Mark A.R. Kleiman | Vox

Is it time to do away with job applicant drug testing?

2018-07-31T12:16:15-04:00

Testing urine for traces of drugs. | Photofusion/UIG/Getty Images

The job market is now so tight that some firms are complaining they can’t hire as many workers as they want to — and indeed, official figures now show more empty jobs than jobless people seeking work. Despite this, pre-employment drug testing continues to be a hiring requirement for many workplaces.

Rules that seemed to make sense when workers were easy to find become less attractive when labor is in short supply. Firms have already started to reconsider their policies against hiring the formerly incarcerated, a reform that will help ex-criminals and their families, and probably also reduce recidivism: Former criminals might not remain former criminals for long if they can’t find a way to make an honest dollar.

The next policy on the chopping block might be drug testing. Much of the current drug-testing regime dates to the 1980s, when many employers adopted “drug-free workplace” policies under strong urging from the federal government and drug-war advocacy groups; pre-employment testing was a key part of those policies.

An estimated 70 percent of companies with more than 2,500 employees use pre-employment screens, and they cover some 40 percent of all jobs.

But as it happens, the research suggesting that screening workers for drug use leads to better job performance is surprisingly thin.

Two studies of postal workers, done in the late 1980s, near the peak of the crack epidemic, tested job applicants — but didn’t show the results to people making hiring decisions. Both found that employees who had tested positive before employment were absent more frequently and were more likely to be fired than those who tested negative. In one of the studies (but not the other), there were also elevated rates of accident and injury among the “positive” group.

In each case, the smaller group of employees who had tested positive for cocaine performed worse on the job than the larger group that had tested positive for cannabis. Neither study included any significant number of opioid or methamphetamine positives, two of the drugs that most concern us today.

A third, smaller study at a large hospital found somewhat worse outcomes for the drug-positive group. But perhaps due to the small sample size (N = 180, of whom only 22 tested positive), the differences were not statistically significant.

And that, as far my search of the literature found, is it. Since none of those studies involved a workplace that actually rejected drug-positive applicants, job-seekers had no incentive to abstain before being tested.

However, in a workplace that uses pre-employment testing as a screen — the usual practice today — employees have every reason to avoid drug use in the days immediately preceding a test, even if they plan to use drugs later. (Three days will suffice to clear the body of the metabolites of most drugs; the exception is cannabis, which may remain detectable for weeks among those who have been using heavily.)

Whether the predictive value of a positive test result is the same when applicants have incentives to actively avoid testing positive isn’t obvious.

No one has properly analyzed the costs and benefits of drug testing

Do two generation-old studies, both of postal workers, constitute anything like an adequate basis for policies applied today to such a wide range of workplaces with diverse workforces? To my knowledge, no one has done anything resembling a benefit-cost analysis, either from a company perspective or from a social perspective.

No one has done an analysis that takes into account the costs of having to recruit more candidates — or relax other hiring standards — to fill the available jobs from the smaller pool of drug-negative applicants. Nor has anyone attempted to measure the external costs of denying employment opportunity to people who use drugs. (By “drugs,” I mean “drugs other than alcohol,” because urine tests do not detect alcohol.)

Here’s one of those unmeasured external costs: As I mentioned, cannabis takes an unusually long time to clear the body. If job seekers who are aware of that fact use other drugs (including the synthetic cannabinoids sold as “Spice” and “K2”) in place of cannabis, both the workplace costs and the social costs of pre-employment testing might be very high indeed. The synthetics are much more potent and much riskier than cannabis.

All of this suggests that it’s time for companies to reexamine their drug-testing policies. One way to start that reexamination would be to use data currently collected in the field to do some fresh research on whether pre-employment testing actually works. One specific kind of study would be especially useful: Studying the job performance of applicants whose tests actually showed some drug use, but below the cutoff that defines a “positive” test.

Everything is already in place to conduct such a study. When a job applicant deposits a urine specimen, the specimen goes to the testing company’s laboratory, along with thousands of others. For each drug covered by the test, the heavily automated process spits out a numerical value, generally calibrated in nanograms of the target substance per milliliter of urine.

We should move beyond crude measures of “passing” or “failing” tests to look at the details

But the company paying for the test doesn’t usually see that numerical value. It learns only whether an applicant has passed or failed the test. Passing — testing “negative — is defined as having less than some specified nanogram level of each drug. The federal Department of Health and Human Services sets the cutoff levels for federally required testing (of federal employees, some contractor employees, and workers in safety-sensitive jobs such as truck driving). Many drug-testing providers use those federal cutoffs for all of their tests, although some private companies specify their own.

Clearly, some of the “negative” tests will involve values just below the cutoff, and some of those applicants will get hired. And that sets up your experiment: Compare the workplace performance (attendance, productivity, injuries, sick days, health care utilization, disciplinary actions, turnover) of those just under the cutoff with otherwise similar employees hired at the same time who tested at zero.

