Heroin is a White-People Problem: Bad Medicine, Economic Rot and the Enterprising Mexican Town that Turned the Heartland on to Black Tar

Drugs

Heroin is a White-People Problem: Bad Medicine, Economic Rot and the Enterprising Mexican Town that Turned the Heartland on to Black Tar

 

The new American junkie is white, suburban or rural, and got hooked on Xalisco's product and personalized service

 

 

By Laura Miller / Salon

 

April 19, 2015

 

 

 

If you happened to live near a certain clinic in Portsmouth, Ohio, in the early 2000s, you might find yourself regularly answering your doorbell to people asking to buy your urine. The town, once awarded All-American City status by the National Civic League, stands across the Ohio River from the site of America’s first “pill mill” — a medical office, usually posing as a “pain clinic,” where people can easily obtain prescriptions for pain-killers — opened in 1979.

By the dawn of the 21st century, Portsmouth was lousy with pill mills, and Oxycontin tablets served as the area’s informal currency. You could buy refrigerators with pills, pay your dentist with them, or hire an off-duty cable guy to hook you up for a tablet or two. Obtaining the clean urine needed to pass the clinics’ desultory random drug tests, however, clearly required more resourceful tactics.

In time, Portsmouth would join the epicenter of a stealthy, ongoing boom in heroin addiction. The number of people who used heroin in the past year doubled between 2005 and 2012, and the number of deaths from heroin overdose have quintupled in the past decade. The vast majority of these new junkies are white and live in rural areas and small towns and cities in the Midwest and New England. Many are poor, but their ranks are swelling with young people from affluent suburban families, particularly jocks and the kids who hang out with them.

How did this happen and how did it go unnoticed for so long? The story, as related in Sam Quinones’s fascinating new book, “Dreamland: The True Tale of America’s New Opiate Epidemic,” is a tale of convergence. One thread is the decay of cities like Portsmouth, who lost their 20th-century industrial base: jobs in manufacturing, mining and other blue collar fields. Another was a misbegotten “revolution” in standard medical practices for treating pain, funded by a pharmaceutical company with a suite of synthetic opiates to peddle. The third and most remarkable element was a new system of illicit drug distribution, designed and entirely operated by the residents of small backwater village in Mexico.

The current upsurge in heroin addiction attracted little attention at first because its roots lie in what Quinones describes as “voiceless parts of the country — in Appalachia and rural America.” In the unconscious moral mythology of America, small town and rural life is associated with hard work, safety and wholesome virtues, while heroin is an affliction of big cities, with their vice, crime and scary dark-skinned residents. To admit that poverty and despair, irrespective of race, fosters heroin abuse is to undermine entrenched, unspoken prejudices that equate this particular addiction with the moral and cultural weakness of “other people.”

Nevertheless, the meth plague, which flourished in many of the same communities, drew plenty of notice. America’s smack crisis snuck up on us by beginning as a legal, and then a quasi-legal phenomenon. What’s most shocking about Quinones’s history of the rise of addictive pain-killers like OxyContin is that the apotheosis of these drugs was based on completely unfounded scientific claims.

In the 1980s, a small contingent of physicians began to argue that doctors were not treating patients’ pain aggressively enough. Physicians were trained to hold back on effective drugs like morphine for fear of causing dependency. Purdue Pharma, which was developing and promoting OxyContin, a timed-release version of oxycodone, embraced this movement. Purdue sponsored conferences at which advocates for a complete overhaul of pain management protocols urged doctors to prescribe pain-killers more readily. It made sure its sales reps reiterated the claim that only 1 percent of patients prescribed opiate pain-killers become addicted to the drug. Addicts, this line of reason held, were people who used opiates recreationally. Some doctors even insisted that pain prevented addiction by keeping patients from feeling the euphoria that causes you to get hooked.

ADVERTISEMENT

That 1 percent figure, often cited in pharmaceutical literature, textbooks and medical journals, was attributed “Porter and Jick,” described in one such publication as a “landmark report.” As Quinones establishes, there is no such report. “Porter and Jick,” the chapter and verse of free-handed opiate administration, was actually a letter sent to the New England Journal of Medicine by two researchers in 1980. One paragraph in that letter stated that an informal search of the authors’ database of hospitalized patients in acute pain showed that few became addicted to opiates administered in controlled settings by doctors and nurses. Via a flabbergasting game of scientific Telephone, this paragraph, which no one seems to have bothered to look up and verify, was reimagined as a full-fledged study. Authorities cited it repeatedly to encourage an enormous increase in the prescription of opiates, all under the mistaken belief that they were not addictive as long the patient was actually in pain.

This, of course, proved to be utterly untrue. Outpatients were prescribed long courses of opiates for conditions and injuries that never would have merited it before — including high school athletes, who are often urged to play through injuries. Many became addicted and began to seek the drugs from shady or downright illegal sources. Chronically unemployed people on dwindling benefits used prescriptions from pill mills and their Medicare cards to buy discounted pain-killers and resell them at a considerable profit to addicts. But OxyContin and its pharmaceutical brethren remained fairly expensive — $20 to $60 dollars per pill, depending on the dose. And it was at this point, in the late 1990s, that cheap, plentiful supplies of high-quality heroin became easily available in dozens of mid-sized American cities.

The dealers of this dark, sticky black-tar heroin all hailed from a set of clans out of the obscure Mexican state of Nayarit, specifically from the vicinity of a town called Xalisco (not Jalisco, which is another Mexican state). Xalisco is a rancho, an outpost settlement inhabited by rugged frontier types fleeing the “stifling classism” of Mexico’s cities. Quinones, who knows rancho culture well and confesses to a “romantic infatuation” with it, describes these settlements as “lawless, wild places, full of amazing tales.” The ranchos also foster a tenacious entrepreneurial spirit, and rancheros have founded chains of tortilla shops and paleta (popsicle) stands that extend all over Mexico, funneling the money back home to their villages to build impressive mansions they like to lord over their neighbors.

The genius of the Xalisco Boys, as Quinones calls this new group of heroin dealers, was to run their drug business like a popsicle stand franchise. A central manager parceled out single doses of black-tar heroin into small balloons. Drivers, typically young men from the farms around Xalisco and often relatives of the rest of the crew, stuffed their mouths with the balloons and delivered orders to customers at home. All you had to do to get your fix was telephone, and a polite, clean, peaceable Xalisco Boy would shortly appear at your doorstep. They dealt only in small amounts. The Boys never used the product, and no one carried a gun; that would have meant jail instead of deportation if a driver were picked up by the cops. The heroin the Boys sold was exceptionally pure because instead of having passed through (and been stepped on by) a series of middlemen, it was usually made by a relative back home, from poppies harvested in the mountains above Xalisco.

