Mephedrone is a stimulant, a class of amphetamine. It comes in pill or powder form and can be swallowed, snorted or injected. Methylenedioxypyrovelrone (MDPV) is also a stimulant, and in addition to bath salt, it can go by the street names Blue Silk, Euphoria, Hurricane Charlie, Ivory Dove and numerous others. It can be taken orally, intravenously or in a vaporous form.

Bath salts first appeared in the United States in 2009, according to the U.S. Drug Enforcement Administration (DEA). The drugs mimic the effects of cocaine, LSD, Ecstasy and/or methamphetamine, although most experts say that comparisons to methamphetamine are the most accurate. Law enforcement agents in Mississippi said the problem grew last year in his rural area after a Mississippi law began restricting the sale of pseudoephedrine, a key ingredient in making methamphetamine. According to the DEA, users have reported impaired perception, reduced motor control, disorientation, extreme paranoia and violent episodes. The price can range from $40 to $140 a gram.

According to one estimate by the Minneapolis Star Tribune, bath salts have been confirmed or suspected in more than 15 deaths nationwide. The American Association of Poison Control Centers reported that calls to poison centers about exposures to bath salts skyrocketed from a total of 303 calls during 2010 to 4,720 calls in the first eight months of 2011. The drug appears most popular in the Southeast, with Louisiana experiencing the most poison control calls as a result of overdose, and Florida leading the nation in ER visits.

Recently, there has been a slew of legislative and regulatory activity aimed at curbing the use and abuse of bath salts, mostly at the state level. MDPV is not yet a DEA scheduled drug, but is banned in Louisiana and Florida. Two of the chemicals needed to manufacture MDPV have been banned in seven states. At least 33 states have taken steps to ban at least one of the chemicals needed to manufacture bath salts, but the products remain widely available on the Internet. The chemicals used to make bath salts can also be found in “plant foods” that are sold legally. Again, the name plant food is deceptive: Do not think of Miracle-Gro or something that you put on your lawn. Plant food is the name for another synthetic drug that is sold under a legal name.

As for federal activity, the Office of National Drug Control Policy has taken notice of the growing problem. In September, Gil Kerlikowske, Director of National Drug Control Policy, convened high-level representatives from the Departments of Justice; Health and Human Services; Homeland Security; Transportation; and Defense, as well as the Food and Drug Administration; the National Institute on Drug Abuse; the Centers for Disease Control and Prevention; the DEA; and the Substance Abuse and Mental Health Services Administration, to discuss the threat of synthetic stimulants on public health and safety.

On September 7, 2011, the DEA did take advantage of its emergency scheduling authority to ban three chemicals used in the manufacturing of mephedrone and MDPV, so that the drugs could be deemed illegal to buy or sell for 12 months while it is studied. It is, in all likeliness, the goal of the DEA to classify both as a Schedule 1 narcotic. On Captiol Hill, Sen. Charles Schumer, D-N.Y., has drafted a bill that would add the chemicals to the list of federally controlled substances. The bill, S. 409, is entitled “The Combating Dangerous Synthetic Stimulants Act of 2011.” It has bi-partisan support from 19 co-sponsors.

Bath salts are of particular interest to the military, due in large part to an incident that occurred in April. Army medic David Stewart murdered his wife and then took his own life, following a high-speed chase on Interstate 5 in Washington State. Toxicology reports revealed bath salts in both of their blood. After the murder-suicide, the couple’s five-year-old son was found dead in their home, the cause of death being suffocation. Navy Surgeon General Vice Adm. Adam Robinson wrote on his blog about the legal consequences and health dangers of synthetic drug use. “Consumption of any of these products meets the criteria for drug abuse and is prohibited,” he said.

The drug has caused enough problems to merit an appearance in the CDC’s “Morbidity and Mortality Weekly Report,” first doing so on May 18, 2011. The report focused on a spike in ER admissions due to bath salt use and exposure. According to the CDC’s data, close to 70 percent of those admitted had a history of substance abuse, and almost 50 percent had a history of mental illness. Some experts believe that the 70 percent is indicative of the large number of addicts who are constantly searching for a newer, better high.

Despite all of the recent activity surrounding bath salts, very little is known about the drug. It has not been thoroughly researched, and its effects are unpredictable. Different batches of the drug can vary widely, in terms of chemical composition, price and potency. As regulations banning its sale continue to pile up, the next step in fighting the drug will almost certainly have to be research, in order to make prevention and treatment strategies more effective.

September is once again Recovery Month, when advocates for substance abuse and addiction recovery around the United States celebrate their achievements with their communities. While many communities celebrate in similar fashion – via recovery walks or attending professional baseball games where recovery advocates are honored for their work – each community is encouraged to put its own personal touch on its events, under the guidance of national organizations and government agencies. In Washington, it is an annual opportunity to bring the advocacy community together to highlight the need for policies that encourage and support recovery.

To help local organizations plan, promote and educate the community during Recovery Month, as well as throughout the year, 75,000 hard copies of the 2011 toolkit were distributed to health care, education, business and faith-based organizations, as well as coalitions and government agencies. Through the website, www.RecoveryMonth.Gov, the Substance Abuse and Mental Health Services Administration (SAMHSA) provides invaluable resources for communities around the country that wish to join in the celebration.

“Faces & Voices of Recovery (FAVOR) is looking forward to 2011’s Recovery Month observances that will bring together hundreds of thousands of people across the country – people in recovery, family members, friends and allies – at events large and small, building our recovery advocacy movement,” said Pat Taylor, the executive director of FAVOR. “We will be educating the public and policymakers about the reality of recovery from addiction to alcohol and other drugs, and are excited about this year’s September 24^th Rally for Recovery! at the 2011 hub in Philadelphia.” The Pennsylvania Recovery Organization – Achieving Community Together (PRO-ACT) will host the event, and more than 12,000 participants are expected, including Office of National Drug Control Policy Director, Gil Kerlikowske, SAMHSA/CSAT Director, Dr. Westley Clark, TV anchor, Laurie Dhue, and contestants for the first-ever Recovery Idol, along with the region’s growing recovery community.