If the truly “drug-free” employees turn out to be better workers than those who barely escaped being screened out, it’s reasonable to conclude that those who are actually screened out would have been worse-than-average employees. We might still debate the details of drug-testing policies, but the basic premise that they work on some level would be sustained.

But if that isn’t the case — if the people who were just below the cutoff perform as well at work as those who were at zero — then there’s little reason to think that those just above the cutoff (potential employees who were screened out) would perform worse. Such a finding would suggest that the current cutoff value is too low, at least for that specific workplace.

(Of course, coming to work under the influence of drugs raises different questions from off-the-job drug use. But the drug most likely to be involved in on-the-job intoxication is alcohol, which, again, urine testing doesn’t detect.)

It might also make sense to compare those who tested zero with all those whose test results were non-zero, or try to identify a “dose-effect curve” between tested drug level and job outcomes: How does performance change as the measured drug level increases? A more adventurous firm might want to go further still, hiring a sample of applicants with test results well above the cutoff, to study whether they actually perform worse on the job than those who passed the drug test.

It’s possible, though far from certain, that hiring applicants who test positive for opioids is riskier than hiring those who test positive for other illicit drugs. Most people who take prescription opioids actually have prescriptions for them, and (possible legal problems under the Americans With Disabilities Act aside) it’s ethically dubious to screen out people on the basis of the medicines they have to take.

Moreover, the standard panel covers heroin but not the fentanyls, and the last thing you want to do is incentivize workers to switch from prescription opioids or even street heroin to fentanyl to be able to find jobs.

If the opioids really stand out from other drugs, that fact will show up in the experiments suggested above, and employers can try to figure out what to do about it after the experimental results are in.

Even employers who want to keep pre-employment drug testing for other drugs might consider no longer screening for cannabis, which currently accounts for about half of all positive test results. Some firms, especially where cannabis is now legal under state law, have already decided to leave cannabis out of their screening programs.

Perhaps it will turn out that pre-employment drug testing is cost-justified, at least for some jobs — especially safety-sensitive ones — even when labor market conditions are tight.

But drug-war passions are fading and job applicants are hard to find. In that shifting social context, companies and public employers, including the military, might want to take a second look at whether pre-employment drug testing actually does the job it was designed to do.

Mark Kleiman is a professor of public policy at NYU’s Marron Institute. His book on drug policy is Against Excess. He is the co-author, with Jonathan Caulkins and Beau Kilmer, of Marijuana Legalization. He blogs at the Reality-Based Community and can be found on Twitter @markarkleiman.

The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

How to prevent casual pot smokers from slipping into abuse and dependence

2018-04-20T09:05:45-04:00

A 4/20 celebration in Colorado. | Getty Images

On April 20 — the informal holiday known as 4/20 — cannabis users celebrate their favorite herb. The day features both heavy smoking and long impassioned speeches in favor of allowing adult consumers unfettered legal access to a substance that some 37 million Americans report having used in the past year.

Those celebrations will not, however, be quite universal, even among cannabis consumers. Presumably most of the roughly 500,000 people whose cannabis use sends them to a hospital emergency department in a typical year — usually as a result of overconsumption, leading to a scary and unpleasant few hours but no lasting injury — will celebrate with reservations, if at all. Those who suffer from the much rarer but much scarier Cannabis Hyperemesis Syndrome, characterized by uncontrolled vomiting, are no doubt even less happy.

You’d expect equally little enthusiasm from the estimated 4.1 million who, by their own self-report, appear to meet the diagnostic criteria for cannabis use disorder. These people use marijuana more, or more often, than they want to; they’ve tried, unsuccessfully, to cut back or quit; they find that cannabis interferes with their other interests and responsibilities; and their use has led to conflict with people they care about.

There are uncounted others who appear to the people around them to have some of these issues, but who don’t acknowledge it. (Not everyone with a drug problem is self-aware.) Of course, those for whom cannabis is a burden rather than a pleasure also have families and friends, who suffer vicariously.

We’re heading toward the “alcohol model,” but there’s still time to shift course

Marijuana policy is heading inexorably toward the model we use for alcohol — weakly regulated commercialized legalization, with taxes that are too low. That’s been a public-health disaster in the case of alcohol. Cannabis isn’t as dangerous, but there’s still no good reason to repeat that mistake. Taxes should be higher and marketing restrictions tighter; there’s even a case for keeping commercial enterprises out of the industry altogether and restricting sales to consumer-owned co-ops.

But here’s a more outside-the-box idea, designed to help people exercise self-restraint about how much cannabis they use and how often: a system of user-set monthly purchase limits.

