Earlier this month, I attended a conference on the best ways to regulate drugs which are illegal now but might not be so in future. Most of the discussion revolved around cannabis and concerns about the effects of commerce. No one wants to repeat the mistakes made with alcohol and tobacco.
I came away better-informed and more positive about the option of cannabis social clubs. They seem to offer a middle course between untrammelled commerce and a Uruguay-style state monopoly – an option that appeals to some researchers but which would, I think, fail for basic consumer reasons. Will two flavours of state weed really fly? Will it work if the state doesn't provide the pot that people want?
As Professor Tom DeCorte of Ghent University noted, in places like Belgium, people have actually turned to cannabis clubs in search of choice, and for better-quality, and in some cases milder, pot.
Professor DeCorte said that clubs are generally run by enthusiasts and seem to regulate themselves well. The only potential problem I could see was the implicit assumption that cannabis use is uniform and habitual. When you join a club that lets you obtain a certain amount of weed – and in some clubs that amount is up to 100 grams per week – maybe that's inducement to consume more, more regularly.
Also among the speakers was Dr Paul Quigley, an emergency medicine specialist and clinical toxicologist at Wellington Hospital, who won some headlines last year by saying that he'd like to see MDMA legalised and regulated as a safer alternative to the novel chemicals currently sending people to ED.
"I would love just 10% of the budget that goes into the War on Drugs to come to me in Health," he said during his talk.
But those chemicals aren't his big problem. He pointed out that he sees 500 alcohol-related presentations for every other drug presentation. He's not a wowser – he's a craft beer enthusiast and a certified beer-taster – but he wants alcohol to be harder to get and more expensive.
He puzzled over ways to moderate the consumption of drugs that are legal now or will be in the future. Education ("PSAs reach an audience that already acts well") and warning labels ("who reads them?") did not seem effective. Merely prescribing a drug does not mean the user will self-regulate well – indeed, the reverse may be true. He even mused ("this is science-fiction, folks") on the possbilities of a licence to consume alcohol – one which could be withdrawn on the basis of, say, a drink-drive conviction, thus preventing entry to licensed premises. It was an enjoyable discourse.
I chatted with Dr Quigley afterwards about some of the other things he's seeing at the frontline. The most interesting was the re-purposing of vapourisers, which currently dwell in a regulatory twilight zone: they're legitimately stocked, but can't be sold as a smoking cessation aid, even though when they deliver nicotine they plainly help people give up smoking.
Vapes aren't going away, and they present a challenge for regulators. Dr Quigley is increasingly aware of them being used as delivery devices for both opiates and methaphetamine. People simply dunk their drugs into watermelon-flavoured e-juice from the local head shop and vape away. This is clearly less harmful than injecting the drugs, especially in the case of opiates, where the means of administration makes fatal overdose much less likely.
With respect to alcohol, he noted problems with current drinking patterns among young people: most notably, the tendency to keep going by consuming energy drinks alongside or with alcohol. The alcohol has a longer half-life than the caffeine and sometimes, tragically, kids who have been put to bed to sleep it off – even in the recovery position – have never woken up because the caffeine wore off and their lungs stopped working.
There's another drug you can buy at the supermarket that causes problems. Wellington ED alone sees about 700 cases annually of paracetamol overdose. They cluster around the weekends and most are impulsive suicide attempts. It's a really terrible way to commit suicide. If it works, it's an awful way to die; and if it doesn't, it can cause serious organ damage.
It may come as a surprise to hear that Dr Quigley does not favour a permissive approach to medical marijuana. He's amenable to legalising recreational use, but believes that medicines must be trialled and approved according to established standards. Having doctors prescribe raw cannabis would be "turning them into drug dealers".
I thought of all this when I read The Guardian's astonishing story of how Florida's love affair with synthetic prescription painkillers tipped over into a heroin boom.
In part, it answers the question: if the black market is so bad, how come America developed such a huge problem with legal prescription drugs? In the case of Florida, it was because the state made such an awful job of regulating prescription.
Florida’s problems started after OxyContin swept on to the market in 1996, just as medical authorities began pressing doctors to pay greater attention to alleviating pain. Unscrupulous businessmen in Florida spotted an opportunity.
Within a few years, hundreds of pain clinics popped up around the state dispensing opioid pills to just about anyone who asked. Among the earliest and biggest was American Pain in the Miami-Fort Lauderdale metro area, with a pharmacy run by former strippers and doctors carrying guns under their white coats.
It took in tens of millions of dollars a year selling OxyContin and generic versions containing oxycodone to people who travelled from Kentucky and West Virginiawhere painkillers were known as “hillbilly heroin”. They came south along the “Oxy Express” by bus or the carload, sometimes driven by dealers who took a cut of the pills.
At one point, more than 90% of all the prescription opioids dispensed by doctors in the US were sold in Florida.
Eventually, in 2010, the state cracked down on prescription.
American Pain was shut down in an FBI raid and its owners were imprisoned. The Florida legislature passed laws to kill off other pill mills and curtail the largely unfettered prescription of opioids. Deaths from oxycodone in Florida dropped 69% in the five years from 2010.
But the clampdown left those already addicted without a ready supply. It limited access to pills, forced up prices on the street, and made heroin a cheaper alternative. As the drug flooded in from Mexico, heroin deaths in Florida more than doubled in 2014 alone to a record 408.
Lord knows what they do about this.
But there is an irony in the fact that Florida has very narrow permissions (and they largely haven't even kicked in yet) for another drug that treats pain: cannabis. But that may soon change – Florida is coming up to a ballot initiative that would considerably expand access to medical marijuana. So more people would have access to medpot for a wider range of conditions, including pain that might otherwise be treated with more dangerous drugs, like those opioids that have caused such a problem.
Sounds good, right? But it's hard not to feel a bit queasy about Big Marijuana descending on the state and showering money on a "Yes" vote that would hugely expand its potential market.
And yet, denying pain relief on the basis that the drugs that provide it could be misused is, to put it mildlly, ethically problematic. At UNGASS last month, delegates from many developing countries spoke compellingly about the suffering caused in their countries by drug control policies that tightly restricted opioid painkillers. On the other hand, our own Expert Advisory Committee on Drugs has advised against Pharmac funding the approved cannabis-based medicine Sativex on the dubious assumption that it might be "diverted".
You're probably looking for a conclusion about now. Well, I don't have one – beyond the oservation that this whole thing is very, very complicated.