Few people realize that planning for Recovery Month is an ongoing process, with a full-time staff, led by Ivette Torres at SAMHSA, dedicated to its success. SAMHSA also invites its Recovery Month Planning Partners from all parts of the country to Washington three times a year in order to develop ideas and themes. Even as Recovery month 2011 is taking place, the planning partners were meeting on September 7 and 8 this year to plan for 2012 and beyond. The “hub” event in 2012 will take place for the first time in Detroit.

Recovery Month 2011 seeks to build on the success of previous years. In 2010, according to SAMHSA, there were 1,072 Recovery Month events (a seven-percent increase, or 71 more events, than the 1,001 events held in 2009) in all 50 States, the District of Columbia, Guam, Puerto Rico and the United Kingdom, with a projected attendance of 3,888,160 individuals (an increase from 1,003,209 in 2009).

SAMHSA has expanded Recovery Month’s social media initiatives while growing its pre-existing and thriving social media channels and outreach. A Twitter account was launched on January 27, 2010, during the quarterly Recovery Month Planning Partner Meeting. The site garnered 1,038 Twitter followers throughout the year. The Recovery Month New Media E-Newsletter was also published on a monthly basis starting in January. SAMHSA conversed with 116 bloggers, which resulted in 25 blog posts that focused on Recovery Month. The Facebook page increased its visibility by 58.6 percent, adding 3,004 new “likes” for a total of 4,898 “likes” since the page’s launch in 2009. The Recovery Month YouTube channel garnered 9,501 new channel views, an increase of 668 percent over 2009, for a total of 10,923 channel views from its launch. Video views increased by 5,047 (or 580 percent) for a total of 5,917 video views, and subscribers increased to 594, a 1,485-percent increase from 40 subscribers in 2009.

In Washington, one of the highlights for recovery month each year is the Recovery Month luncheon. This is a chance for national leaders to join with people from around the country as they celebrate. Attended by Kerlikowske and SAMHSA Administrator Pam Hyde, the lunch this year was hosted by the National Council on Alcohol and Drug Dependence (NCADD). The featured speaker was Judy Collins, an advocate of recovery for many decades. The author of two books, one of which focused on the loss of her son after his own struggles with addiction, Collins spoke of her experiences and the role recovery has played in her life.

At the luncheon, the 9th Annual Rhode Island Rally 4 Recovery was recognized by SAMHSA as the top rally in the nation in 2010. “The State of Rhode Island is honored to be part of the National Recovery Month movement, and we look forward to making this month the biggest and best ever,” said event organizer, Jimmy Gillen, who serves as executive director of the Anchor Recovery Community Center in Providence.

Also at the lunch was the reading of a presidential proclamation, which officially recognized September as National Alcohol and Drug Addiction Recovery Month. In his proclamation, President Obama cited that, “Recovering from addiction to alcohol and other drugs takes strength, faith and commitment. Men and women in recovery showcase the power each of us holds to transform ourselves, our families and our communities. As people share their stories and celebrate the transformative power of recovery, they also help dispel myths and stigmas surrounding substance abuse and offer hope for lifestyles free from alcohol and other drugs.”

Obama calls on advocates to promote recovery and to support the growth of healthy, resilient individuals and families in the United States. He gave special mention to the abuse of prescription medication, reaching what he calls “epidemic levels”. The proclamation made reference to the 2011 National Drug Control Strategy, which supports successful, long-term recoveries through research, education, increased access to treatment and community-based recovery support. The President called on the nation to promote second chances and recognize each individual’s ability to overcome adversity.

Recovery Month will be back in 2012, so please visit www.Recoverymonth.gov for updates.

The Republicans, now in the majority in the House of Representatives, in large part ran on a platform of smaller government and spending cuts. While a large percentage of their candidates would not specify exactly what programs should be cut, this still does not bode well for health and behavioral health programs. The appropriations bill that funds the Department of Health and Human Services – and in turn SAMHSA and the NIH – is the largest non-military domestic spending bill to come out of congress each year. It is produced by the Appropriations subcommittee on Labor, HHS, and Education, or Labor/H for short. Being one of the largest spending bills, it naturally has a huge bull’s-eye on it.

There have been discussions and rumors that the House leadership would like to see domestic spending reduced to FY 2008 levels, or at the very least FY 2010 levels. This was the goal of the Sessions-McKaskill amendment, introduced in 2010, and defeated by the Senate. Yet now, with a new political landscape, FY 2008 levels for domestic discretionary spending may be returning. Regardless, it is highly unlikely that the House of Representatives will approve any increases for SAMHSA or NIH. Of course, the Senate remains in Democrat hands. So passing any budget can be difficult, and a government shut down this time next year is a possibility. This could have a severe impact on those who depend on Medicare to cover the cost of their treatment, and countless other social services.

The House Appropriations Committee, responsible for establishing funding levels for every federal program, will be chaired by Hal Rogers of Kentucky. While Mr. Rogers does not have an impressive record of supporting Labor/HHS programs in the past, he is a dedicated founder of the newly established House Caucus on Prescription Drug Abuse. Mr. Rogers has been a strong voice for establishing policies that can cut prescription drug abuse and illegal trafficking. However, most of his work thus far has focused on law enforcement and their involvement in this issue. It remains to be seen if this zeal carries over to funding research and services that are connected to this issue. The subcommittee responsible for appropriations to the Department of Health and Human Services, and in turn agencies such as NIDA and SAMHSA, will be Denny Rehberg of Montana. He has a mixed record on health and substance abuse issues, but only an 11 percent rating from the American Public Health Association. He cast a “no” vote on the House bill to enact the Wellstone/Domenici Parity act. He later voted “yes” on the final version, but the initial “no” vote is making many in the advocacy community very cautious.