It’s difficult not to admire the Xalisco Boys just a little bit. They embody the sort of independent industrious spirit that we consider quintessentially American. Unlike the big, vicious, borderland Mexican drug cartels, with which they have sometimes been confused, the Boys were nonviolent and low-profile, preferring to target smaller cities without established dealers or prominent gangs. When another clan came to town to open up a rival tiendita, or store, they didn’t fight over territory. This was a business of return customers, not turf. Instead, they competed on service or — having gotten the drug cheaply, direct from the source — on price. To the amazement of every junkie who bought from them and every cop who tried to roll them up, the Xalisco Boy drivers were on salary, and much of their earnings were sent directly back to their families. All they dreamed of was going home to their villages to impress their neighbors with their wealth.

One reason why the current heroin epidemic is so white is that the rancheros apparently were fearful of African-Americans, who they associated with gangs and the sort of extravagant violence destined to attract police attention.

Eventually the big-time cartels did move in on the Xalisco Boys’ action a bit, although tienditas still exist in many small American cities. The heroin that helped kill actor Philip Seymour Hoffman in New York City last year, for example, was a brown powder, most likely supplied by a Mexican cartel instead.
Nevertheless, black tar heroin, however unobtrusive and pacifist its distributors may be, still ruins and takes lives. Despite their gumption, the Xalisco Boys spread a scourge. Strikingly, Quinones found that the only watchmen who noticed the mounting toll, who spoke out about it and and fought it, were people working for the government. “We’ve seen the demonization of government and the exultation of the free market in America over the previous thirty years,” he writes. “But here was a story where the battle against the free market’s worst effects was taken on mostly by anonymous public employees.” The flip side to American individualism is a strong sense of communal responsibility, and that, thank god, has not perished with the factories and mills.

Medical Marijuana: Will the Risks of Marijuana Outweigh Its Benefits?

PSYCHIATRY & MENTAL HEALTH

Medscape Family Medicine

Do Physicians Use Marijuana?

Carol Peckham

DisclosuresFebruary 05, 2015

Marijuana Usage in Physicians

The Medscape Lifestyle Report 2015 included questions on physicians' use of marijuana and their opinions on legalization. Other surveys have been conducted on physicians' attitudes toward medical marijuana, but very few have asked about doctors' own history of usage. A 2013 Gallup poll^[1] reported that 38% of Americans have tried marijuana, a percentage that has increased by only 5% since 1985. Only 7% say they are currently using it. In this year's Medscape survey, physicians report a lower rate of history of marijuana use, with just under a quarter reporting ever having tried it. Three percent say they've used marijuana in the past year, also a lower percentage than that found in the Gallup poll for the general population.

There is no difference in marijuana usage between burned-out and non–burned-out physicians. There is also very little difference in usage between male (25%) and female (21%) physicians (Figure 1).

Figure 1. History of marijuana use by gender.

Marijuana history varies somewhat by specialty, however (Figure 2). In this survey, emergency medicine physicians report the highest history of marijuana use (31%), followed by plastic surgeons, orthopedists, and psychiatrists at 29%. The least likely to report ever using marijuana are nephrologists (15%), endocrinologists (16%), and rheumatologists (17%).

Figure 2. Marijuana use by specialty.

Physician Use of Marijuana and Alcohol

A study of French medical students found an association between high-risk alcohol and high-risk cannabis consumption but no correlation with anxiety or depression.^[2] The Medscape 2015 report echoed these results, finding a correlation between higher levels of alcohol consumption and a greater tendency to have used marijuana, although there was no association between burnout and usage of either of these substances. Of those who have more than two alcoholic beverages per day, 45% claim to have ever used marijuana. The less physicians drink, the less likely they are to have used marijuana; only 12% of those who don't drink at all claim to have ever used marijuana (Figure 3). It is worth emphasizing that Medscape physician responders report very light to moderate drinking habits; just under a third of all physician responders said they didn't drink at all, and about half claimed having less than one drink per day.

Figure 3. Marijuana and daily alcohol use.

Physician Age and Marijuana Use

According to the Gallup poll, when filtered by age, 49% of Americans ages 30-49 years and 44% of those 50-64 years have used marijuana at some point; the youngest and oldest groups had the lowest percentages (36% and 17%, respectively).^[1] Usage by age differs slightly among physicians who responded to the Medscape survey (Figure 4). The highest usage rate (32%) is among the baby boomers, ages 56-65. It drops considerably in the next two younger age groups, with 21% of those 46-55 and only 17% of those 36-45 reporting use. That number rises again among the youngest physicians (under 35) to 25%.

Figure 4. Physician marijuana history by age group.

This pattern—peak history of usage in midlife, then a decline in younger physicians, followed by a rise in the youngest doctors—reflects a general trend reported in a national survey^[3] that has tracked substance abuse over several decades in the general population. In the latest report on this survey, those in their 50s tended to be a "very drug-experienced segment of the population, as might be expected due to the fact that they graduated from high school near the peak of the drug epidemic." The authors then observed a decline in drug-taking in the next younger age groups, who had a greater perceived sense of risk during the years when they were growing up. The survey is now reporting an increasing trend of drug-taking in college students, which they attribute to "a generational forgetting of those risks ... through a process of generational replacement of older, more drug-savvy cohorts with newer, more naive ones." According to recent government data, marijuana use is declining in high-school adolescents.^[3,4]

Legalizing Medical Marijuana

Alcohol was once illegal because of its devastating effects from addiction and the deleterious impact of heavy use on the body and the brain. Although these harmful effects remain, our culture is at ease now with alcohol's legality and recreational use. This is one argument for the legalization of marijuana, which so far has not been demonstrated to exhibit harmful effects as severe as those of alcohol, even with long-term use.

Increasing evidence shows that, compared with many other pharmaceutical interventions, marijuana used in medical treatments is relatively safe. In the United States, 22,134 deaths related to pharmaceuticals and 9429 additional deaths from the use of unspecified drugs were recorded in 2010.^[5] According to recent data from the Centers for Disease Control and Prevention (CDC), no deaths caused by medical marijuana overdose have been confirmed in the United States.^[6]In fact, a report in JAMAconcluded that there are 25% fewer opioid overdose deaths each year in states where access to medical marijuana is legal, compared with states where it is not. Death rates decreased dramatically in the years immediately after legalization.^[7]

However, it is naive to justify legalizing marijuana's recreational use simply on the basis of its relative safety compared with alcohol and other drugs. Cannabis, taken recreationally or medically, is still a drug. And any drug with beneficial effects also has harmful ones. Furthermore, no one is certain what the actual benefits—and, conversely, full harm—from marijuana may be.