Under such a system every buyer would be required to set up an account (with a number rather than a name, to protect privacy) and to choose a monthly quota, stated in milligrams of THC. Every purchase, wherever made, would be registered against that account number, and when the user’s own chosen limit was reached, no further purchases could be made that month. (The system could be state-run, or federal.) As an escape hatch, a user could be allowed to increase the quota after a one-week waiting period.

The myth that marijuana is harmless

The biggest barrier to adopting this idea, or any idea for adequate cannabis regulation, is the widespread belief that cannabis is “natural,” “harmless,” and “non-addictive.” Those beliefs are partly an overreaction against “reefer madness” propaganda, partly the product of the zeal of legalization advocates, and partly a result of the skilled marketing and lobbying efforts of the cannabis industry.

Today’s cannabis is several times as potent as it was a generation ago. Stores in the states where cannabis is now openly sold under state law compete to offer stronger and stronger pot; reported percentage THC content on the stores’ online menus now averages in the mid-teens, with some strains claiming to be as high as 25 percent.

Legalization advocates confidently predicted that users would compensate for higher potency by cutting back their consumption, but that hasn’t happened. The number of people who report using cannabis daily or nearly daily has multiplied by approximately a factor of seven over the past quarter-century. It now stands at some eight million (out of 37 million who have used it in the past year).

Other studies find that those daily and near-daily users consume about three times as much cannabis per day of use as more casual users. More evidence that people aren’t adjusting for potency: The estimated dollar value of cannabis sales has soared, even as potency-adjusted prices have fallen drastically.

There’s no reason to think that occasional cannabis use is harmful, but there’s just as little no reason to think that frequent heavy use is benign, and a substantial body of evidence challenges the myth of harmlessness. One Dutch study, for example, found that excluding foreign students from buying cannabis in “coffee shops” led to improvements in their grades, while the grades of their Dutch classmates, who still had access, stayed flat.

Speaking out about the risks of cannabis should not be equated with supporting prohibition

None of this means that cannabis ought to remain illegal. Prohibition is simply no longer a practical option. With the estimated retail cannabis market now above $40 billion per year, with state after state permitting an activity the federal government still forbids, with increasing concern about too many arrests and too much incarceration, and with the need to focus drug enforcement on the supply of heroin and the fentanyls, there’s no way to put the genie back in the bottle, even if the public wanted to, which it overwhelmingly doesn’t.

The only remaining practical question — much as the die-hard drug warriors deny it — is what form legal availability will take. Following the alcohol model will lead to ever-higher levels of problematic cannabis use. According to Jonathan Caulkins of Carnegie Mellon and Steven Davenport of RAND, cannabis prices in Washington and Colorado are falling at 2 percent per month; one store in Seattle now sells what it claims to be 16 percent THC flower at $15 per quarter ounce. That translates to about 25 cents a stoned hour — much cheaper than an alcohol buzz.

Since legal cannabis is remarkably cheap to grow, and since competition will force prices down to no more than a reasonable margin over production costs, the bottom is not in sight. And taxes assessed as a fraction of retail price will fall as prices fall.

Low prices generate high volume, but they also mean that high volume is the only way the industry can stay in business. Daily and near-daily users account for some 85 percent of current cannabis sales. That means the for-profit commercial industry will, like its illicit counterpart, and like the alcohol industry, be financially dependent on the minority of users who are chemically dependent. That industry will do everything in its power to create and sustain the biggest possible population of chronic stoners.

That’s the bad outcome user-set quotas might help prevent. Virtually no one starts out wanting to be a three-joints-per day smoker, spending most of his or her waking hours under the influence. A quota system would prevent some people — there’s no way in advance to tell how many — from sliding down that slippery slope.

User-set monthly limits aren’t a perfect policy

Of course, no system could make it impossible for someone to lose control of his or her cannabis use. A user could choose to set a very high initial limit, or keep increasing the limit to accommodate a growing habit. But some would choose a modest limit, and would regard hitting their quota early as a signal that they were using more than they intended to.

But a user-set quota system would also do very little harm, since it wouldn’t actually limit the freedom of any user more than trivially. Users could even choose to opt out by choosing an absurdly high limit.

So here’s a thought to keep in mind as you light up: There’s no contradiction between deciding a commodity ought to be legal and still thinking that some people might need a public-policy “nudge” to keep their use of that legal commodity under control.

Mark Kleiman is professor of public policy at NYU’s Marron Institute. His book on drug policy is Against Excess. He is the co-author, with Jonathan Caulkins and Beau Kilmer. of Marijuana Legalization. He blogs at The Reality-Based Community and can be found on Twitter @markarkleiman.

Psychedelic experiences might “cure” smoking and OCD. Should we allow them?

2016-09-25T17:02:43-04:00

Suppose a pilot study on a new smoking-cessation program found that 80 percent of the subjects had quit successfully, most of them without much struggle.