Also of concern is the recently released report of the National Commission on Fiscal Responsibility and Reform. Among their recommendations are the elimination of the Office of Safe and Drug Free Schools, as well as a 10-percent across-the-board staffing cut at the federal level, with additional cuts to the Congressional and White House budgets. On the discretionary spending front, they propose rolling back spending to FY 2010 levels starting in FY 2012, and require a 1-percent budget cut every year from FY 2013-2015.

While at first glance the staffing and budget cut seems like sound economic policy, keep in mind how dependent our field is on agencies and offices such as SAMHSA, ONDCP, and NIH. Less people doing more work means that our allies in government will be less efficient, and not in a position to give us the help we need. Like it or not, the funding streams for addiction treatment and prevention are heavily linked to federal funding, which need to be protected at all levels.

Of course, all of this looks forward to FY 2012. In reality, the budget for FY 2011 has still not gone into effect. The government has been operating on what is known as a “continuing resolution” since September 30, 2010, at FY 2010 levels. Despite several attempts to pass the FY 2011 budget in the closing days of the 111th congress, and the lame duck session this past December, it never came to fruition. This was due in large part to Republicans blocking the legislation in the Senate, knowing they would have a better chance to cut spending if they could postpone votes on the FY 2011 budget until the new Congress was sworn in. The current continuing resolution is in effect until February 4, 2011. If a budget, or new CR, is not passed before then, it will result in a government shutdown. That means any and all services reliant on government funds will cease to operate until a budget is passed. This could severely impact substance abuse services.

As far as health care reform is concerned, it is almost a sure thing that the entirety of the bill will not be repealed. With the Democrats in the Senate and the White House, there is no way that such legislation will pass. However, this does not mean that changes will not be forthcoming. What it comes down to is how certain provisions of the Affordable Care Act are being funded. Those parts that require appropriations over the next two years face trouble in the House. Even before the election, Republicans attempted to chip away at certain provisions via the Johnanns amendment, which would have taken billions of dollars out of the Public Health and Prevention fund created by the act. The amendment was defeated, and $40 million allocated to SAMHSA for the integration of substance abuse treatment into primary care was preserved. In California, grassroots efforts by groups such as CAADAC and CFAAP urged a defeat of the amendment, joining with hundreds of other national associations.

According to the National Council of Community Behavioral Health, we will likely see many proposals related to changing the healthcare reform law, and most concerning to the addiction and mental health community will be efforts to scale back, or delay the Medicaid expansion scheduled for 2014. We have already discussed that federal discretionary funding will not be growing, and that additional federal Medicaid assistance is unlikely. The consequences of these actions is to put further pressure on state and county appropriations, further eroding addiction and mental health funding for indigent populations.

Of particular concern to the research community, and those whom support NIDA and NIAAA, is the election of Pat Toomey of Pennsylvania to the Senate. Mr. Toomey has a history of challenging NIH grants that he considers to be controversial, and has attempted to de-fund specific grants in the past. While most of these grants were focused on human sexual behavior, many are connected to the prevention and treatment of HIV. Members of the substance abuse treatment community, as well as many outside it, understand what a critical role substance abuse plays in the transmission of HIV, both via risky behavior with syringes, and unsafe sexual behavior brought on by substance abuse.

Also of concern is the appointment of Rep. Joseph Pitts to chair the subcommittee on health of the influential Energy & Commerce committee. Pitts, by virtue of this position, will have oversight of all HHS departments, including NIH and SAMHSA. Pitts, like Tomey, has a history of challenging the scientific merit of NIH grants that have focused on human sexuality. Not only do challenges to specific NIH grants reflect a lack of knowledge about the scientific process and how specific grants are chosen to be funded, but it is a threat to the culture of NIH, thus impacting the thousands of grants that focus on addiction research. With NIDA and NIAAA in the NIH forefront due to the possibility of a new institute being created, it is very possible that many of their grants can come under scrutiny. Also, if a new institute is created in place of two, Congress may see this as an opportunity to cut research funding in order to appear fiscally responsible. At NIH, Director Francis Collins has already spoken his mind. The reduction in funding proposed by Speaker-to-be John Boehner would be “very devastating” and would demoralize scientists, whose odds of winning a research grant from the agency could drop to about 10 percent, he told the Washington Post.

A notable absence in the 112th congress will be that of Rep. Patrick Kennedy, the undeniable Congressional champion for substance abuse treatment over the last decade. Following closely on the heels of Rep. Jim Ramstad’s retirement after the 111th Congress, the Addiction, Treatment, and Recovery Caucus has lost both its Democrat and Republican chairmen in a span of just two years. This means that Congress is now without a member whose top priority is substance abuse treatment and prevention. Many members of Congress are sympathetic to the issue, but none currently in Congress make it a top priority, save possibly one exception, Rep. Mary Bono-Mack of California, who has worked hard to become a visible leader on the issue. Rep. Tim Ryan of Ohio will be taking over as the Democratic chairman of the ATR caucus, joining Rep. John Sullivan of Oklahoma as the Republican chairman.

Without a doubt, it’s going to be an interesting and challenging two years.