The American Medical Association acknowledged some therapeutic benefits of cannabis in a policy statement^[8] but added, "The patchwork of state-based systems that have been established for 'medical marijuana' is woefully inadequate in establishing even rudimentary safeguards that normally would be applied to the appropriate clinical use of psychoactive substances. The future of cannabinoid-based medicine lies in the rapidly evolving field of botanical drug substance development, as well as the design of molecules that target various aspects of the endocannabinoid system. To the extent that rescheduling marijuana out of Schedule I will benefit this effort, such a move can be supported."

Positions on Legalization by Specialty

A 2014 Gallup poll reported that over half (51%) of Americans support legalization.^[9] Among physicians who responded to the current Medscape survey, 59% of those who have ever used marijuana support total legalization, and 20% support it only for medicinal purposes. Even among physicians who have never used marijuana, 51% support some form of legalization (23% total and 28% medicinal). Positions on marijuana legalization vary somewhat by specialty (Figure 5).

Pathologists, at 69%, and intensivists and radiologists, at 67%, were the most favorable toward some degree of legalization. Family physicians hold the least favorable view on marijuana legalization, with half of them supporting legalization of some form and nearly a quarter (23%) saying it should never be legalized. (The remaining FPs remained uncertain.) The American Academy of Family Physicians does not endorse legalization but urges its members to be knowledgeable about their state laws and consult with state medical boards on guidance for the use of medical marijuana.^[10]

Psychiatrists who responded to the Medscape survey were the second least likely specialty to advocate legalization, with only 51% favoring legalization and 24% completely opposed to it. (Of interest, 29% of psychiatrists reported a history of usage, which was fourth from the top among all physicians.) The American Psychiatric Association has also come out against legalization of marijuana, at least until it has been well investigated, particularly given its potential harm on adolescent users.^[11]

Some research offers promise on treating specific conditions (eg, multiple sclerosis, inflammatory bowel disease, and fibromyalgia), but there is less acceptance of legalization than might be expected among physicians in specialties that treat these conditions. These specific conditions, and the evidence for use of marijuana in treating them, will be discussed in more detail later.

There is some institutional support for the use of cannabis in treating symptoms of multiple sclerosis, so one might expect that more than 57% of neurologists responding to our survey would favor some form of legalization.

Marijuana has anti-inflammatory properties, and some research suggests that it is helpful in relieving inflammatory bowel disease symptoms and irritable bowel syndrome. However, in our survey, only 54% of gastroenterologists support legalization, perhaps because of the lack of well-controlled randomized studies.

There is limited evidence that marijuana can relieve symptoms in patients with fibromyalgia, but no studies to date have found it to be of benefit in treating arthritic pain. This may explain why rheumatologists, at 51%, were among the three specialties least likely to support legalization.

Figure 5. Marijuana legalization support by specialty.

Physician Usage and Views on Legalization by Region

Analyzing physician opinions by region demonstrates that marijuana usage and support for legalization go hand in hand (Figure 6). But do the highest percentages of physician support for either medical or total legalization always occur in states where marijuana is now legal in some form?^[12]

A 2014 Gallup poll reported that among all Americans, the greatest level of support of legalization, at 57%, is in the East and the West.^[9] Physicians in the Southwest, which has four states where medical marijuana is legal, report both the highest rate of history of usage (31%) and the most positive view toward legalization (64%). The Northeast, where all of the states have some form of legalization, holds the second spot for physician support of legalization (61%). However, in the Southeast, marijuana is not legal in any of its states, and yet an identical 61% of its physicians also support legalization. Notably, usage history (29%) in the Southeast is actually higher than in the Northeast (27%). Furthermore, physicians who live in the Great Lakes area, where half of the states have some form of legalization, are at the bottom of the list in support for legalization (50%) and second to the bottom in usage history (19%). The North Central region, which has no states with legalization laws, is second from the bottom for support of legalization, with 52% of physicians favoring it and only 18% having ever used marijuana.

Figure 6. Physician history of use and legalization support by region.

Medical Uses of Marijuana

In 2013, the New England Journal of Medicine presented its readers with a case study of Marilyn, a 68-year-old woman with metastatic breast cancer, and asked whether they would prescribe marijuana to help alleviate her symptoms; 76% responded positively.^[13] A Medscape poll of clinicians regarding medical use of marijuana, conducted in 2014, found similar support for a therapeutic role for cannabis. About 70% of physicians believed that marijuana had real medical benefits, although only 1% had ever used it for medicinal purposes themselves.

Two cannabis-derived pharmaceuticals are available in the United States and Canada: dronabinol (schedule III) and nabilone (schedule II). A third, nabiximols, is available in Canada but is not approved by the US Food and Drug Administration. Both the Institute of Medicine and the American Medical Association have supported the therapeutic benefits of cannabinoids for pain relief, control of nausea and vomiting, appetite stimulation (particularly among cancer patients), and for reducing pain and spasticity in patients with multiple sclerosis.^[8,14] The American Academy of Neurology has also just released guidelines for using cannabis in treating multiple sclerosis.^[15]

Nevertheless, healthcare workers face complicated and as yet unresolved issues related to cannabis as therapy. The legalization of marijuana for recreational or medical use in a number of states now provides the opportunity to study its effects—beneficial or harmful—in more substantive ways than previously, which ultimately will help the clinician to make decisions about cannabis use in practice.

Treatment of Non-cancer Chronic Pain

Cannabinoids appear to have some benefit in relieving neuropathic pain.^[16-19] Preliminary recommendations have been issued from the College of Family Physicians in Canada to help guide clinicians in prescribing cannabis for this purpose.^[20] To date, however, most research does not indicate a similarly favorable risk-benefit ratio for marijuana's use in relieving arthritic pain.^[21-23] Some evidence suggests that cannabis may reduce the need for opioids in patients with chronic pain, although most of these studies are based on patient self-reports.^[24] One small study in 2011^[25,26] suggested that in patients taking long-acting opioid analgesics for various chronic pain conditions, a potential combination treatment with vaporized cannabis could reduce pain and might also cut opioid dosing.

Multiple Sclerosis

Cannabis is being used in the management of pain and spasticity from multiple sclerosis, although evidence of its value is still limited.^[27-30] Despite the current state of evidence,^[31] the American Academy of Neurology released guidelines in 2014 on its use in treating patients with multiple sclerosis.^[15]

Cancer

Dronabinol and nabilone are indicated for the treatment of nausea and vomiting associated with cancer chemotherapy and anorexia associated with weight loss.^[32] Although evidence to date of marijuana's effectiveness in relieving symptoms of cancer (pain, nausea and vomiting, loss of appetite, and weight loss) have been inconclusive, recent studies are promising.^[33,34] Some interesting research suggests that cannabinoids may have an antiproliferative effect on tumors of different origin, which bears clinical investigation.^[35,36]

Inflammatory Bowel Disease and Other Gastrointestinal Conditions

Because of its anti-inflammatory properties and effects on motility, cannabis preparations are considered promising tools for the management of inflammatory bowel disease and other gut disturbances.^[37-40]

Will the Risks of Marijuana Outweigh Its Benefits?