But when Matthew Johnson and his colleagues at Johns Hopkins reported precisely that result in 2012 — in a study with 15 participants, all of whom had previously failed to quit smoking more than once — that rapid follow-up didn’t happen. The treatment involved the use of psilocybin, the active agent in psychedelic “magic mushrooms.”

Of course, the Hopkins result may turn out to be a flash in the pan. It had a small sample and no control group, and was not “blind” (that is, subjects and experimenters all knew the material involved was psilocybin, so expectation effects might have influenced the results). But 80 percent success in treating stubborn nicotine addiction is unheard of and worth following up.

Four years later, the only follow-up currently in progress is another study by the same team: a randomized (but still not blind) trial of psilocybin against the nicotine patch. That work is funded by two small foundations, the Heffter Research Institute and the Beckley Foundation. Both Heffter and Beckley focus on the psychedelics; the much larger private and public funders focused on smoking and health aren’t yet interested. That lack of enthusiasm, among both funders and the broader scientific community, speaks volumes about how edgy the whole topic of psychedelics as therapy remains.

Still and all, as we come up on a half-century since the Summer of Love created national awareness of the “psychedelic culture,” ideas around these drugs are changing. The psychedelics are attracting fresh attention, in an entirely different key.

The drugs show promise in treating nicotine addition, OCD, and severe headaches

Medical researchers are finding that these substances may have value in managing pre-death anxiety and treating problems ranging from obsessive-compulsive disorder (OCD) to the debilitating kind of headache known as “cluster headache,” and there is renewed research (following up on older studies) on their effectiveness in treating alcohol abuse disorders. One striking feature of psychedelic therapies is that just a few episodes are required to achieve long-term effects: The smoking study involved only three guided “trips.”

The cultural experiences of the ’60s cast a long shadow over our understanding of psychedelics. (Getty)

There are also striking findings about nonmedical benefits. An earlier group of studies from that same lab at Hopkins, with Roland Griffiths as lead author, found that a few hours of preparation spaced out over two months, followed by a single day-long session, can produce truly profound psychological experiences.

In surveys after receiving psilocybin, the answers of about two-thirds of the participants suggested their session reached the heights of a “mystical” or “unitive” or “transcendent” experience, as measured by an established set of psychological rating scales. Those scales had been developed to characterize “peak experiences” achieved by spiritual seekers, typically through such techniques as meditation, fasting, waking, ecstatic dancing, and repetitive prayer. “Mystiform” experiences have been reported to shift worldviews, attitudes, mood, and behaviors for the better — sometimes dramatically so.

Test subjects rate their lab-based psychedelic experiences as profoundly meaningful

Indeed, at a two-month follow-up, about two-thirds of the study participants still regarded their day with psilocybin as among the five most personally meaningful and spiritually significant of their lives (on the level of the birth of a child); about one-third recalled it as the single most meaningful and significant.

And there were indeed lasting beneficial changes in mood and behavior, and increased scores on the well-established and hard-to-change personality trait called “openness.” Another study from the same team found major positive effects 14 months out.

Such experiences are now on offer in a variety of ritual and nonritual contexts, including both practices of established religious denominations that make use of psychedelics and less formal gatherings of occasional seekers with itinerant leaders.

But even as new evidence comes in, public and official attitudes toward the psychedelics, and their legal status, remain largely stuck in the ’60s. Getting our approach to those drugs right this time will require freeing ourselves both from stereotypes rooted in the tie-dyed, bohemian world of Hair and from the categories created by current drug laws and used in the debates about those laws — in particular the notion that all drug policy comes down to “prohibition” versus “legalization.”

Psychedelics pose different challenges from the "hard" drugs — or even pot

The psychedelics are “drugs” in two senses: They influence brain chemistry other than by providing nutrition, and they are covered under international drug treaties and US drug laws. Until they can be shown to have medical benefit, they remain in schedule 1 of the Controlled Substances Act, contraband except for research purposes. But in terms of the uses to which they can be put, the harms they create, and the risks they pose, they bear only a vague resemblance to the drugs current drug policies were designed to handle.

Cannabis, alcohol, tobacco, and the “hard” drugs — heroin and the other opiates and opioids, cocaine and crack, methamphetamine and the other amphetamine-type stimulants — are wildly different from one another, but they share a central risk: the formation of bad and hard-to-break habits (“substance use disorders” to clinicians, “addictions” to the rest of us). Bad habits do form around some of these substances, but those problems are comparatively rare.

In addition, all of the other classes of drugs that constitute the “drug problem” are — or have been, in the case of alcohol — associated with large, flourishing, somewhat organized illicit markets with varying but substantial levels of arrest, incarceration, and trafficking-related violence. Even tobacco has spawned a substantial illicit market to exploit tax differentials across jurisdictions. For the currently prohibited drugs, the damage from illicit markets extends from the US back to source and transit countries such as Mexico and Guatemala.