According to the same Website, the fiscal effects of this measure could vary substantially depending on: (1) the extent to which the federal government continues to enforce federal marijuana laws and (2) whether the state and local governments choose to authorize, regulate and tax various marijuana-related activities. There could be savings of potentially several tens of millions of dollars annually to the state and local governments on the costs of incarcerating and supervising certain marijuana offenders.

Marijuana is classified by the Drug Enforcement Agency as a schedule 1 narcotic, the same classification given to cocaine, heroin and methamphetamine. In 1936 the Federal Bureau of Narcotics (FBN) noticed an increase of reports of people smoking marijuana, which further increased in 1937. The Bureau drafted a legislative plan for Congress, seeking a new law, and the head of the FBN, Harry J. Anslinger, ran a campaign against marijuana. During this particular time frame, the media was swarmed with propaganda regarding the effects of marijuana. Anslinger devised advertisements and commercials to inform the public of the believed side effects of marijuana. Citizens who were high on marijuana were portrayed as crazy, insane, suicidal, had murderous intentions and the like, according to the propaganda.

Blatant racism was also a factor in creating policy. As Anslinger once wrote, “There are 100,000 total marijuana smokers in the U.S., and most are Negroes, Hispanics, Filipinos and entertainers. Their Satanic music, jazz and swing, result from marijuana usage. This marijuana causes white women to seek sexual relations with Negroes, entertainers and any others.” Disregarding the scientific research on the subject and the falsified claims, the Marijuana Tax Act passed in 1937 quickly and with little debate and no opposition in Congress.

According to SAMHSA’s most recent National Survey on Drug Use & Health, released just this September, marijuana was the most commonly used illicit drug (15.2 million past-month users). The survey also found that among 12 to 17 year olds, marijuana use increased by 9 percent — going from 6.7 percent in 2008 to 7.3 percent in 2009. Consider these numbers in context: Among persons aged 12 or older, the rate of past-month marijuana use in 2008 (6.1 percent) was similar to the rate in 2007 (5.8 percent). The rate of current marijuana use among youths aged 12 to 17 decreased from 8.2 percent in 2002 to 6.7 percent in 2006 and remained unchanged at 6.7 percent in 2007 and 2008. So the increase in marijuana use from 2008 to 2009 is especially poignant.

Monitoring the Future, the nation’s largest and most cited longitudinal study on substance use in children, is funded by the National Institute on Drug Abuse and conducted by Dr. Lloyd Johnston and his team at the University of Michigan. According to the most recent results, marijuana use among American adolescents has been increasing gradually over the past two years (three years among 12th graders) following years of declining use, according to the latest Monitoring the Future study, which has been tracking drug use among U.S. teens since 1975.

“So far, we have not seen any dramatic rise in marijuana use, but the upward trending of the past two or three years stands in stark contrast to the steady decline that preceded it for nearly a decade,’’ said Johnston, the study’s principal investigator, last December. “Not only is use rising, but a key belief about the degree of risk associated with marijuana use has been in decline among young people even longer, and the degree to which teens disapprove of use of the drug has recently begun to decline. Changes in these beliefs and attitudes are often very influential in driving changes in use.” The proportion of young people using any illicit drug is also up slightly over the past two years. This measure is driven largely by marijuana use, because marijuana is the most widely used of all illicit drugs.

The Drug Policy Alliance is one of the chief supporters of Proposition 19. “Prop. 19 would reduce racial disparities in California’s criminal justice system by taking away a major excuse for law enforcement to search, harass and arrest young black and brown men; weaken Mexican drug cartels by taking away their profits; and allow marijuana to be controlled, regulated and taxed,” said Bill Piper, Director of National Policy for the Drug Policy Alliance. “While some marijuana users become dependent on the drug — about 9% — it is safer and less addictive than alcohol or tobacco. Most importantly, repealing marijuana prohibition would end the practice of destroying people’s lives by branding them criminals for nothing more than using marijuana. The war on marijuana has become a means of disenfranchising communities of color, allowing the facade of a marijuana arrest to be used to legally discriminate against people of color in housing, employment and public assistance. Instead of wasting billions of dollars arresting and incarcerating people for marijuana, the U.S. should spend that money on treatment for the small number of marijuana consumers who need it.”

The California Society of Addiction Medicine is in a unique position: It takes no official position on Prop. 19, but wants Californians to look at the research before they make up their minds on how to vote. Dr. Timmen Cermak is president of the California Society of Addiction Medicine, and has written extensively on the issue. Cermak represents the doctors who specialize in the treatment of drug abuse, including alcohol. CSAMS is committed to combining science and compassion to treat our patients, support their families and educate public policy makers. Less than one-third of the Society of Addiction Medicine’s 400 physician members believe prison deters substance abuse. Most believe addiction can be remedied more effectively by the universal availability of treatment.

According to the FBI, nearly half — 750,000 — of all drug arrests in 2008 in the United States were for marijuana possession, not sales or trafficking. Cermak believes Prop. 19 does offer a way out of these ineffective drug policies. However, two-thirds of CSAM members believe legalizing marijuana would increase addiction and increase marijuana’s availability to adolescents and children. A recent Rand Corp. study estimates that Prop. 19 would produce a 58-percent increase in annual marijuana consumption in California, raising the number of individuals meeting clinical criteria for marijuana abuse or dependence by 305,000, to a total of 830,000. Marijuana is addicting to 9 percent of people who begin smoking at 18 years or older. Withdrawal symptoms — irritability, anxiety, sleep disturbances — often contribute to relapse. Because adolescent brains are still developing, marijuana use before 18 results in higher rates of addiction — up to 17 percent within two years — and disruption to an individual’s life. The younger the use, the greater the risk.

