07/10/16 Doug McVay

The Veterans Affairs department releases a new estimate of veteran suicides -- 20 per day in 2014 -- and we speak with the authors of new research showing that medical marijuana laws are associated with a reduction in prescription medication use.

Century of Lies
Sunday, July 10, 2016
Doug McVay
Drug War Facts
Download: Audio icon col071016.mp3



JULY 10, 2016


DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century Of Lies. Century Of Lies is a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org.

It's been a busy week. The Department of Veterans Affairs released new data on veteran suicides. Many listeners are probably aware of their earlier report, which estimated that 22 veterans a day committed suicide in 2012. That report was based on limited data so though that number was picked up and used by a number of advocates and organizations, some -- like the VA -- questioned its accuracy. Now, the VA along with the Centers for Disease Control have done a much more in-depth study using national data over the period 1979 to 2014. The VA now finds that in 2014, a total of 20 veterans per day committed suicide.

Here are some of the key findings from the report, as announced by the VA on Thursday:

– 65 percent of all veterans who died from suicide in 2014 were 50 years of age or older.
– Veterans accounted for 18 percent of all deaths from suicide among US adults. This is a decrease from 22 percent in 2010.
– Since 2001, US adult civilian suicides increased 23 percent, while veteran suicides increased 32 percent in the same time period. After controlling for age and gender, this makes the risk of suicide 21 percent greater for veterans.
– Since 2001, the rate of suicide among US veterans who use VA services increased by 8.8 percent, while the rate of suicide among veterans who do not use VA services increased by 38.6 percent.
– In the same time period, the rate of suicide among male veterans who use VA services increased 11 percent, while the rate of suicide increased 35 percent among male veterans who do not use VA services.
– In the same time period, the rate of suicide among female veterans who use VA services increased 4.6 percent, while the rate of suicide increased 98 percent among female veterans who do not use VA services.

The final report will be publicly released by the Department of Veterans Affairs later this month.

Congress this week approved the final version of S.524, the Comprehensive Addiction and Recovery Act, called CARA for short. CARA is this session's big drug bill. It's intended to address the epidemic of overdose deaths that the US is currently experiencing. The House and Senate passed different versions of the bill, so members met in a conference committee to work out the differences. The bill could also be amended in committee, so members offered several amendments, a few of which were approved. Unfortunately, one of the most important amendments put forward was rejected. Here's the lead author of that amendment, Senator Patty Murray, introducing the amendment:

SENATOR PATTY MURRAY: Thank you Mr. Chairman. As I said in my opening statement, I am very glad that we've been able to reach some important bipartisan agreement on this issue, but our states need more to tackle the opioid crisis head-on. They need new investments. This amendment will provide $920 million in funding for states to expand access to prevention and treatment services, especially for those who cannot afford it.

There is no reason we can't all support this amendment. We all agree the funding is desperately needed to help our communities stop the wave of overdose deaths and to properly treat addiction to prescription opioids and heroin, and specifically we know that without more funding to expand access to medication assisted treatment, states will not have the resources they need to put people on the path to recovery and save lives.

We're debating a bill to address the opioid epidemic. It should include the funding necessary to actually fight that epidemic. So this amendment would provide funding to states for medication-assisted treatment, allow nurse practitioners and physician assistants to prescribe the drug buprenorphine to help their patients cope with and recover from addiction, and importantly, the bill empowers these providers to treat patients while deferring to states' scope of practice laws. This is critical for many of our rural communities that have been hit hard by this epidemic.

The amendment is also fully paid for by a set of offsets that both parties have supported in previous votes, and would not add a single dollar to the deficit. The bottom line is, is when someone is ready for treatment, we need to make sure our health care system is ready to treat them. And I'm very concerned that if we pass a bill that changes our nation's opioid policies but completely ignores the funding that would enable cities and states to put those policies into practice, that funding might never come. For far too many families, there is no later. There is no next time. This is the opioid bill this year, and frankly, people across the country are running out of time.

So let's make the tough choices. Let's vote for this amendment. And let's make sure this bill takes an absolute necessary step forward in expanding access to the life-saving treatments that families across the country need.