Scientists at Johns Hopkins have been studying the effects of the ingredients in “magic mushrooms.” (AFP/Getty)

The psychedelics, by contrast, because they are for the most part used occasionally rather than habitually, generate much smaller illicit markets and relatively tiny amounts of arrest, incarceration, and violence.

That means that the two strongest arguments for legalizing other drugs — reducing the harm done to consumers by taking impure chemicals in unknown quantities and eliminating illicit markets — have much less force with respect to the psychedelics. Rather, the case for making these substances legally available under some set of new rules has to rest on a combination of the value of personal liberty and the good results that can accrue when these drugs are used properly.

There are practical hurdles to proving therapeutic benefits

The benefits of the psychedelics are varied, and do not always fit into neat categories. Some benefits are purely and obviously medical; if psilocybin turns out to treat cluster headaches or OCD, the decision to approve it for those purposes — once the appropriate studies are complete — will require some political nerve but not any rethinking of basic categories.

However, establishing the therapeutic benefits of psychedelic drugs poses special scientific challenges. Even if such studies encountered more support and less resistance than they currently face, meeting the standard of evidence require for approval by the Food and Drug Administration would be anything but straightforward.

The benefits seem to flow not from the chemicals alone, but from taking them with appropriate preparation, guidance, and follow-up. That complicates the research process enormously; it’s much easier to give 1,000 subjects the same dose of an SSRI than it is to give 1,000 people the same preparation for, and guidance in, a psilocybin session.

Psychedelic experiences also seem to be as varied as the people who undergo them; there is no reason to be confident that a chemical and a process helpful to one group of subjects will be equally helpful to a differently constituted group.

There are also financial hurdles. The drug approval process relies on the willingness of a sponsoring manufacturer to invest millions of dollars over a period of years on a molecule that almost always has a fairly low probability of winning final approval.

That willingness, in turn, depends on there being a pot of gold at the end of the research rainbow. Such a pot of gold probably does not exist for the psychedelics, both because they are well-known chemicals whose composition can’t be patented and because their therapeutic uses will typically involve very small numbers of administrations per patient. Thus it’s hard to see pharmaceutical companies spending money on psychedelic research. (There’s a strong case for creating a nonprofit corporation, financed at Treasury borrowing rates, to bring to market valuable drugs that can’t profitably be studied under the existing system; that’s a longer story for another day.)

The fuzzy line separating "medical" from "spiritual" benefits

But medical value is not the end of the story, or even necessarily the most important part of the story. In fact, the line between “medical” and “spiritual” or “religious” use is blurry. Reducing the fear of death among people with terminal diagnoses, for example, is clearly palliative care and therefore considered part of “medicine.” There’s now some evidence that the psychedelics can be successfully used for that purpose, as adjuncts to therapy.

But there’s also evidence that the same drugs can be used to reduce the fear of death in people who aren’t under a medical death sentence. There’s no doubt that being relieved of such a primal fear is beneficial. However, since being afraid to die is “normal” and not pathological, reducing that fear isn’t in any obvious sense a medical outcome; instead we’ve handed the problem of existential dread to philosophy, religion, and literature.

Now, it might not seem very important whether we call reduced fear of dying a “medical” benefit or a “spiritual” one, but those categories matter a great deal for legal purposes. A drug for “medical” use needs to be approved by the FDA as “safe and effective,” and may only be administered or prescribed by someone with an appropriate qualification (for example, a physician or nurse practitioner). “Safe and effective” has been interpreted to mean “safe and effective in the treatment of some recognized disease or disorder.“

Our current medico-legal system is not yet equipped to handle drugs that can improve on “normal”: make us “better than well.” (For example, Viagra was approved for the treatment of “erectile dysfunction”; the FDA would not have recognized a claim that it improved normal male sexual performance or satisfaction, which is, of course, why most of its users take it.) But that is not the only possible interpretation of the plain language of the Food, Drug, and Cosmetic Act: There’s no logical reason why a drug couldn’t be shown to be “safe and effective” at improving the well-being of healthy people in some regard.

The problem of whether to approve drugs to make people better than well is likely to confront us soon, entirely outside the psychedelic context, as progress is made on cognitive enhancers (as distinct from simple central nervous system stimulants such as the amphetamines). It’s not at all clear what the outcome will be, or even what it should be, given the risk that performance-enhancing drugs (inevitably with unwanted side effects) might become the focus of an “arms race” among competitive students and professionals, as various bodybuilding substances have among athletes.

(One “better than well” idea now gaining some popularity, though to date without convincing scientific evidence to support it, is that periodic use of some of these drugs in doses so small as to be barely detectable subjectively — “microdosing” — might offer a range of “wellness” benefits. There are lots of questions about how to study, and how to regulate, that practice, which is likely to have a risk-benefit profile more like taking nutritional supplements than like taking full-dose psychedelics Some informal trials are in the field now; we might know more about microdosing in a year.)