Cermak asserts that Prop. 19 erroneously states that marijuana “is not physically addictive.” This myth has been scientifically proven to be untrue. CSAM believes that Prop. 19 asks Californians to officially accept this myth. Public health policy already permits some addictive substances to be legal — for instance, alcohol, nicotine and caffeine. Cermak asks that if Californians decide to legalize marijuana, who will pay for the additional treatments that will be needed? If marijuana is legalized, a truly fair, socially just public policy would use tax revenue from marijuana sales to pay for increased treatments. The Society of Addiction Medicine strongly recommends that, if marijuana is legalized, restrictions must minimize access for anyone younger than 21, and a tax on revenues must be directed to treatment.

Many who represent the treatment community are staunchly opposed to Prop 19. “We agree with the stance of the California Society of Addiction Medicine,” said Warren Daniels, Founder and President of CFAAP, the California Foundation for the Advancement of Addiction Professionals. “If the public decides to try legalization as an alternative strategy, it would be well advised to be aware of the addictive nature of marijuana and to be prepared to create an effective public health, prevention and treatment response to what will undoubtedly be an increase in marijuana use.”

The Community Anti-Drug Coalitions of America, a very influential voice in federal drug policy and prevention, has also weighed in on the issue. “With national data already showing softening attitudes and across-the-board increases for drug use — particularly marijuana, which increased in all grades according to a recent survey — this is not a message we can afford to send to California or the rest of America’s youth,” said Gen. Arthur T. Dean, CADCA Chairman and CEO, in a recent press release. “Marijuana already costs the United States $181 billion annually in increased health care and treatment costs, crime and lost productivity. So any revenue gained by taxing marijuana would be far outweighed by the health care and criminal justice costs to the state.”

Even law enforcement organizations are split on this issue. Those groups opposed to Proposition 19 include the California District Attorneys Association, and the California Police Chiefs Association, Yes on 19’s endorsements include that of the National Black Police Association. “At each step of my law enforcement career — from beat officer up to chief of police in two major American cities — I saw the futility of our marijuana prohibition laws,” said Joseph McNamara, former police chief in San Jose and Kansas City, MO, now a speaker for Law Enforcement Against Prohibition (LEAP). “But our marijuana laws are much worse than ineffective: they waste valuable police resources and also create a lucrative black market that funds cartels and criminal gangs with billions of tax-free dollars.”

For the most part, members of Congress, even from California, have been silent on the issue. Perhaps because it is a state issue that politicians are hesitant to interfere with, perhaps because the issue is so closely contested. Whatever the reason, California’s congressional delegation has taken a pass on getting involved. The lone exception seems to be Senator Diane Feinstein, who called Proposition 19 “a jumbled legal nightmare that will make our highways, our workplaces and our communities less safe.”

Other federal policymakers have expressed their disapproval. Not surprisingly, the Office of National Drug Control Policy is in opposition. Gil Kerlikowske, John Walters, Barry McCaffrey, Lee Brown, Bob Martinez and William Bennett were directors of the Office of National Drug Control Policy in the administrations of Presidents Obama, George W. Bush, Bill Clinton and George H.W. Bush, respectively. In an op/ed piece in the Los Angeles Times, they cite that no country in the world has legalized marijuana to the extent envisioned by Proposition 19, so it would be impossible to predict precisely the consequences of wholesale legalization. They also express concern over increased social costs.

A chief concern of these experts is highway safety. They cited a 2004 meta-analysis published in the journal Drug and Alcohol Review of studies conducted in several localities showed that between 4 percent and 14 percent of drivers who sustained injuries or died in traffic accidents tested positive for delta-9-tetrahydrocannabinol, or THC, the active ingredient in marijuana. Because marijuana negatively affects drivers’ judgment, motor skills and reaction time, it would stand to reason that legalizing marijuana would lead to more accidents and fatalities involving drivers under its influence. The authors closed the op/ed by citing the bi-partisan effort it took to produce the piece.

All polls have reported this vote going down to the wire, and the result is sure to influence future policy. Regardless of the result, advocates on both side of the issue have taken this opportunity to educate the public. In the end, however, it is almost certain that the courts will have the final word, as state and federal laws are bound to conflict.

The Director of ONDCP — also referred to as the “Drug Czar” — is Gil Kerlikowske, the former chief of police in Seattle. In introducing the strategy to Congress, he presented it as informed by scientific breakthroughs in the fields of treatment and prevention; innovations in law enforcement; and the input of both the federal government and local agencies. Kerlikowske, and the ONDCP deputy director, A. Thomas McLellan, brought with them to Washington the hope that the ONDCP could shift its focus away from the “supply” aspect of drug control, which entails law enforcement, to the “demand” reduction aspect, which includes prevention and treatment.

While Kerlikowske and McLellan appear to be sincere about this shift in direction, the budget of ONDCP has not reflected such a change in course. Despite President Obama’s statement that “I directed the ONDCP to re-engage in efforts to prevent drug use and addiction, and to make treatment available for those who seek recovery,” the budget is still weighted heavily on the demand side. Some experts, such as John Carnavale of Carnavale Associates, have pointed out that at least in the Reagan White House the budget matched the rhetoric — the “War on Drugs” was aimed at busts and harsh jail sentences for traffickers, and had the supply-side budget to match.

“The administration’s drug strategy is largely similar to President Bush’s failed strategy, especially when it comes to short-changing drug treatment while wasting money on ineffective supply-side programs,” said Bill Piper, Director of National Policy at the Drug Policy Alliance. “It does, however, break from the past in several important respects. Most notably by setting numeric goals for reducing fatal drug overdoses, embracing needle exchange, and supporting reform of the crack/powder cocaine sentencing disparity. Combined, these changes could be a first step to implementing a new bottom line in U.S. drug policy; one that focuses on reducing the problems associated with both drugs and the war on drugs.”