Neuropsychiatric Effects

The neuropsychiatric effects of marijuana are of particular concern and still not yet fully known. Of interest, in Colorado, physicians who legally use medical marijuana to treat their own conditions are considered unsafe to practice until they no longer need such treatment. (The use of other substances, such as alcohol or sedating medications, does not preclude Colorado doctors from practicing.)^[41]

Neurocognitive performance. An 8-year study^[42] and a meta-analysis^[43] found that marijuana had few long-term effects on learning and memory. The meta-analysis reported that "any negative residual effects on neurocognitive performance attributable to either cannabis residue or withdrawal symptoms are limited to the first 25 days of abstinence. Furthermore, there was no evidence for enduring negative effects of cannabis use."  Recently, however, a large study found neuropsychological decline in adults who had been heavy users of marijuana in their adolescence.^[44] In addition, stopping the drug did not prevent further decline. Further studies are needed. To offer some perspective, research to date finds the effects of heavy alcohol use on young people's brains to be far more detrimental than those of marijuana. In fact, some research suggests that marijuana might be somewhat neuroprotective in young users of alcohol.^[45,46] It should be strongly stressed, however, that young brains are vulnerable to the negative, even long-term, effects of all substances that affect the brain, including marijuana.

Addiction. Contrary to the views of many of its proponents, research suggests that a quarter to a half of those who use marijuana daily are addicted to the drug.^[47]

Mood disorders and psychosis. The effects of marijuana on depression and anxiety are unclear. A longitudinal study found no association with mood disorders, although it did find higher incidences of bipolar disorder.^[48] Other evidence supports an association between marijuana use and a higher risk for future development of psychotic symptoms, but the link is contentious.^[49-52] A 2014 study on post-traumatic stress disorder suggested that concomitant use of medical marijuana nullified the benefits of existing treatment in these patients.^[53]

On a more favorable note, a 2015 regression analysis reported a lower suicide rate in young men in states where medical marijuana was legal, compared with the rate in states where it wasn't. The authors believe that it is the first study to examine the relationship between marijuana and suicides. The study could not establish a causal relationship, of course. Another factor that could play a part in the decrease in suicides was the reduction in alcohol use in those states where marijuana was legal.^[54]

Cardiovascular Effects

Research is now pointing to adverse cardiovascular effects from cannabis use, including myocardial infarction, sudden cardiac death, cardiomyopathy, stroke, transient ischemic attack, atrial fibrillation, and cannabis arteritis.^[55-57] For example, in a French study, 1.8% of adverse effects reported from cannabis use were cardiovascular complications, which were associated with a death rate of 25.6%.^[58]

Pulmonary Effects

The effects of smoking marijuana on lung function are unclear, partly because most users also smoke tobacco.^[59] Lung cancer studies to date largely do not support an association with marijuana use, possibly because of the smaller amounts of marijuana regularly smoked compared with tobacco.^[60,61] There may be a risk, however, in heavy users.^{[62, 63]}

Accidental Overdose in Children and Young People

After marijuana was legalized in Washington State, marijuana poisonings spiked in adolescents.^[64] In January 2015, a leading anti-marijuana group reported an increase in the number of children treated for accidental marijuana consumption in Colorado as well, and a surge in the numbers of adolescents treated for cannabis abuse.^[65] "Trying to draw any conclusions with less than 1 year of data is irresponsible," pro-cannabis Marijuana Policy Project spokesman Mason Tvert said. In addition, if alcohol use is declining in these states, it would be important to determine whether there is also a decline in treating alcohol use or other forms of drug abuse that might offset the increase in cannabis abuse treatment. In a policy statementissued in January 2015 reaffirming opposition to legalization of marijuana, the American Academy of Pediatrics recommended that where it is legal, regulations should be enacted to insure that all product is distributed in childproof packaging to prevent accidental ingestion.^[66]

How Heroin Became the Face of Drug Addiction in Small-Town America

Drugs

How Heroin Became the Face of Drug Addiction in Small-Town America

 

A perfect storm of supply and demand is fueling the drug’s rapid rise in popularity.

 

By Allegra Kirkland / AlterNet

 

January 27, 2015

Like most heroin users, Ory Joe Johnson’s addiction began with a perfectly legal prescription. After a bad car accident in which he broke his nose, jaw, collarbone and ankle, the Wyoming native was prescribed Vicodin for the pain. The meds eventually ran out, but his dependence on them remained. To fuel it, Johnson began dealing drugs, starting with crank (a low-quality powdered form of meth), and as the years passed and his addiction metastasized, eventually moving up to heroin. At the peak of his dealing career, Johnson was funneling drugs to a network of local college students and his reach extended to a constellation of southern Wyoming towns.

The subject of a recent GQ profile, Johnson is now serving nine years in prison for possession and intent to sell. Though he is just one dealer in just one corner of the country, his story has much to say about how heroin is gripping its pale white fingers around the throats of America’s small towns.

To make something clear right off the bat, we are not experiencing a heroin “epidemic.” As the GQ article points out, more Americans huff glue than use the drug, and the total number of users is a tiny fraction of the U.S. population. But for a number of reasons, including high national rates of opiate addiction, rock-bottom prices, corrupt medical professionals, and a surge in supply from Mexico, heroin usage is on the rise. In 2012, some 669,000 Americans reported using heroin in the past year, according to the National Survey on Drug Use and Health. That year alone, 156,000 people started using the drug—nearly double the number of people in 2006 (90,000). As the DEA’s regional head for the Midwest put it in an interview with BBC, “Heroin addiction is probably at its all-time high.”

Click to enlarge.