Some denominations are carving out space for the religious use of psychedelics

Religious or spiritual use is not recognized at all by the drug laws. The use of peyote, which contains mescaline, in Native American ceremonies is exempted from federal law by the American Indian Religious Freedom Act (1978) and its amendments (1994), known as AIRFAA. Over the past decades the courts have begun to carve out religious exemptions under the Religious Freedom Restoration Act (RFRA), which was passed following a controversial 1990 Supreme Court case that undercut previous understandings of the “free exercise of religion.”

A shaman in the Coafan region of Ecuador boils leaves used in ayahuasca. (Wade Davis/Getty)

“Religious use” requires neither FDA approval nor a clinician; precisely what it does require remains to be determined by case law, or by new legislation. The Drug Enforcement Administration is prepared to consider applications from religious groups for permission to worship with otherwise banned drugs, under legal protections less complete than those now enjoyed by the Native American Church under AIRFAA but resembling the protection given to non-native religious groups by court orders interpreting RFRA.

The main applicants, at first, are likely to be practitioners using the Amazonian “tea” called ayahuasca. That potion is brewed from the leaves of a shrub containing the hallucinogen dimethyltryptamine (DMT) and the bark of a vine containing harmala alkaloids. Those alkaloids have their own psychoactivity and also make DMT orally active. (Otherwise DMT must be smoked, snorted, or injected to be effective.)

Ayahuasca, long in traditional use by the indigenous peoples of Amazonia, became the basis of two Christian denominations, the Unaio de Vegetal (UdV) and the Santo Daime. The Brazilian government, after examining the practices of those groups, fully legalized the religious use of ayahuasca in 1992.

The UdV, which is rather tightly organized and involves long-term membership in congregations, established a branch in New Mexico. That branch won a lawsuit in 2006 a under the Religious Freedom Restoration Act; the case, O Centro v. Conzales, established the UdV’s right to import the tea and use it for worship.

The Santo Daime tradition, more decentralized and less congregational, also has attracted people from the US as “ayahuasca tourists” to the Amazon and as participants in ceremonies offered by Santo Daime groups in the US or by freelance practitioners claiming a Santo Daime lineage. A Santo Daime church won its own RFRA case in 2009; how much that precedent protects other practitioners remains unclear, but Santo Daime worship, though relatively widespread, has not been much of an enforcement target.

Both the UdV and groups practicing in the Santo Daime tradition restrict use of ayahuasca to ceremonial occasions, and hold services that fill the several-hour period of altered consciousness that follows taking the tea. This minimizes the risk of people wandering around under the influence and doing or suffering harm.

Group worship also offers some (not perfect) protection against the psychedelic version of clergy sexual abuse. That deplorable practice, exploiting both the vulnerability of people in altered states and their tendency to transfer their awe at the experience to adoration of the person who offers it, has plagued both the psychedelic-tourist trade and informal psychedelic “guiding” in the US. (The same risk could arise in the medical context; best practice seems to be to have opposite-sex pairs of therapists, in part as chaperones for the patient.)

Moreover, the tea causes considerable, and sometimes fairly explosive, gastric distress, which worshipers accept as part of the purification process but which probably chases away people whose interest is merely casual. Thus this set of religious exemptions does not seem to pose much risk of eliding into virtual legalization for mass consumption, as “medical marijuana” has in California.

What about spiritual use that's not explicitly religious?

On the other hand, some of the traveling “shamans” seem to operate on a more or less fee-for-service basis, welcoming all paying customers without doing any real screening in advance or offering any support afterward, when support is sometimes needed: An ayahuasca trip can be as hard on the spirit is it is on the gut. The absence of a congregation deprives seekers of mutual help in dealing with the aftereffects of difficult experiences and in integrating flashes of spiritual insight into their daily lives.

There’s an argument, of course, for allowing the use of drugs that are neither medical nor religious nor performance-enhancing in any measurable way, simply because they provide experiences that their users find pleasurable or otherwise valuable. And that argument is stronger, in two ways, for the psychedelics than it is for most other controlled substances.

First, the value that some people put on their psychedelic use is very high indeed. Here, for lack of numerical evidence, I must substitute anecdote:

I know people who use a variety of nonpsychedelic chemicals, legal and illegal, in what might be called “social” or “recreational” mode, who value that practice, and who would be reluctant to give it up. And I know people who used some of those nonpsychedelic chemicals years ago and still look back fondly on those experiences. (Also, of course, I know some people who intensely regret their past experiences and others who still struggle with substance use disorders, and have known a few who died.)