DOUG MCVAY: That was Senator Patty Murray, a Democrat from Washington state, speaking in favor of her amendment to S.524, the Comprehensive Addiction and Recovery Act. Her amendment failed to get support from the Senate side by a rollcall vote of 3 to 4.

Representative Steve Cohen, a Democrat from Tennessee and one of the staunchest supporters of marijuana law reform in Congress, offered two amendments that related to medical marijuana. As the bill dealt primarily with opiates and heroin, he withdrew the amendments during the debate without a vote. Here's Representative Cohen giving his opening remarks:

REPRESENTATIVE STEVE COHEN: I applaud the bill. But I want to suggest that one of the major reasons we have an opioid problem in this country, one of the reasons young people use heroin, is because this Congress, and governments throughout this country, have wrongly sent a message to young people that marijuana is more dangerous to you than heroin. That's the message we send by having marijuana as schedule one, that marijuana is more dangerous than heroin.

Young people see that, and they think government lies to them about drugs. And they try marijuana, and they find out that it's not harmful, and that it doesn't ruin their lives, not that they should be doing it when they're under 21, not that they should even necessarily be doing it later, but in DC and many states, you can do it legally, and people do it and aren't killing themselves, and aren't causing -- committing crime because they do it. But this Congress and governments throughout this land have told young people, we are old fogies, we don't know what we're talking about, we think marijuana is more dangerous than heroin. Therefore they think it's okeh to do heroin, and then they die.

We need to be straight and honest, and marijuana should not be schedule one. It really shouldn't be scheduled, but at a minimum, it should be schedule two, as is this drug in this particular bill. Schedule one for marijuana is wrong, and it is an alternative pain killer that could do good for people who would not then go to prescription drugs and get hooked on opioids and maybe kill themselves.

So let's get straight, and let's make our laws realistic and not have people think it's a bunch of old fogies that don't know what they're doing and they lie to us. Furthermore, I say it's not, and I yield back the balance of my time.

DOUG MCVAY: That was Representative Steve Cohen, the Tennessee Democrat and marijuana law reform supporter speaking in the conference committee hearing on S.524, the Comprehensive Addiction and Recovery Act. The final version of that bill went to the President for his signature.

You're listening to Century of Lies. I'm your host, Doug McVay, editor of DrugWarFacts.org.

DAWN PALEY: Hey, my name's Dawn Paley, I'm the author of Drug War Capitalism, and I just want to give a shout out to the people at Drug Truth Network, who are doing amazing work to get the stories out. You know, Amy Goodman from Democracy Now talks about trickle-up journalism, I'm a firm believer, you know, like, where these stories are being reported first. Who's on the ground covering this conference and doing all these interviews? It's Doug McVay. Drug Truth Network. So listen up, and thanks again for your so important work in terms of just getting the truth out there and getting these stories, which are just so repressed in the mainstream media, out to the broader public.

JOHANN HARI: And, Doug, I should say as well, you should be really proud of the work that you've done with Drug War Facts. For years and years, it is really one of the most invaluable resources on the internet, and you should be really proud because you've put a huge amount of work into that. I see that being cited all over the world, it's absolutely crucial and invaluable what you've done. You know, I've heard people cite it from, in, off the top of my head I can remember people citing it in Uruguay, in Mexico, in Germany, in, you know, in Vietnam I heard someone quote it. You've had a huge influence in the work you've done, and you should be really proud of that. It's a crucial part of the fight that we've been part of.

DOUG MCVAY: This week, a new article published in the journal Health Affairs shows that medical marijuana laws may have led to significant reductions in prescription drug use. The article, titled Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D, was written by Ashley C. Bradford and Professor W. David Bradford from the University of Georgia at Athens. I spoke with them this week to discuss their findings.

PROFESSOR W. DAVID BRADFORD: I am David Bradford, I'm a professor of public policy in the Department of Public Administration and Policy at the University of Georgia.

ASHLEY C. BRADFORD: I am Ashley Bradford, I'm a master's student, also at the University of Georgia, also in the Public Administration and Policy Department.