(Source GQ)

It’s impossible to understand the drug’s recent resurgence without looking at the rise of prescription opiates in the 1990s. In "The New Heroin Epidemic,” a terrific investigative piece in the Atlantic, Olga Khazan traces the emergence of blockbuster pain medications like Oxycontin and Percocet. Big Pharma executives waged an aggressive marketing campaign to popularize the drugs, downplaying the risk of addiction, sending thousands of doctors on junkets across the U.S. to learn about the pills and offering sales reps millions in bonuses for convincing doctors to prescribe them. Their efforts succeeded, but with devastating consequences. As the drugs became more widely prescribed, painkiller abuse skyrocketed; the number of deaths caused by prescription painkiller overdose quadrupled between 1999 and 2011. In some states, prescription abuse was facilitated by corrupt doctors who overprescribed, sold prescriptions on the side, and even exchanged the pills for sexual favors.
The Atlantic article uses the case study of West Virginia to explain how prescription pill addiction heralded the current surge in heroin use. A poor state with a high concentration of physically demanding manufacturing and mining jobs and little else in the way of economic opportunity, West Virginia was a ripe target for prescription drug abuse. As Khazan writes, by 2009 residents were annually filling an astonishing average of 19 prescriptions per person. Around this time, medical and state authorities started cracking down, jailing corrupt physicians, establishing databases to prevent patients from getting prescriptions from multiple clinics, and developing pills that were less easy to crush into powder form. Prescription pill use fell. But people were already addicted, and were going to find another outlet. Three out of four new heroin users say they abused prescription painkillers before turning to the drug.

This spike in demand for heroin coincided with a surge in supply. Mexican cartels, which are moving out of the marijuana market as legalization gains a firmer hold in the U.S., are sending cheap, high-quality heroin across the border. As the Washington Post reported, “The amount of cannabis seized by U.S. federal, state and local officers along the boundary with Mexico has fallen 37 percent since 2011, a period during which American marijuana consumers have increasingly turned to the more potent, higher-grade domestic varieties cultivated under legal and quasi-legal protections in more than two dozen U.S. states.” Heroin has advantages for both opiate addicts and traffickers. It costs only $10 a pill, compared to $80 for oxycodone, and is easier to transport and conceal than marijuana.

Of course, this isn’t the first time Americans have embraced heroin. But, as every article about the drug’s resurgence points out, the face of heroin use has changed. In the 1960s and '70s, heroin took hold in urban centers. “Forty or fifty years ago heroin addicts were overwhelmingly male, disproportionately black, and very young," according to the Economist. "Most came from poor inner-city neighborhoods.” Today, many heroin users live in suburban and rural areas—places like southern Wyoming and the foothills of West Virginia. Ninety percent of users are white, and more than half are women. It doesn’t take too many logical leaps to understand why the drug’s newfound popularity has been met with so much attention, and why the media is so willing to label it an epidemic.

Click to enlarge.

(Source: The Economist)

This changing user demographic has been met with a shift in official response. “Now that heroin addiction is no longer a disease only of the urban poor, attitudes are changing. The Obama administration’s latest national drug strategy, published in July, criticized ‘the misconception that a substance use-disorder is a personal moral failing rather than a brain disease,’” according to the Economist. They have called for the expansion of needle-sharing services and greater access to naloxone, a drug that can reverse the effects of heroin overdose.

It’s critical that federal and state authorities expand drug and psychological treatment services for heroin users. Physicians interviewed in the Atlantic article say that a combination of drug treatment and talk therapy is the best way to wean people off of its influence. But the areas that are particularly blighted by the drug, like rural West Virginia, are often the least equipped to handle it. They are economically depressed regions with limited access to health services, few job opportunities and bare-bones police departments. Only two-thirds of West Virginians have access to mental-health treatment, and the medical officer for the Substance Abuse Mental Health Services Administration said that only a handful of places in the country have enough providers able to offer drug treatment alongside therapy. This is where we have to focus our energies. Because in the kinds of towns where Ory Joe Johnson was pushing heroin—dusty roadstops of 3,500—addiction is an epidemic.

Slate

Mellow, Paranoid, Happy, or Mean

By Brian Palmer

Why do people respond so differently to the same drugs?

Mean drunk or generous drunk?

Composite by Slate. Photos courtesy of Shutterstock.

Maureen Dowd, a 62-year-old Pulitzer Prize–winning columnist for theNew York Times, had a bad marijuana trip earlier this year. As part of her research into the legalization of recreational cannabis in Colorado, she ate a few too many bites of a pot-infused candy bar, entered a “hallucinatory state,” and spent eight paranoid hours curled up on her hotel room bed. Dowd used the experience as a jumping-off point to discuss the risks of overdosing on edible marijuana, which has become a major issue in pot-friendly states. It’s also possible, however, that Dowd just doesn’t handle cannabis very well. While pot mellows most people out, everyone has heard of someone who barricaded himself or herself in a dorm room after a few bongs hits in college. (Or maybe that someone is you.) Why do people react so differently to the same drug?

The question itself may be something of a fallacy. Cannabis is not a single drug—it contains dozens of compounds, and they appear to have varying, and sometimes opposing, effects on the brain. Tetrahydrocannabinol, or THC, and cannabidiol, or CBD, have been the subject of some intriguing research. In 2010, researchers showed that pretreating people with a dose of CBD can protect against the less pleasant effects of THC, such as paranoia. In a similar 2012 study, participants took pills that contained only one of the two chemicals, rather than the combination that you receive in cannabis. The subjects who took THC pills were more likely to suffer paranoia and delusion than those who took CBD.

The researchers went one step further to investigate which specific cognitive effects of THC are likely to lead to paranoia and other symptoms of psychosis. After taking either THC or CBD, participants watched a series of arrows appear on a screen and responded by indicating which direction the arrows were pointing. Most of the arrows pointed directly left or right, but occasionally a tilted arrow appeared. (Researchers called the tilted arrows “oddballs.”) Subjects who took the CBD had a heightened brain activity response to the oddballs. That’s the way a nondrugged person typically reacts—repetitions of the same stimulus don’t interest us, but a sudden change grabs our attention. The THC-takers had an abnormal response: They found the left and right arrows, which constituted the overwhelming majority of the images, more noteworthy than the oddballs. The researchers’ interpretation is that THC may undermine our ability to ignore routine, unimportant stimuli. Ignoring the ordinary is an important skill—we can’t function if every chirping bird or billboard grabs our attention and refuses to let go. Focusing obsessively on every meaningless detail in the environment may contribute to the paranoia that some pot users experience.

The differing effects of THC and CBD partially explain why some marijuana strains—which differ in the ratios and amounts of THC and CBD—are believed to provide giddy, excited highs, while others are thought to mellow the user, regardless of one’s personal neurological peculiarities.

Although both THC and CBD are present in marijuana, your brain may be more receptive to one of the chemicals than the other. Maureen Dowd’s brain may have a strong affinity for THC, while the mellower smokers may take up CBD more efficiently.

There is probably also a psychological element in addition to the neurochemical explanation. Consider the effects of alcohol. There are mean drunks, loud drunks, amorous drunks, withdrawn drunks, teary drunks, and many more kinds. There are no differences in the drug itself—unlike cannabis, alcohol has only one psychoactive substance—so there has to be another explanation.