But I don’t know one former alcohol or nicotine or cocaine or opiate user who believes that he or she is happier or healthier or wiser today as a result of things learned from that past experience. (Cannabis is a partial exception here. MDMA, or “ecstasy,” constitutes a major exception; it’s considered a psychedelic by some people but has different effects and raises different policy questions from the classic hallucinogens such as psilocybin.)

The Steve Jobs case for LSD

By contrast, I know many people who say precisely that about the psychedelics: They made use of them years ago, once or on a few occasions, have no particular interest in doing so again, but claim with some fervor that they are calmer, more loving, more creative, more socially useful, better people as a result of those encounters. (Steve Jobs, reflecting on his own experiences, once suggested that Windows would be a much better operating system if Bill Gates had tripped at least once.)

Those accounts are consonant with the quantitative results reported in the Hopkins spirituality studies. Anecdote is not data, and since I haven’t done a survey to find out how any of my acquaintances have tried the psychedelics with trivial — or bad — results, I can’t say how likely the lasting good results are. Still, that’s what the people I know say, and they don’t say it about other drugs. It would require, I think, substantial evidence of risk to counterbalance those reported benefits.

And that leads to the second point of difference. The risks of the psychedelics — centered on bad acute experiences and their aftereffects and on reckless activity under the influence — are smaller, and more easily controlled with reasonable precaution, than the risks of habituation to alcohol, nicotine, the hard drugs, or even cannabis. For neurochemical reasons — in particular, the acute tolerance effect that makes daily use of these drugs unrewarding — the classic hallucinogens have very limited risks of forming persistent bad habits.

Still, “smaller” doesn’t mean “negligible.” Even in well-designed settings, some people — and especially those who are already fragile psychologically — have experiences they aren’t prepared to handle, sometimes with lasting aftereffects.

The word that keeps coming up when you talk to people about their psychedelic use is “sacred” (which, let us not forget, has as one of its meanings “taboo”). Sacredness is not something our contemporary society thinks about very clearly or manages very sensibly, but sacred things are to be handled, at all, only with due care and the right intention. As the Nazi in Raiders of the Lost Ark found out the hard way, if you deal with the sacred disrespectfully, you’re likely to get burned.

The long-run challenge is to build institutions, cultural practices, a supply system, and a set of public policies that encourage thoughtful — one might say “reverent” — use of these powerful materials and discourage casual or reckless use. It’s likely that the policies will play, directly, only a minor role in shaping behavior.

There’s a strong case against making the psychedelics items of commerce; it’s perfectly possible to recognize enormous potential for beneficial uses without thinking that LSD should be promoted and sold the way alcohol is promoted and sold. (Indeed, there are good reasons to doubt that alcohol itself should be promoted and sold that way, or that the alcohol model is a good replacement for cannabis prohibition. Fixing alcohol policy and developing alternatives to commercialization for cannabis will be two long, hard struggles.)

The psychedelic mushrooms and cacti can be fairly easily grown by non-experts; some, especially the mushrooms, can be harvested in the wild, as can a variety of DMT-bearing and harmala-bearing plants from which to brew local versions of ayahuasca. (Note: Harvesting wild mushrooms is not for non-experts; mistakes can be deadly.) It’s hard to see a strong case for criminalizing that sort of self-supply.

For those who want to acquire supplies from others, it would seem reasonable to require that the psychedelics be produced and distributed on a not-for-profit basis, without any advertising. People experiencing the psychedelics for the first time ought to be strongly counseled — if not legally required — to do so with appropriate (which does not necessarily mean medical) supervision. But even such a relatively restrictive approach would require rethinking the very basis of not only our domestic drugs laws but the international drug treaties; neither is a current possibility.

So what is to be done in the short run?

Get a move on medical research. That means securing serious funding — millions of dollars per year — from foundations or wealthy individuals. By contrast with cannabis, research approvals don’t present insuperable barriers; while all research cannabis comes from a single lab, supplies of research psychedelics are available from several sources.
Create a corps of guides for medical and spiritual uses alike, with both adequate training — drawing on the expertise developed in decades of informal experience — and a strong professional ethic, mutually policed.
Develop reasonable procedures — stiff enough to repel merely pretextual claims, but not so difficult as to seriously burden sincere religious exercise — for granting religious (RFRA) exemptions to the controlled-substance laws when it comes to the spiritual uses of the psychedelics. (Yes, developing those rules will not be easy, and mistakes of permission and exclusion will inevitably be made.)
Create not-for-profit sources of supply for both religious and medicauses, minimizing the risk of active marketing by producers. It shouldn’t be hard to find philanthropic sources for the small amounts of capital required.
Move toward changes in FDA practice — or, if necessary, in statute — to recognize performance enhancement as a basis for drug approval.

