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This collection of statements provides you with CASAColumbia’s stance on pressing addiction issues.
Research documented in CASAColumbia’s two recent reports, Adolescent Substance Use: America’s #1 Public Health Problem (2011) and Addiction Medicine: Closing the Gap between Science and Practice (2012), affirms that addiction is a brain disease that typically originates with substance use in adolescence.
In the U.S., 9 out of 10 people who meet clinical criteria for addiction started smoking, drinking or using other drugs before age 18. The earlier substance use begins, the greater the likelihood of developing addiction. Individuals who first use any addictive substance before age 15 are 6 1/2 times as likely to develop addiction as those who delay first use until age 21 or older; yet the average age that high school students report starting to use an addictive substance is between 13 and 14 years.
Given that three-fourths (76%) of all high school students report having used an addictive substance in their lifetime and almost half (46%) have done so in the past month, it is critical to understand the link between adolescent substance use and addiction and address it accordingly. 1 in 8 high school students meets clinical criteria for addiction and, among those who have used an addictive substance in the past month, 1 in 3 already has a disorder.
The combination of several factors makes adolescence the critical period of vulnerability for beginning to use addictive substances and for developing the disease of addiction:
Adolescent substance use not only increases the risk of addiction, it also has profound social and financial costs. It is directly linked to the three leading causes of death among adolescents—accidents, homicides and suicides—and is implicated in poor academic performance, cognitive impairment and school dropout; unprotected sex and unintended pregnancies; mental health problems; violence and criminal involvement; and numerous potentially fatal medical conditions.
Adolescent substance use is our country’s largest preventable and ultimately most costly health problem. To address it, the public, health professionals and policymakers must recognize it as a health problem rather than a normal rite of passage, help young people delay substance use for as long as possible, be vigilant for signs of risk and intervene appropriately as we do for any other health condition.
CASAColumbia recommends that the U.S. Food and Drug Administration (FDA) take immediate action to assert the regulatory authority granted in the Tobacco Control Act and regulate e-cigarettes as cigarettes, and that the federal and state governments tax them accordingly.
As is the case with conventional cigarettes, e-cigarettes deliver nicotine, an addictive drug. A growing body of evidence suggests that early use of nicotine increases the risk of addiction involving not only nicotine but also other drugs. In fact, 95% of cases of addiction involving nicotine originate with substance use before age 21. High school students who have ever smoked cigarettes are 9 times likelier to develop addiction involving alcohol or other drugs than those who have never smoked. Tobacco, alcohol and other substance use and addiction is the largest preventable and most costly health problem in the U.S.
As the tobacco industry knows only too well, the best way to get a lifetime user is to start them early. This explains current e-cigarette marketing tactics that revive the glamorous promotional cues which for decades have attracted young people to the deadly habit of cigarette smoking. E-cigarettes are designed to look like cigarettes, are often flavored in ways that appeal directly to children and adolescents, including candy and menthol, and may be used as a bridge to other addictive substances, including conventional cigarettes.
While e-cigarettes probably are less toxic than conventional cigarettes, there is no evidence to assure their safety and some evidence to suggest they may carry negative health effects that should not be ignored. If e-cigarettes were used only as replacement products for smokers who have been unable to quit smoking, they appear to be harm reduction products; however, research on how these products are used is very scarce and some suggests that e-cigarettes are being used to supplement rather than replace other tobacco use. E-cigarettes also are promoted as safer than combustible tobacco products because of the lack of secondhand smoke. While it is true that e-cigarettes do not produce carcinogenic smoke, there is not sufficient evidence to prove they have no secondhand effects.
Given the history of cigarette marketing in this country and the horrific health consequences and costs that resulted, we should be very careful about endorsing this new product without first developing a solid understanding of its impact on health, public safety and the anticipated market for new users.
There may be therapeutic value in a vaporized nicotine delivery system for the purpose of tobacco use cessation. Companies interested in developing such products should use the established FDA process for bringing drugs to market while assuring their safety and efficacy.
Decriminalization is a public health-based approach that imposes penalties designed to discourage marijuana use and encourage treatment when necessary. Under decriminalization, marijuana remains an illegal drug but people who are caught possessing small amounts of marijuana (typically 1 ounce or less) for personal consumption are fined rather than arrested. Marijuana trafficking, distribution, and sale remain subject to serious criminal penalties, as does driving while intoxicated by marijuana.