There are scads of studies exploring the diverse effects of alcohol, much of it focusing on variations in alcohol-related aggression, but none of the studies are entirely satisfying. Psychological research rarely is. (That’s not a knock on psychologists or psychiatrists—it’s just a very tricky field.)

Top Comment

An old friend of mine, normally a nervous, sharp-tongued guy, gets completely mellow when he drinks. He pretty much stops talking and just smiles at the world like he's figured out the Secret of Life.  More...

-Mr. T & Sympathy

One theory is that some people don’t care very much about the consequences of their actions, even when they’re sober. When these people drink, they get aggressive, and their lack of foresight means they don’t bother to check their mean-drunk impulses. In a 2012 study, researchers at Ohio State showed that people who ignored consequences when sober got really excited about shocking their opponents in a drunken reflex competition. The study was widely publicized, but shocking a person in a laboratory setting is vastly different from punching someone in a bar. The legacy of the infamous Milgram experiment is also relevant—anyone participating in a psych experiment allegedly involving shocking other participants may well know it’s just pretend. Several other personality characteristics, such as anxiety levels, have been suggested as explanations for how people behave when intoxicated. Most of these studies are based on laboratory scenarios that don’t mimic well the drinking experiences you get in the wild.

There may a genetic basis for differing responses to alcohol. In a 2010 twin study, researchers attributed one-third of the variation in alcohol-induced aggression levels to genetic factors. The research was based on self-reporting, though, and the ability to estimate our own anger and aggression levels isn’t necessarily consistent from person to person.

Although the research hasn’t settled on simple explanations, it’s clear that some combination of personality traits, genetics, and experience affects how people respond to intoxicants. You can’t blame it all on the drug. Maureen Dowd’s rough night in Denver had something to do with the amount and kind of dope she consumed, as well as her own reaction to certain psychoactive chemicals. But her psychological makeup also likely played a role. I can think of a few people who might accuse her of an inability to consider the consequences of her actions.

Brian Palmer is Slate's chief explainer. He also writes How and Why and Ecologic for theWashington Post. Email him at explainerbrian@gmail.com. Follow him on Twitter.

SCIENCE NEWS

Legalization trend forces review of marijuana’s dangers

Pot may be far less risky than highly addictive drugs, but it's not harmless

BY LAURA SANDERS 

2:06PM, MAY 30, 2014

HIGH TIMES  Marijuana legalization advocates tout pot’s medicinal benefits and low addictiveness, while critics point to its neurological dangers. Research shows that the reality is somewhere in the middle.  

TANG YAU HOONG

Magazine issue: 

June 14, 2014

•  EMail
•  Print
•  Twitter
•  Facebook
•  Reddit
•  Google+

SPONSOR MESSAGE

Some people think marijuana is nature’s gift to humankind: a nonaddictive drug, safe at any dose, that opens the mind, lifts the spirit and transports the user to a more profound reality.

“The illegality of cannabis is outrageous, an impediment to full utilization of a drug which helps produce the serenity and insight, sensitivity and fellowship so desperately needed in this increasingly mad and dangerous world,” a user named Mr. X wrote in the 1971 book Marihuana Reconsidered.

Close to 30 years later, Mr. X was revealed to be the legendary science communicator and astronomer Carl Sagan. His message still reverberates with many Americans, whose support for legalizing marijuana has tripled since 1989 — from 16 percent to 54 percent today. In Colorado and Washington state, voters legalized recreational marijuana use in November 2012. That formal embrace of marijuana may signal a growing shift in acceptance. Today, 21 states and the District of Columbia sanction medical use (up from 16 in 2010) and 17 have curbed punishments for possession of small amounts of recreational cannabis.

Marijuana as medicine is gaining support in studies, both to tamp down nausea and pain and to directly counter insidious diseases such as epilepsy, cancer and multiple sclerosis (SN: 6/19/10, p. 16). But what about for healthy people? Is marijuana really a safe way to rise above the tumult and distress of daily life?

Michele Leonhart, the head of the U.S. Drug Enforcement Administration, says no. In congressional testimony in 2012, she portrayed marijuana as a dangerous addictive drug on par with methamphetamines or heroin. Like other drugs cordoned off by her agency to a list called Schedule I, she said, marijuana has no medical use and a high potential for abuse.

Convinced of marijuana’s dangers, the DEA and vocal groups of police officers, educators and public health officials remain steadfastly opposed to the growing legalization movement. Legalization poses significant health and safety risks to Americans, they argue. This addictive drug wipes out memories, steals IQ points and triggers psychosis, leaving behind a zombie nation of slackers vegetating in their parents’ basements, opponents say. The consequences may be especially damaging for teens.

Who is right? The people who contend that marijuana is a misunderstood salve for the soul or those who claim it’s a dangerous narcotic that turns people into dimwitted potheads?

Turns out it’s neither. Though the research is far from definitive, the scientific evidence that does exist suggests that marijuana is far less dangerous than highly addictive drugs like heroin, methamphetamines and alcohol. But it is not harmless. Pot can probably cause permanent changes in the developing brains of adolescents. And though marijuana is not highly addictive, about 10 percent of users become dependent.

Altered states

Marijuana can speed up the heart, expand blood vessels in the eye and make the mouth feel cottony. It also has several targets in the brain.

Brain structure	Effect of marijuana on brain region
Amygdala	Can alter emotional states
Basal ganglia	Reduces motor activity; users may move less
Cerebellum	Can impair coordination
Cortex	May alter complex thinking, making it hard to pay attention or switch quickly between two tasks
Hippocampus	Memory center becomes less efficient, making it harder to learn and remember new information
Hypothalamus	Stimulates appetite, giving marijuana users the well-known "munchies" effect
Nucleus accumbens	Can make users want to use again by targeting this area, which is part of the brain's reward system

Source: K. Franson; Credit: Alila Medical Media/Shutterstock

It’s unlikely that existing research will be able to provide a clear-cut answer about whether legalization is a good idea. But in a way, that debate is already over. As popular sentiment shifts and laws become more lenient, marijuana becomes a bigger piece of the social fabric.
“We’re at this point, whether we like it or not, where things are changing, and they’re changing fast,” says Susan Weiss, associate director for scientific affairs at the National Institute on Drug Abuse (NIDA) at the National Institutes of Health. Her agency is funding studies to better understand the effects of marijuana, she says, so that the science can better inform public policy.

Your brain on pot

When a person tokes, eats or vapes cannabis, a wave of THC, or tetrahydrocannabinol, washes into the brain.