The strategy focuses heavily on prevention, which aligns it well with the Obama White House’s emphasis on prevention of chronic diseases in its health care reform efforts. To achieve this, ONDCP places an emphasis on community involvement. Among its highest priorities, the strategy calls for the development of a community-oriented national prevention system, and providing scientifically supported information via the National Youth Anti-Drug Media Campaign. There would also be support for mentoring initiatives, and the fostering of collaboration between public health and public safety organizations.

The plan also emphasizes a desire to see primary care as a bigger part of the solution, as it would increase early interventions. ONDCP would like to see increased screenings in all healthcare settings, which would in turn require more education for health professionals so they can recognize the warning signs of substance abuse. As prescription drug abuse remains a rampant problem, drug monitoring programs are also part of the strategy for primary care settings.

Because substance abuse in America is as much a criminal justice issue as a health issue, there is also a fair amount of the strategy dedicated to the criminal justice system, and reforms that would advance new directions in drug policy. ONDCP wants to promote alternatives to incarceration through a variety of methods. These would include encouraging partnerships between law enforcement and community organizations, mandating treatment for chronic offenders that “disproportionately burden the health care and criminal justice systems,” and supporting post incarceration re-entry efforts, such as job placement and access to drug-free housing.

There is also commitment to working on the international level, since the U.S. is one of the most lucrative markets for illegal drugs. In addition to conducting joint law enforcement operations with other nations, the ONDCP aims to expand support for international prevention and treatment initiatives. Partners for this effort would include the United Nations and the Organization of American States.

“As Director Kerlikowske has witnessed in his listening sessions with the recovery community, there’s more to recovery than not using alcohol or other drugs,” said Pat Taylor, Executive Director of Faces and Voices of Recovery. “We salute the agency’s recently released strategy’s attention to the barriers to recovery that are keeping people from housing, jobs and driver’s licenses as they work to get their lives back on track…With the “War on Drugs” over and a renewed emphasis on prevention, treatment and recovery, the strategy is identifying long-overdue solutions that address addiction as the public health crisis that it is.”

Included in the coalition are such prominent advocacy organizations as the American Psychological Association, the National Association of State Alcohol and Drug Abuse Directors (NASADAD), Community Anti-Drug Coalitions of America (CADCA,) the American Psychiatric Association, The American Society of Addiction Medicine (ASAM) and the International Certification and Reciprocity Consortium (IC&RC.)

“The Friends of NIDA is an organization that is organized around a consensus message about drug abuse and what needs to be done to understand and treat it,” said Marie Dyak, Executive Director of the Entertainment Industries Council. “It does what it is designed to do: advocate for science-based research to treat a very complex disease, aspects of which do not exist in so many other chronic illnesses.”

The Friends are most well known for its briefings on Capitol Hill. Always well attended—sometimes by more than a hundred Congressional staff—it seeks to inform policy-makers of the benefits of NIDA research, as well as its “real-world” applications. Briefings almost always include an introduction by NIDA Director, Dr. Nora Volkow, and feature one or two NIDA-funded scientists who explain their research. Often, someone who has benefited from treatment based on NIDA research also speaks. Briefing subjects try to blend NIDA research priorities with important political topics, such as treatment for veterans, prescription drug abuse and methamphetamine addiction. Other briefing topics include drug use and HIV, the role of genetics in substance abuse, and treatment in the criminal justice system. The briefings are always presented in conjunction with the Congressional Addiction, Treatment and Recovery Caucus. Members of Congress, including ATR Caucus chair Rep. Patrick Kennedy, Rep. Grace Napolitano, Rep. Brian Baird and Rep. Rick Larsen, have frequently attended and spoken at the briefings.

One memorable briefing, on the subject of prescription drug abuse, featured a 19 year old from Massachusetts named Nick, who spoke about his addiction to prescription drugs, how it led to other abuses and its effect on his life and his family. As he paused several times to compose himself, he worked his way through his story and clearly made an impact on almost everyone in attendance. He courageously told his compelling story of becoming addicted to Vicodin and OxyContin. He noted that over time, he also became addicted to heroin and found that he no longer recognized his life. Nick also spent time in the criminal justice system and was at one point pronounced dead in an emergency room. At that point, he said that he chose to muster his strength to dedicate himself to a treatment regimen that included the medication buprenorphine as an adjunct to counseling. Since then, Nick said that he is growing stronger every day and is appreciative of the opportunity to be an active and important part of society.

Nick was asked to review for the audience core “take home messages.” Nick called on a strong investment in prevention programming—from the elementary grades through high school. In addition, he explained that addiction “does not discriminate” and noted that the treatment protocols made possible through the research at NIDA literally saved his life.

It is these presentations, unfiltered and unpolished, that give a human face to the benefits of NIDA research. Other memorable speakers include those who partook in a briefing on nicotine and tobacco addiction, including Shirley Reimer, a patient who quit smoking through the National Quitline, and shared the story of her success, and Preston Young, a patient who quit smoking during a translational clinical research study funded by NIDA, who spoke about his personal experience with nicotine addiction.

 “The Friends of NIDA has done an excellent job educating Congress on the benefits of investing federal resources into addiction research,” said Rob Morrison, Executive Director of NASADAD. “Through Hill briefings that feature NIDA-funded researchers and people in recovery telling their stories, policymakers make the connection between the front-end investment and the dividends seen in their District.”

Like many advocacy-based coalitions in Washington, the Friends are almost always most busy during the appropriations season. Thanks in large part to Ed Long of Van Scoyoc Associates, the Friends are always successful in including comments in the reports accompanying both House and Senate appropriations legislation. This “report language,” as it is called in D.C., expresses support from the committees for specific work being done at NIDA, and encourages it to continue in the future. Such congressional support is critical to a government agency such as NIDA, as continued funding is a large part of the recipe for progress.