CASAColumbia supports the decriminalization of marijuana because it more appropriately addresses marijuana use as a public health problem, rather than a crime. Incarcerating people for using marijuana serves neither the individual’s nor the public’s interest. Having a criminal record for marijuana use is damaging to individuals’ livelihoods and life opportunities, particularly for youth. CASAColumbia recommends that possession of marijuana for personal use not result in:
CASAColumbia also recognizes that the enforcement of marijuana laws has disproportionately impacted racial minorities. Racial bias is a serious problem that occurs in the enforcement of many laws, indicating that the solution requires more systemic changes. Although decriminalization alone will not eliminate racial bias in law enforcement, it would reduce racial disparities in arrest rates and incarceration for marijuana possession.
Marijuana laws should aim to deter marijuana use and facilitate treatment when needed. There is not yet sufficient evidence to suggest which consequences or penalties are most effective at deterring use and facilitating treatment. In designing and evaluating the effectiveness of a system of penalties for marijuana possession, states should consider the following recommendations:
For individuals charged with more serious marijuana crimes (e.g., distribution), courts should explore the use of alternative sentencing programs such as drug courts and evaluate their effectiveness in reducing substance use, recidivism, and costs.
CASAColumbia opposes the legalization of marijuana for recreational use because it will increase access to and use of the drug among adolescents. Marijuana is an addictive drug that can interfere with brain development and exacerbate mental health conditions. The risks of marijuana use have been demonstrated through clinical and epidemiological research and the concerns about these health risks and the adverse consequences of legalization have been consistently voiced by national medical societies (e.g., American Medical Association, American Society of Addiction Medicine, American Psychiatric Association and the American Academy of Pediatrics).
Because legalizing marijuana is expected to increase the number of people who use the drug, it is also likely to increase the number of people who develop a marijuana use disorder. The addiction treatment system does not have the resources to treat everyone who currently needs care and is not prepared to handle an increase in patient demand.
Instead of legalization, CASAColumbia supports keeping marijuana illegal but decriminalizing personal use (see our accompanying position statement). Decriminalization is a public health approach that prioritizes treatment over incarceration and eliminates commercial incentives to promote marijuana use.
Marijuana use poses significant health risks to adolescents.
When used regularly during adolescence and early adulthood, a period of active brain development, marijuana can alter the structure and function of the brain, impairing learning and memory, and increasing the risk of addiction and psychosis. Although there is conflicting research and direct causation remains unclear, the bulk of evidence suggests that teens who use marijuana are at risk for cognitive impairment. Early and regular use during adolescence is associated with lower IQ later in adulthood and with decreased activity and/or connectivity in the areas of the brain related to executive function, learning and memory. Whether cognitive deficits are reversible is not completely clear. Early initiation and regular use are also associated with greater likelihood of developing a marijuana use disorder, which occurs in roughly one in six adolescent users – a rate that is nearly double that found among adult-onset users. Early initiation and regular use of marijuana also confers a higher risk for psychosis, especially among those predisposed to mental health problems. In addition to the health risks, adolescent marijuana use is associated with reduced educational attainment and increased likelihood of dropping out of high school.
Unfortunately, regular or heavy use is the norm among young marijuana users, a pattern unlikely to be improved by legalization. National survey data suggest that on average, high school students who currently use marijuana use it 2 or 3 days per week.
Marijuana use poses significant health risks to adults.
Approximately 9% of adults who use marijuana become addicted to it; this number may rise as levels of THC in marijuana increase. Regular marijuana use poses additional health risks, including cognitive and respiratory problems. Marijuana use can also exacerbate pre-existing mental health and medical problems and other substance use disorders.
Marijuana use also poses a risk to drivers and others on the road. Marijuana is the illicit drug most frequently reported in connection with impaired driving and motor vehicle accidents, including fatal accidents. Following alcohol, cannabis is the second most commonly detected substance in drivers who were fatally injured in car crashes. There is evidence that the cumulative effects of marijuana and alcohol when used together cause greater impairment to driving than either substance alone.
Legalization is likely to increase marijuana use.
The very act of legalizing marijuana sends a message that the drug is safe and acceptable to use. This shift in cultural norms puts adolescents, in particular, at risk. Legalizing marijuana for adult recreational use is expected to decrease teens’ perception of the harms of marijuana. Data from three decades of survey research indicate that decreased perceptions of harm are strongly associated with increased rates of adolescent use.
Legalization will inevitably lead to the growth of a commercial marijuana industry whose business model will be to promote marijuana use. The tobacco and alcohol industries provide an illustrative example of how businesses that profit from addictive substances put the public’s health at risk. Through innovations in product development, marketing and lobbying, the tobacco industry made its product more addictive and dramatically increased its consumer base in a relatively short period of time. The nascent marijuana industry has already begun implementing tobacco’s successful strategies. The alcohol industry garners roughly half of its profits from under age and excessive drinking, both of which are injurious to public health. The growing marijuana industry will similarly be incentivized to promote underage and heavy use. In Colorado, where recreational marijuana use is legal, 87% of the profits come from people who use the drug five to seven days per week. People who begin using marijuana as teens are much more likely to become the heavy users who drive profits, so a marijuana industry would need to market to teens in order to generate the greatest profits.