Thought to be the major psychoactive ingredient in marijuana, THC latches on to a protein in the brain called cannabinoid receptor type 1, or CB1. These receptors are sprinkled liberally throughout the brain, especially in the cortex, where thinking takes place; the basal ganglia, which helps control movement; the appetite-regulating hypothalamus; and the hippocampus, a structure involved in forming memories.

CB1 receptors are an important part of how the brain works, says neuroscientist Valerie Curran of University College London. “They’re not put there by God so we can all enjoy cannabis,” she says. “They’re put there because we have our own cannabis in our brains.”

The brain’s self-made cannabis consists of molecules called endocannabinoids, which hit the targets that cannabis hijacks. One of the primary endocannabinoids is named anandamide, after the Sanskrit word for bliss. The brain’s endocannabinoid system influences pain, memory, mood and appetite, and plays a role in helping the brain grow.

So when foreign THC taps into this system, the effects can feel profound, says psychologist Mitch Earleywine of the University at Albany in New York. “It’s got a novelty,” he says. “It’s got its own receptor system and its own set of effects. The fact is that not a lot of other substances hit that CB1 receptor.“ That’s how cannabis elicits its particular brand of euphoria and cognitive flexibility, says Earleywine, who also serves on the board of NORML, the National Organization for the Reform of Marijuana Laws, which pushes to legalize the drug.

Unlike some other reality-altering drugs, cannabis doesn’t seem to be lethal, even in high doses. “Can you die from alcohol just by drinking yourself to death? Yes, you can,” says pharmacologist Kari Franson of the University of Colorado Denver. “Can you die from marijuana just from ingesting too much or smoking too much? Well, not really. You pretty much have to fall down and hit your head to die from it.” (A paper published in the April Forensic Science International does describe the deaths of two presumably healthy young men from heart trouble under the acute effects of cannabis. But overall, deaths seem to be rare.)

Leaning green

From the 1960s until about four years ago, the majority of Americans thought pot should be illegal. Today, views have shifted, with 54 percent supporting the legalization of marijuana.

Source: Pew Research Center 2014

Marijuana may not be deadly, but there are some clear downsides. A mental juggling act called working memory, the ability to hold pieces of information in mind, is diminished in someone who’s high, 40 years’ worth of studies show. Marijuana use has been linked to cardiovascular problems, most recently in a paper in the April Journal of the American Heart Association thatdescribes heart problems in young cannabis users. Cannabis intoxication may double a driver’s risk of a car crash, scientists reported in 2012 in BMJ. And heavy smokers can show more signs of lung damage compared with nonsmokers, though whether that actually leads to more disease is unclear, according to a 2013 reviewpublished in the Annals of the American Thoracic Society.

“We’re worried about having another drug that’s highly prevalent and very accepted by society,” says Weiss of NIDA. The burden of problems will only get worse, she says, including altered brain development, poorer school and work performance and higher numbers of people who are addicted. Between 2009 and 2011, as use rates went up, the rate of emergency room visits for cannabis intoxication rose by 19 percent, according to the Drug Abuse Warning Network.

Addiction

The concept of addiction plays front and center in the debate. Marijuana proponents are fond of pointing out that the drug is less addicting than tobacco and alcohol, substances that are legal for adults. And that is correct. On a relative scale, marijuana just isn’t as addictive as other substances, says Franson.

“Think about those poor little rats pushing levers to get cocaine. They forgo eating, forgo sex, forgo everything because they just want to hit that lever,” she says. Marijuana’s addictive allure doesn’t compete with opiates, or even alcohol or tobacco. But that doesn’t let marijuana off the hook, she says. “It’s not the worst offender, but it still does have some of those addictive components,” Franson says.

It’s not clear what goes on in the brain to cause pot addiction, or why so many people escape it. Marijuana somehow reduces the number of CB1 receptors in the brains of people who smoke regularly, an effect that might contribute to addiction, scientistsreported in Molecular Psychiatry in 2012. But after a month of abstinence, the receptors bounced back to normal levels everywhere except the memory-forming hippocampus. Regular marijuana use might also influence an addiction-linked pathway that involves the neurochemical dopamine, though the details of that interaction aren’t clear. Studies, mainly on animals, suggest that over time, cannabis might change the feel-good parts of the brain, including the neurons that produce dopamine, in ways that prompt people to keep using it.

Average number of daily U.S.
emergency room visits for drug use in
teens ages 12–17

197

Alcohol, alone or with other drugs

165

Marijuana
 

74

Pain relievers

Source: 2011 SAMHSA Drug Abuse Warning Network

Those changes might explain why some people struggle to stop using marijuana. About one user in 10 becomes dependent, defined by criteria described in theDiagnostic and Statistical Manual of Mental Disorders. Those criteria include two key features: tolerance and withdrawal. 

Experienced marijuana users need to up their dose as they become tolerant. “You need more of the drug to have the same effect,” says Franson. Animal studies bear that out: Mice exposed habitually to THC need more and more of the drug to show the same motor deficits.

Marijuana withdrawal is even more contentious than tolerance. After stopping heavy marijuana use, some people — but not everyone — experience irritability, anxiety and loss of appetite. Still, those symptoms are mild compared with an opiate or alcohol withdrawal, Earleywine says. “If you tell an opiate addict you’re ‘addicted’ to marijuana, you’re probably going to get kicked in the crotch,” he says.

But if cannabis isn’t lethal and doesn’t cause debilitating withdrawal, then is habitual use really such a bad thing? The answer, it turns out, probably depends on the age of the smoker.

Trouble for teens

Scientists can’t say with confidence what marijuana does to the body and brain long-term, for several reasons. It would be unethical to randomly assign study participants to use an illicit drug for months, so the best scientists can do is look for associations — particular traits, abilities or limitations that appear more frequently in people who use cannabis. This approach leaves open all sorts of variables: People are from different backgrounds and smoke marijuana from different sources, for starters. The most these studies can offer is possible links.

One of the strongest links found so far comes from studies of young people. The teenage brain is still growing and refining its neural connections — a process that’s regulated in part by the brain’s natural endocannabinoid system. Marijuana use when the brain is vulnerable may interfere with its normal development. “The developing brain is at risk,” Franson says.

Young adults, ages 18-25, who used marijuana at least once a week were more likely than nonsmokers to have structural differences in two brain areas thought to be involved in addiction, the nucleus accumbens and the amygdala. The differences were more pronounced with increased use, researchers reported April 16 in the Journal of Neuro­science. Scientists don’t know whether these brain differences track with any behavioral deficits.

Adolescents who heavily use marijuana are more likely to perform poorly in school and drop out, though the effects of cannabis can’t be easily separated from other social factors. New Zealanders in one study who used marijuana heavily during their teens showed an IQ drop of about eight points by the time they’d reached age 38. Because the study began before the participants started using marijuana and ran for decades, the results offer some of the strongest evidence yet that marijuana contributes to an IQ decline. But even these results come with caveats and methodological limitations.