The need to free the psychedelics from the established categories of drug policy means more than crafting appropriate exceptions and exemptions to current laws. It also involves moving past the idea that there are two possible positions with respect to every drug: total prohibition (except perhaps for medical use) and total legalization on a commercial basis. As a longtime critic of both the drug war and the legalization movement, I know from bitter experience how deeply entrenched those categories are. But they’re a bad fit for most drugs, and an especially bad fit for the very unusual drugs called psychedelics.

Mark A.R. Kleiman is a professor of public policy at the NYU Marron Institute on Urban Management and the author of Against Excess: Drug Policy for Results. Find him on Twitter @MarkARKleiman.

The Big Idea is Vox’s home for smart, scholarly excursions into the most important issues and ideas in politics, science, and culture — often written by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

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This inexpensive anti-drunk driving program could save 100,000 lives a year

2019-03-05T21:16:05-05:00

New research, published this Tuesday in Lancet Psychiatry, suggests that a fairly cheap and simple policy change could save enough lives — specifically among women — to more than reverse the ugly uptrends in American mortality rates, and could do so over a period of months rather than years.

South Dakota runs a program called 24/7 Sobriety as a non-jail alternative offered to people arrested for alcohol-involved crimes, primarily repeat drunk driving. As a condition of pretrial release or probation, they are required to stop drinking. Compliance is monitored by taking a breath test twice a day, seven days a week, for an average of about four months, and skipped or positive tests (anything but a reading of zero) are punished with a night or two in jail.

The program costs less than $2 per participant per day; offenders are required to bear that cost, presumably out of the money they would otherwise spend on alcohol.

The initial program evaluation showed big effects on future drunk driving by program participants (down 50 percent over the following two years). Subsequent studies by the RAND Drug Policy Research Center showed that for the entire population — not just participants — 24/7 Sobriety reduces drunk driving arrests by 12 percent. It also reduces arrests for domestic violence by 9 percent, even though domestic violence charges are rarely the reason an offender is put on the program.

The new study by RAND’s Nancy Nicosia, Beau Kilmer, and Paul Heaton examines total-population, all-cause mortality — it drops an average of 4 percent after a county adopts the program. Even though most of the offenders are men, the lives saved seem to concentrate among women.

Deaths from injury (accident, suicide, and homicide) and cardiovascular events (heart attack and stroke) go down more than deaths from other conditions. That number is so astonishing as to be hard to believe, and in fact the study team held up publication for a year to check the math and wait for another round of data to come in. But so far, the result seems to be solid.

If that figure is right, and if the South Dakota results could be matched nationwide, a 4 percent reduction in mortality would mean slightly more than 100,000 avoided deaths per year. Those are big “ifs,” and there is still research to be done to nail down both the numbers of lives saved and the causal mechanisms that save them. (Perhaps reduced drinking by male heavy drinkers leads to reduced stress among — or less heavy drinking by — their female partners.)

But the drunk driving results alone, which are amply demonstrated and easy to understand, more than justify the very modest costs of the program. And surely if the state is justified in telling drunk drivers that they have to stop driving, it’s justified in telling them they have to stop drinking: No one needs a bottle to get to work.

Saving 100,000 lives a year would be a great achievement under any circumstances. But right now there’s additional reason to look hard for programs to reduce mortality rates, especially among women.

Over the past 15 years, death rates have risen for white non-Hispanic American adults who do not attend college. The rise in mortality shows up in two recent studies: one by Anne Case and Angus Deaton of Princeton, the other by Gina Kolata and Sara Cohen of the New York Times. The Case and Deaton study focused on the age range 45 to 54, while the Times analysis found rising death tolls among all age groups up to 65, with the rate among younger adults rising fastest. Both studies show those without college educations hit the hardest. Reanalysis of the Case and Deaton results by Andrew Gelman of Columbia shows a smaller rise in mortality among the middle-aged, concentrated among women.

This should not be happening. With rising incomes, improved medical care, and safer homes, roads, and workplaces, mortality rates trend down, not up, except when disturbed by war, pestilence, or major economic dislocations such as the collapse of the Soviet Union after 1989. We don’t expect to see figures like these in the United States.

And white non-Hispanic Americans stand out not only from the residents of other advanced countries, but also from African Americans and Latinos, whose mortality has continued to fall steadily. Figuring out what has gone wrong and what to do about it ought to be a major political issue, though so far only Hillary Clinton seems to have mentioned it.

In that context, the power of 24/7 Sobriety to save lives, and especially women’s lives, meets an urgent need. Even a fraction of the estimated effect, if extended to the whole county, would more than reverse the trends found by Case and Deaton, and by Kolata and Cohen.

It’s time — long past time — to get the sobriety show on the road.

Mark Kleiman is a professor of public policy at the NYU Marron Institute for Urban Management, a member of the Committee on Law and Justice of the National Research Council, and an editor of the Journal of Drug Policy Analysis.