W. DAVID BRADFORD: So, what we found was that when we looked at all the prescriptions that were written in Medicare Part D, and that's the component of Medicare that pays for prescription drugs, that when states implemented a medical marijuana law, that in seven of the nine disease categories we examined, the use of FDA approved prescription medications actually fell when a medical marijuana law went into place, and that suggests that people are substituting away from prescription drugs into something else when marijuana becomes available, and really given the other analyses we did in the paper, the only plausible interpretation is that people are substituting towards marijuana.

DOUG MCVAY: Now, when you say the prescription use was dropping, how were you measuring that?

W. DAVID BRADFORD: So, the way that we measured the response in prescribing to medical marijuana law implementation, is that we looked at what happened to the number of daily doses that were filled at the pharmacies by Medicare enrollees from 2010 to 2013 in states with and without marijuana laws, and as states changed from not having one to having an effective one. We looked at the number of daily doses and saw that the doses, as I said, in seven of the nine categories that we examined, fell. For example, for pain related drugs was the largest category, and there we saw that when a medical marijuana law went into effect, about 1,800 -- physicians wrote about 1,800 fewer daily doses in the average year.

And this actually translated, in 2013, we estimate that the 17 states and the District of Columbia that had an MML in place had about $165 million fewer dollars spent on Medicare Part D drugs, just in those seven categories, than states without an MML.

DOUG MCVAY: Now, what kind of -- what disease categories were you looking at where the -- and which ones had the biggest impact?

W. DAVID BRADFORD: So, we looked at nine. We looked at drugs that are used to treat anxiety, depression, glaucoma, nausea, pain, psychosis, seizures, sleep disorders, and spasticity. And in all of those except for glaucoma and spasticity, we found large and significant reductions in FDA approved prescription use when MMLs went into effect.

We actually did not expect to find a negative result in glaucoma. Glaucoma's a special case, here. While it's widely approved as one of the indications by states for which a person can apply for an MML, and it's also widely known, sort of most common search terms along with medical marijuana is glaucoma. The clinical evidence is actually pretty interesting with glaucoma, it seems that the treatment effect is such that it reduces intraocular pressure by about 25 percent. The effect lasts only about an hour, however, so it's not really an effective treatment for glaucoma, and we expected that what would happen is that, you know, as patients read media coverage and hear media coverage about the MML and the potential for glaucoma, for treating glaucoma, hear about the symptoms, more people would go to the doctor to be diagnosed, but of course doctors are not going to be able to let them leave without an actual treatment. So we actually thought we'd see an increase in glaucoma prescriptions. We found an increase, but it was not statistically significant.

DOUG MCVAY: Okeh. Interesting. Now, so, not just pain relief, but also nausea and anxiety. One of the other news items in the last couple of days that's of particular interest, yesterday the Veterans Affairs Department issued an updated estimate of the number of servicemembers who are committing suicide back here in the US, and they found that it's at approximately 20, that is to say, 20 veterans a day on average who are committing suicide. Many of them simply taking an overdose of the prescription medications. I realize this is speculating, but, could you speak for a moment about the possible implications as far as safety is concerned, and, well, drug consumer safety, I suppose you could say.

W. DAVID BRADFORD: You know, one of the things that is problematic in this entire area of trying to understand how we, you know, evolve our drug policy, particularly with regards to marijuana, is that there is an unfortunate dearth of strong clinical evidence about what benefits marijuana has for conditions. You know, what my co-author and I did in this paper is that we examined areas where there was at least some clinical evidence, and we took that from meta-analyses, that is, summaries of all the literature that were published by -- recently in a large study, and also an earlier study from the National Academy of Medicine. And, the sad fact is that because marijuana is a schedule one drug, and because of what's called the NIDA rule, that restricts the access for clinical studies of marijuana to NIDA, the National Institute of Drug Abuse as the source of the product, there is in fact not much in the way of evidence. It's -- this is an area where we just clinically don't know enough.