Coast-to-coast

In the last decade, a growing number of states have passed laws legalizing marijuana, both for medical and recreational use. The numbers are expected to rise. In April, Maryland became the 18th state to ease punishment for marijuana possession and the 21st to allow medical marijuana.

Source: National Conference of State Legislatures, NORML; Credit: Vectorapz™, adapted By E. Otwell

Marijuana’s long-term effects on people who start using the drug as adults are even less understood, but the hints provided from some studies suggest that it’s not as harmful as adolescent use. That same IQ study, for instance, found no decline in people who began using cannabis as adults.

A different study, published in the May Addictive Behaviors, looked at whether the cognitive effects of marijuana in adults go away when people stop using. “It’s generally known that the acute effects are there,” says study author April Thames of UCLA. “The question is, do these reverse over time?”
Most of the negative effects of marijuana — poorer attention, working memory and mental nimbleness — were absent in adults who had not used the drug for a month, Thames and her colleagues found. However, a person’s ability to plan and make complicated decisions was still impaired a month out.

The results offer just a “snapshot at the time we did the testing,” Thames says. They describe an association, not causation. “The question down the road is, what kind of implications does that have for everyday functioning?”

Scientists have largely failed to turn up compelling evidence that adult pot smokers risk permanent brain problems, Earleywine says. “Being stoned all the time is a strange way to live your life,” he says, but data just aren’t there to argue that a cannabis-fueled lifestyle is permanently harmful to the adult body and brain.

The new reality

As researchers try to make sense of study results, the nascent marijuana industry is charging ahead in a Wild West capitalistic society. That’s worrisome, many scientists say. Policies should regulate the quality and strength of marijuana, and keep it away from children, Franson says.

In Colorado, where drug laws have been loosened, first for medical marijuana and then for recreational use, a growing number of children under 12 have been admitted to emergency rooms for acute marijuana intoxication, according to a study in the July 2013 JAMA Pediatrics. There ought to be tighter controls over shops, particularly those that sell marijuana-infused products like chocolates and cookies that entice children. Many marijuana retailers “look like sweets shops,” Curran says.

NIDA is keeping tabs on ER visits as well as the increasing levels of THC in cannabis seized by law enforcement agencies, and how marijuana legalization has affected the health of people in Colorado and Washington State.

Some researchers see the growing availability of marijuana as inevitable and are advocating ways to keep the drug out of the hands of young people.

No worries

As high school seniors think pot is less of a problem, mirroring adult attitudes, their use of the drug is going up. Marijuana use might be particularly risky for young brains, studies suggest.

Source: Monitoring the Future study, 2013, Univ. of Michigan

“Kids are growing up on a much more toxic form of marijuana than they would have done years ago,” Curran says. Today’s plants are very high in THC and low in a compound thought to counter its effects called cannabidiol, or CBD. THC levels in marijuana have increased from 3.4 percent in 1993 to 8.8 percent in 2008, according to a marijuana potency-monitoring project at the University of Mississippi. A more regulated market might keep the most potent marijuana out of the hands of young people, Curran says.

More accurate testing and labeling of marijuana products would help, many researchers believe. THC concentrations can vary from seller to seller and even batch to batch. “People need to know what they’re getting,” Franson says. “It’s just named these weird names.” Purple Urkel, Girl Scout Cookies and Super Silver Sour Diesel Haze are some of the options available in stores. Colorado is trying to improve labeling to describe important differences, which is particularly urgent for people who rely on certain doses of THC or CBD to treat medical conditions.

When marijuana is eaten, THC takes longer to reach the bloodstream, and its absorption rates can vary greatly. This imprecise delivery system can cause people to take much more than they intended. Proper labeling might help people better titrate their dose, Franson says.

Even Earleywine, who supports legalization, says he’s concerned about commercialization of marijuana. “America is so free market and wild that it’s going to take some reining in to make sure that no one is penalized for it and medical users have access, but it’s not sponsoring every sport event or on TV every five seconds,” he says. Current restrictions on cigarettes might be a good model for the burgeoning marijuana industry, he says.

Imperfect science leaves people on both sides of the marijuana debate wanting more. But in a way, the good-or-bad, yes-or-no argument is over: Marijuana is creeping across the country. That’s probably not catastrophic for adults, but for young people, the implications are more worrisome. Just how worrisome is something scientists are still figuring out. That knowledge may help ease the transition to an ever-greener world.

---

Editor's note: This article appears in the June 14, 2014 Science News under the headline: "High times: Legalization trend forces consideration of pot's dangers."

Citations

E. Jouanjus et al. Cannabis use: Signal of increasing risk of serious cardiovascular disorders. Journal of the American Heart Association. April 23, 2014. doi: 10.1161/​JAHA.113.000638
M. Asbridge, J. A. Hayden and J. L. Cartwright. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. February 9, 2012. doi: 10.1136/bmj.e536
D. P. Tashkin. Effects of marijuana smoking on the lung. Annals of the American Thoracic Society. Vol. 10, June 2013. doi:  10.1513/AnnalsATS.201212-127FR
J. Hirvonen et al. Reversible and regionally selective downregulation of brain cannabinoid CB1 receptors in chronic daily cannabis smokers. Molecular Psychiatry. Vol. 17, June 2012. doi: 10.1038/mp.2011.82.
H. H. van Hell et al. Chronic effects of cannabis use on the human reward system: An fMRI study. European Neuropsychopharmacology. Vol. 20, March 2010. doi: 10.1016/j.euroneuro.2009.11.010
J. M. Gilman et al. Cannabis use is quantitatively associated with nucleus accumbens and amygdala abnormalities in young adult recreational users. Journal of Neuroscience. Vol. 34, April 16, 2014. doiI:10.1523/JNEUROSCI.4745-13.2014
M. H. Meier et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academies of Science. August 27, 2012. doi: 10.1073/pnas.1206820109
A.D. Thames et al. Cannabis use and neurocognitive functioning in a non-clinical sample of users. Addictive Behaviors. Vol. 39, Issue 5, May 2014. doi: 10.1016/j.addbeh.2014.01.019
G. S. Wang, G. Roosevelt, K. H. Heard. Pediatric marijuana exposure in a medical marijuana state. JAMA Pediatrics. Vol. 167, Issue 7, July 2013. doi:10.1001/jamapediatrics.2013.140
Z. Mehmedic et al. Potency trends of delta-9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008. Journal of Forensic Sciences. Vol. 55, Issue 5, September 2010. doi: 10.1111/j.1556-4029.2010.01441.x