths.

Evaluating the Impact of the State’s Restrictions on Prescribing

Over the past five years, in its efforts to curb opioid use, Massachusetts has adopted several policies that make it more difficult for pain patients to receive prescription opioids from physicians.

In 2016, the Massachusetts State Legislature voted to limit first-time opioid prescriptions to a seven-day supply for adult chronic pain patients. Yet, there are unintended consequences of this law. When a suffering patient is cut off from legal opioids, but still desires to use the drug, the black market meets this demand. Drugs acquired through illicit sources, however, are inherently more dangerous than those purchased legally for a variety of reasons, including consumers’ lack of information about the true contents, potency, and quality of the substances. Shifting people from doctor-prescribed opioids to the black market contributes to the number of overdoses on highly potent illicit drugs, such as fentanyl.

In Massachusetts and many other states, deaths from opioids that are most commonly acquired on the black market accelerated the number of opioid deaths only after prescribing rates decreased, which indicates the troubling relationship between restrictions on prescribing opioids and increased overdose deaths.

Concurrently in 2016, Massachusetts strengthened its Prescription Drug Monitoring Program (PDMP), a statewide database that requires physicians to check a patient’s prescribing history before issuing them drugs. However, academic evidence examining PDMPs in other states suggests that they may also be associated with increased overdose deaths. According to one National Institutes of Health study examining the implementation of a PDMP in New York, “[p]rescription opioid morbidity leveled off following the implementation of a mandated PDMP” but “morbidity attributable to heroin overdose continued to rise.”

It’s understandable for state leaders and the public to seek answers to, and assign blame for, opioid-related problems. But Massachusetts should look inward at its own policies. By increasing access to opioids through legal channels, lawmakers could work to decrease the harms of the black markets and reduce overdoses and the risks surrounding drug use. Massachusetts actually reduced overdose deaths with this approach when it expanded medication-assisted treatment in 2017.  But the attorney general’s unfounded lawsuit ignores what has worked and runs the risk of undermining the commonwealth’s current public health success. 

Massachusetts Data:

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