And so one of the things that is currently happening in this debate is whether or not, you know, the DEA should reschedule marijuana from schedule one to schedule two, and if that were to happen, then it would open up the doors to facilitating more research, so that we could in fact find out whether marijuana is something that could be useful for PTSD in the case of veterans, or other people who've undergone trauma. How effective it is for anxiety, depression, and pain, and a whole host of other conditions, where there's anecdotal and some limited clinical evidence. But the most important thing is to try to get strong, double-blinded, placebo controlled clinical trials done, where there's standardized dosing, where we can actually understand what the dose response profile is for this product, and develop safe alternative ways of managing things like pain.

As you well know, issues about suicide are one thing. There is also, as we're talking, an enormous and actually profoundly worrying epidemic around opioid abuse, misuse, and death. And, you know, there is evidence, actually, my co-author and I are working with the faculty here at the University of Georgia on another paper that's suggesting that particular forms of medical marijuana laws, particularly ones that emphasize dispensaries, can be effective at diverting people away from opioid death. And so, this is part of a -- this is a potential tool in the arsenal to help us attack a number of public health problems. But for that we need evidence, and I think for the evidence we need rescheduling.

DOUG MCVAY: One of the arguments that gets used quite frequently is the, what we call the "safer" argument, the idea that alcohol is more dangerous than marijuana use because with alcohol you actually have the potential for a lethal overdose, and it's a -- a person could actually reach that point with alcohol relatively easy, whereas you would -- it's just not possible to consume that much marijuana. How would -- you were able to measure the reduction in prescription medication use because we have databases showing the actual amounts being prescribed. We are hoping to try and see a replacement effect, but, can you think of how we could possibly measure something like that, if there is such a thing? I'm not asking you to speculate whether it happens, but how would we measure to find out if it's happening?

W. DAVID BRADFORD: You're asking how would we understand whether or not people are substituting, actually substituting, marijuana in place of an FDA approved drug?

DOUG MCVAY: Well, actually, forget FDA approved, I'm actually -- this is one that you wouldn't even have been looking at because you couldn't have, it's alcohol.

W. DAVID BRADFORD: Oh, I see. Yeah.

DOUG MCVAY: Would it be -- do you think it would be possible? I mean, like I say, I'm not asking you to speculate about whether such substitution effect happens, more a question of, you're a public policy professor, how would we look to find something like that?

W. DAVID BRADFORD: The question about the relationship between marijuana use and alcohol use, of course, is a large dataset, observational dataset, that was a survey that at this point asks people. And indeed, there are such surveys available in the US, there's one called NSDUH, which is the --

DOUG MCVAY: You mean the National Survey on Drug Use and Health?

W. DAVID BRADFORD: Yes, thank you. The NSDUH study does ask people questions about their use of many illicit drugs, as well as alcohol. And from that, patterns of use can be inferred. One of the things that makes it a little harder for people to understand the relationship between co-use or substitute use between alcohol and marijuana and public policy is that many of these datasets, at least publicly available versions of them, don't have things like state identifiers on them, because of HIPAA regulations that are intended to protect privacy. They've been interpreted for many datasets as meaning that you can't actually identify what state a person is from, for fear of potentially identifying the person.

So, that makes it harder to know how people react to medical marijuana laws when they're put in place because we just can't see where people are. You can, in some restricted sites, go look at the protected data, and more studies about that question need to happen. There is clearly, you know, clearly we're dealing with at least two separate issues here. One is, how do people recreationally use alcohol and marijuana, and the second is, how do people medically use marijuana. I'm an economist, and my co-author is a sociologist, so we're not clinicians, but I don't think either one of us are aware of any clinical use of alcohol. However, there does seem to be clinical use of marijuana, so we do need to understand the distinction between people who are using marijuana motivated by a recreational desire, and others who are using it for clinical purposes, for treatment purposes.

And really for most states right now, the live policy question is how to appropriately take steps, you know, carefully take steps that would sort of appropriately from the state's perspective increase access to clinical treatment. And I think fewer states are interested at the moment in looking at the recreational legalization.

DOUG MCVAY: Right on. Well, and, back to the study you've actually done here, the -- my little mind thing -- the, I mean, one advantage I suppose that you're looking at the actual numbers of, because we've had self-report data coming out, you know, studies from some of the dispensaries. What you're looking at is a lot more reliable than self-reports, and you can actually measure a financial impact. How much -- the reduction in prescription, how much does that equate to when it comes to dollars?