States that legalize marijuana will likely adopt minimum age laws as a way to deter teen use; however, such laws are not very effective at keeping substances out of the hands of teens. Because teens’ primary sources of marijuana are their friends and family, if it is legal for adults, teens will have greater access to it, and greater access is associated with greater use. Alcohol is by far the most commonly used substance among teens, despite minimum legal drinking age restrictions.
Public health measures can help to reduce teen substance use. For example, there is reason to believe that the same strategies that have reduced smoking would also reduce marijuana use: strongly enforcing minimum purchase age laws; setting very high sales and excise taxes; imposing environmental use bans; prohibiting advertising, marketing and placement in entertainment media; and implementing sustained public awareness campaigns. All of these policies working together can have a positive impact on public health.
However, discussions about legalizing marijuana fail to take into account the substantial investment needed to adequately regulate the drug and prevent adolescent use. States that have legalized marijuana use to date are imposing only modest taxes (relative to cigarette taxes), which are insufficient to keep prices high enough to deter adolescent use, and so far are failing to make adequate investments in other public health efforts.
Legalizing marijuana will increase the number of people suffering from untreated addiction.
Currently, only one in 10 people with alcohol or drug addiction receive treatment. In states where marijuana is legalized, we can expect more people to use the drug and consequently develop a marijuana use disorder. The problem is especially concerning for adolescents; marijuana is the primary drug used by most teens admitted to addiction treatment programs. Increasing the number of people with marijuana problems will place additional demands on a treatment system that is already severely under-resourced; as a result, a greater percentage of people who need treatment will not receive it. It is incumbent on states that are considering legalizing marijuana to commit resources to offer effective prevention and treatment services for those who are at risk of or develop a marijuana use disorder.
CASAColumbia encourages research on the medicinal value of marijuana and the use of any U.S. Food and Drug Administration (FDA)-approved medications derived from marijuana or containing cannabinoids. However, CASAColumbia opposes state “medical marijuana” laws because they bypass the FDA review process.
The FDA’s process for approving new drugs is the current standard for verifying that a medication is safe and effective for a particular indication. The FDA evaluates data on the safety, efficacy, dosage and side effects of new medicines and oversees the manufacturing process to ensure quality control and proper labeling. Without FDA review, there is no centralized evaluation of the evidence to determine whether a drug works to treat a specific condition and what dose is safe and effective.
State “medical marijuana” laws by-pass FDA review and allow patients to use marijuana if they have specific medical conditions approved by the state. Some states currently list medical conditions (e.g., some psychiatric and neurological disorders) based primarily on anecdotal reports, expert opinions and non-randomized studies. There is not sufficient high-quality evidence from randomized, controlled clinical trials to determine whether marijuana is actually safe and effective for treating most of these conditions. State medical marijuana laws also create a distribution channel that lacks sufficient oversight of standardization and purity of each “dose.” Furthermore, state marijuana laws approve smoked marijuana as medicine. Smoking is not a medically-accepted route of administration for any medication because smoking can damage the lungs and results in second hand exposure.
High-quality research has found that individual components of marijuana, known as cannabinoids, have therapeutic value for select health conditions, including chemotherapy-induced nausea and unwanted weight loss from AIDS. The two cannabinoids that are most studied for their therapeutic value are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is responsible for the intoxicating ("high") effects of marijuana; CBD does not cause intoxication.
The FDA has approved two THC-based drugs, Cesamet (which contains a compound similar to THC) and Marinol (which contain THC). The FDA is currently reviewing clinical trials of drugs that contain CBD only and drugs with a combination of CBD and THC. More research is needed to develop better medications. Cesamet and Marinol are not ideal and may offer inadequate treatment because of their poor time of onset, duration of action, and time of offset. Some have suggested that cannabinoids are less effective when isolated and that whole-plant based drugs are more effective.
CASAColumbia strongly encourages more high-quality research on the medicinal value of cannabinoids to treat health conditions. While administrative and legal barriers (including marijuana’s DEA classification as a Schedule I drug) make it difficult to conduct such research, forgoing FDA review and allowing state legislators or voters to make health care decisions without this centralized review of the evidence poses an unacceptable risk to the public’s health.
The FDA is currently reviewing the medical evidence supporting the safety and effectiveness of marijuana for medical purposes. The FDA’s review may result in a recommendation that the drug be downgraded from Schedule I, which would create more opportunities for research and treatment.