The Friends also receive leadership and advice from a very knowledgeable and influential Board of Advisors. Many former ONDCP and NIDA directors sit on the board, including General Barry McCaffery, Dr. Alan Leshner (Currently the CEO of The American Association for the Advancement of Science), Dr. Bob Dupont and Dr. Charles Schuster. Also on the board is former U.S. Representative and Chair of the House Committee on Commerce, Thomas Bliley.

The leadership of NIDA has always been appreciative of the Friends efforts. Cindy Miner, Director of the NIDA Science Policy Division, remarked, “Through their educational efforts, the Friends of NIDA have been an important ally in raising the public’s awareness of NIDA’s scientific achievements in addiction research, and consequently helping to reduce the stigma of addiction.”

(Materials from all Friends of NIDA briefings can be found at http://thefriendsofnida.org/events.asp)

Yet while legislation and federal funding exist to provide for the prevention and treatment of substance abuse and addiction, no such programs exist for the protection and care of problem gamblers. The same applies to the professionals who treat these patients. While funding for the training of substance abuse counselors and the treatment of drug addicts and alcoholics is small when compared to the size of the problem drug addiction presents for our country, these funds tower over the funding received by the problem gambling field, which hovers dangerously close to zero.

However, the statistics on those who problem gambling affects warrant a review of the allocation of these funds. Four to six million American adults and 500,000 adolescents meet the criteria for a gambling problem. Fifty percent of problem gamblers in treatment meet current or lifetime criteria for substance abuse, and 30 percent of substance abusers in treatment meet current or lifetime criteria for problem gambling.

Problem gambling is defined as gambling behavior that causes disruptions in any major area of life: psychological, physical, social or vocational. The term problem gambling includes, but is not limited to, the condition known as Pathological or Compulsive Gambling, a progressive addiction characterized by increasing preoccupation with gambling; a need to bet more money more frequently; restlessness or irritability when attempting to stop; chasing losses; and loss of control manifested by continuation of the gambling behavior in spite of mounting, serious, negative consequences.

Recently, federal legislation has been introduced to address the issue. The Comprehensive Problem Gambling Act authorizes the Federal health agencies to address problem gambling and provides an appropriation of $71 million over five years for grants to state, tribal and local government health agencies, non-profits and universities on the prevention, treatment and research of problem gambling. Introduced in June 2009 by Reps. Moran, Terry and Wolf, HR 2906 has 42 sponsors to date: 33 Democrats and nine Republicans. Such senior members of the House as Rosa DeLauro (D-CT), Barney Frank (D-MA) and Mike Castle (R-DE) have signed on as co-sponsors. Senators Brownback (R-KS) and Merkley (D-OR) are scheduled to introduce the Senate companion bill, hopefully on March 8 (as of this writing).

“While no hearings have been scheduled, we remain optimistic the bill will pass this year,” said Keith Whyte, Executive Director of the National Council on Problem Gambling (NCPG), the national advocate for programs and services to assist problem gamblers and their families. “When [the Comprehensive Problem Gambling Act] passes, it will literally be the first-ever Federal grants for problem gambling prevention and treatment programs.” The mission of the NCPG is to increase public awareness of pathological gambling, to ensure the widespread availability of treatment for problem gamblers and their families and to encourage research and programs for prevention and education. There are currently 35 state affiliates of the NCPG.

The act would amend the Public Health Service Act to require the Secretary of Health and Human Services (HHS), acting through the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), to establish and implement programs for the identification, prevention and treatment of problem and pathological gambling. It would require the Secretary to carry out a national campaign to increase knowledge and raise awareness of problem gambling. The Secretary would also be empowered to encourage media outlets to provide information aimed at preventing problem gambling and target their message to radio and television audiences of, but not limited to, sporting events and gambling. The Secretary would be authorized to make grants to states, local and tribal governments and nonprofit agencies to provide comprehensive services with respect to the treatment and prevention of, and education about, problem gambling.

The act would also require the President to establish and implement a national program of research on problem gambling, appoint an advisory commission to coordinate federal research, and consider the National Gambling Impact Study Commission’s recommendations. Acting through the SAMHSA Administrator, the President would also be required to develop a Treatment Improvement Protocol for problem gambling.

There are now 33 states that provide some public funds, usually through the Single State Agency (SSA). The Association of Problem Gambling Service Administrators (www.apgsa.org) is the trade association that represents problem gambling services at the state level, similar to how the National Association of State Alcohol/Drug Abuse Directors (NASADAD) represents the SSAs.

A search of the National Institutes of Health (NIH) database revealed that there are currently nine active NIH-funded studies that focus on pathological gambling. This is not to say that there are not other NIH-funded studies that could provide insight to the brain activity that relates to problem gambling. Several studies on other types of addictions could help the problem-gambling field find answers and develop better treatment protocols. But only nine such studies represent research directly related to problem gambling, with the funding for these grants totaling less than $2 million.

“There is a dire need for SAMHSA and other agencies to provide technical assistance, program development and best practices to make the most efficient and effective use of these funds,” said Whyte. “Problem gambling is highly co-morbid with substance abuse, and there is increasing evidence that providing services to treat problem gamblers will reduce usage of other public services, not just health-related but also criminal justice, and provide overall savings to agencies and states.”

Given the high co-morbidity of problem gambling with substance abuse and mental health, the resistance of many substance abuse/mental health providers to brief screening and prevention initiatives has been a major challenge. In response, NCPG has developed National Problem Gambling Awareness Week (www.npgaw.org), a grassroots campaign to raise awareness of problem gambling and to encourage health care providers, especially substance abuse and mental health personnel, to screen their clients for problem gambling during the week.