W. DAVID BRADFORD: Ah, yes, it's a good question. So, recall that our data go from 2010 to 2013. There's always a lag with data in getting it processed. And this is again sort of all prescriptions written under Medicare Part D in the country. So, 2014 data's not quite available yet, it should be available within a month or so, so we'll update the study at that point. But, if we just take 2013, and look at it, there were at that time 17 states and the District of Columbia that had legalized medical marijuana, and that translated into $165 million less in Medicare spending for those 18 states, if you include DC, for the nine categories that we studied. We actually have imputed what that would be nationally, if all the states turned it on.

ASHLEY C. BRADFORD: So, if you kind of actually turn on all the states, as if they had all adopted medical marijuana laws, we found actually that Medicare would have saved $468 million, in savings, which is about half a billion dollars. And that makes up about half a percent of Medicare Part D's total budget.

DOUG MCVAY: Half a billion dollars.

ASHLEY C. BRADFORD: Yes, half a billion dollars.

DOUG MCVAY: Billion, with a B.

W. DAVID BRADFORD: If all the states had turned it on.

DOUG MCVAY: Which -- I always think people should do the right thing in policy -- should adopt the right policies because they're the right thing to do, but I find that a lot of people, they look at the bottom line, and that's a pretty good bottom line.

W. DAVID BRADFORD: As we, as my co-author and I said in the paper, we're not suggesting that saving a $165 million, that actually happened, or even saving half a billion dollars in 2013, and it would be, we believe, much larger today of course because we have more and more states with MML in place. That's not the reason to do the policy. However, it is one factor to consider, that if you're thinking about providing opportunities for people to better, and again, this is important to remember, in conjunction with their physicians, their clinicians, to better manage their clinical conditions, then that's the primary reason that we would undertake this policy change.

However, it's not I think unreasonable to consider that there are in fact some financial benefits to Medicare. Now, having said that, we also do want to emphasize that we're not saying that society as a whole saved $165 million in 2013, because of course if people were substituting from prescription drugs to marijuana, people were having to buy the marijuana completely out of pocket. So in some sense, that was a cost shifting from Medicare to the enrollees. But as an economist, I would say to that, that yes, it's not a net change in all of society's spending, but, when people voluntarily choose to do something, they only do it if the benefits to them are greater than the cost to them. And so, a voluntary shift like that would still represent what we economists would say would be an increase in the efficiency of the system.

DOUG MCVAY: So, do you have any -- what questions am I not asking?

W. DAVID BRADFORD: I think that one of the things that a person could reasonably take from our research is that, that this is one more piece of evidence that the scheduling of marijuana as schedule one under the Controlled Substances Act of 1972 is outdated. That scheduling is defined as products for which there's a high potential for abuse, and for which there is no evidence of any clinical benefit. And, what we're showing in this paper is that indeed, patients along with their physicians are acting as if there is clinical benefit when medical marijuana is suddenly available to them.

And I think that that goes hand in glove with the other trials and clinical evidence that exists in the literature that suggests that indeed there's a good reason to believe that there is clinical benefit from marijuana. And at a minimum, that would suggest that schedule one is just completely inappropriate. And, we would encourage policymakers and the DEA, and the actually the Attorney General, who has the ultimate authority, to reconsider that scheduling decision.

DOUG MCVAY: That was Ashley Bradford and Professor W. David Bradford, they're both at the University of Georgia at Athens, she's a graduate student and he's a professor of public policy. Their article, Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D, appears in the July 2016 issue of the journal Health Affairs.

And well, that's it for today. Thank you for joining us. You've been listening to Century Of Lies, a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org. The Drug Truth Network is on Facebook, please give its page a like. Drug War Facts is on Facebook too, give it a like and share it with friends. You can follow me on Twitter, I'm @DougMcVay and of course also @DrugPolicyFacts.

We'll be back next week with thirty minutes of news and information about the drug war and this Century Of Lies. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.