To protect public health and encourage research on the potentially therapeutic components of marijuana, CASAColumbia recommends the following:
Medications prescribed by a physician are the most effective, potentially lifesaving, treatment for opioid addiction. Medication-assisted treatment (also called MAT) reduces drug use and overdose rates and helps retain people in treatment longer, which is associated with better outcomes. MAT also reduces criminal behaviors and infectious disease risk and improves occupational, psychological, and family functioning. Studies suggest that combining MAT with therapy yields the best results.
Unfortunately, there is a widespread misconception among providers, policy makers and the public that “abstinence-based” or “medication-free” treatment – without MAT – is best. Given the evidence supporting MAT’s effectiveness, this philosophy is not supported by research and is potentially dangerous.
FDA-approved medications to treat opioid addiction include methadone, naltrexone and buprenorphine, which is often combined with naloxone. Naltrexone blocks the effects of opioids so people do not get intoxicated (high) or overdose if they use. Methadone and buprenorphine reduce cravings and withdrawal symptoms and allow individuals to improve their functioning in everyday life. When taken as prescribed, these medications do not cause the feeling of intoxication associated with opioid abuse. Because these medications have different mechanisms of action, different side effects and risks, and are available in different health service locations, the medication that is best for any individual will vary.
Methadone has been proven effective through over 40 years of research. The other medications are newer and therefore are less well studied, but data suggest that they may be as effective for many groups of people with opioid addiction.
The length of treatment with MAT depends on the duration and severity of the addiction, the patent’s physical and psychological health and preferences, and other factors affecting recovery. People with an earlier stage or less severe form of addiction may benefit from taking medication for a shorter period of time (for example 6-12 months), depending on their treatment progress. For people whose addiction has progressed to a chronic condition, they may need to take medication for many years or even the rest of their lives, just like people who have asthma, diabetes or heart disease.
The research supporting MAT is strong enough to conclude that MAT is an “evidence-based” treatment, meaning, it has been proven to work. All addiction treatment programs and providers should offer MAT directly or through referral; those that do not should not be considered “evidence-based” providers. Federal and state agencies that pay for addiction treatment services should require that MAT be made available to all patients treated in programs they support. Prohibiting or discouraging the use of MAT or denying reimbursement for this service is unethical, violates parity, and is inconsistent with acceptable medical practice.
In order to reduce crime and save taxpayer dollars, the U.S. justice system must address risky substance use and addiction as health problems and provide effective intervention and treatment. While individuals who commit crimes as a result of their substance use must be held accountable, incarceration alone cannot prevent or treat a disease.
As of 2005, 1.5 million (66%) of the 2.3 million inmates incarcerated in the U.S. met the clinical criteria for addiction. An additional 458,000 inmates had histories of substance use; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or other drug law violation; or shared some combination of these characteristics. In total, 85% of America’s prison and jail inmates are substance-involved.
Crime related to risky substance use and addiction is not limited to adults in the justice system. 78% of 10- to 17-year olds in the juvenile justice system are substance-involved. Among juvenile offenders, 44% meet clinical criteria for addiction involving alcohol and drugs other than nicotine as do more than half of juvenile offenders incarcerated in state prisons and local jails.
People entering the justice system as juveniles or adults who are risky users but not addicted do not routinely receive any interventions to help them reduce their risky use, and despite these high rates of addiction among both adult and juvenile offenders, few in need of treatment receive it. CASAColumbia found that less than 4% of juvenile offenders and only 11% of all prison and jail inmates with addiction receive any treatment. Most of those who do receive treatment do not receive evidence-based care.
CASAColumbia has documented the profound link between substance use and crime in 3 national research studies of America’s justice system: Behind Bars; Behind Bars II: Substance Abuse and America’s Prison Population; and Criminal Neglect: Substance Abuse, Juvenile Justice and the Children Left Behind, and has documented the enormous return on investment possible from providing addiction treatment. If all inmates who needed treatment and disease management received such services and a mere 10% remained substance free, crime free and employed, our nation would reap an economic benefit of more than $90,000 per year for each of these inmates.
To reduce the number of substance-involved offenders, the justice systems must employ trained health care professionals to screen, assess, intervene and treat these offenders using evidence-based pharmaceutical and psychosocial therapies and provide care for co-occurring health (including psychiatric) conditions. Addiction treatment for inmates must be medically managed, and corrections-based treatment programs and providers should be required to be accredited. We must also expand the use of treatment-based alternatives to incarceration and assure that individuals with addiction facing release and re-entry receive appropriate post-release treatment, disease management and support services.
This information will be used to better customize your experience and help inform future tools and features on our website.