The American Psychiatric Association recently proposed to shift problem gambling into the new Behavioral Addictions section of the DSM-V, which is currently being compiled. This has the potential to help substance abuse and mental health professionals recognize the relationship between substance abuse and problem gambling, given the similarities in the underlying neuro-biological mechanisms. It would also provide additional validity to problem gambling as an addiction, requiring the necessary programs to appropriately diagnose and treat the disorder.

The author wishes to thank Keith Whyte for his cooperation in developing this article.

While the legislation going to conference between the House and Senate is over 1,900 pages, there are parts that apply to substance abuse treatment and prevention.  In some cases, the House and Senate provisions are fairly close. Yet in others, it remains to be seen which version will prevail when the final bill is introduced.

In Washington, the substance abuse and mental health advocacy communities came together under one banner to push for these provisions.  Led by the Legal Action Center, the Coalition contains over 30 organizations.  Represented are organizations representing treatment centers, prevention, consumer’s rights, health professionals, and a slew of other interests.

First and foremost, both bills require that substance use disorders, as well as mental health disorders, be part of the minimum benefits package.  The senate version, though, exempts large employers from this provision. “In my view, the largest victory is the inclusion of coverage of substance use disorder services as part of the essential benefit package,” said Rob Morrison, Executive Director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD.)  “ This represents a giant opportunity to increase access to addiction treatment services and demonstrates that the work of the Coalition for Whole Health did a fantastic job to make this happen. “

Perhaps one of the most important provisions is how those newly enrolled in Medicaid will be classified when it comes to substance abuse treatment.  While the Senate version of the bill expands coverage to those at 133% of the poverty level, new enrollees would be placed in a plan that includes addiction and mental health treatment services.  Childless adults would be eligible for this plan.  The House version, however, allows for enrollment for those up to 150% of the poverty level.  Those newly enrolled would be provided addiction and mental health services, at a state’s option, according to a respective state’s plan.  The House version would also prohibit enrollment of childless adults, unless the state can demonstrate that the plan has the capacity to meet the health, mental health, and substance use disorder needs of the individual.

Workforce development is also part of the proposed legislation.  The House version is very simple, as it authorizes workforce development grants for providers of mental health and substance use services.   $60 million is authorized for the program, and the report accompanying the legislation specifies training for addiction physicians.

The Senate version of the bill is more detailed in this area.  Perhaps most importantly, it would qualify individuals practicing pediatric counseling for a loan repayment program.  It also authorizes grants to higher education institutions for substance abuse and mental health professionals.   Priority will be given to those schools where training focuses on the needs of vulnerable populations, as well as those where applicants display a familiarity with evidence based methods.  Unfortunately, the senate only provides for $35 million for this program, with $8 million going to social work and $12 million going to graduate psychology.  $10 million would go to mental health and substance abuse.

In the fall of 2008, the behavioral health advocacy community saw over a decade of work pay off when the Paul Wellstone & Pete Domenici Mental Health Parity Act was signed into law.  Both the Senate and House versions of health care reform requires individual, small group, and large group insurance plans to comply with the regulations set forth in Wellstone-Domenici.

“One of the most crucial components of the healthcare reform legislation now being debated is the concept of parity. The bill includes the principles contained in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, the federal law passed last year which prohibits unequal treatment limits and financial requirements for mental health and substance use treatment,” said Linda Rosenberg, executive director of the National Council for Community Behavioral Healthcare.   “The parity provisions are essential given that mental health and substance use treatment have traditionally been subject to blatantly discriminatory limits on coverage that restrict access to effective and, at times, lifesaving therapies.”

Screening and prevention is another part of the bill where the Senate version is far different than the House.  The House provides $30 million for new SBIRT grant programs.  The Senate’s effort is more fragmented. Substance use prevention is included in a section authorizing community health team grants supporting medical homes.  Substance use disorders services are also required to be provided at school based community health centers.  It would also allow state or local health departments which receive grant funds through a public health grant program administered by the CDC to enter into contracts with substance use and mental health providers.

Finally, there is the matter of including the federal agencies that work in mental health and substance abuse in relevant working groups and studies.  The House version adds SAMHSA to the list of agencies to be consulted for the development of a national prevention and wellness program.  The senate version includes SAMHSA as an agency to be included in the “Interagency Working Group on Health Care Quality.”  It also directs states to consult with SAMHSA when addressing Medicaid coverage of mental health and substance abuse prevention and treatment.

If and when the health care reform package does become law, there is still more work to be done.  All of the programs and changes it provides for must be implemented.  Also, these new or modified programs must be funded, which means a whole new round of advocacy at the appropriations level. “The work has only just begun,” said Morrison.  “As the saying goes, the devil is in the details.  Or in this case, the devil is in the details – and the implementation.”

The task of investigating whether a merger is in the best interest of science and the NIH falls to the Scientific Management Review Board (SMRB.)  Not less than once each seven years, the Board must provide advice to the NIH Director and other appropriate agency officials, through a report to the NIH Director, regarding the use of organizational authorities reaffirmed by the NIH Reform Act of 2006. A working group of the Board, the Substance Use, Abuse, and Addiction workgroup, has been charged with investigating the plausibility of a merger.  The working group thus far has been soliciting comments from experts in addiction research, from the public, and experts in NIH administration. Their work to date has been transparent and open.

The two institutes differ greatly in size.  The budget of NIDA is more than double that of the NIAAA.   NIDA’s budget for FY 2008 was just over $1 billion, compared to $438 million for NIAAA.  This is indicative of Congress- and the publics- view of the disease of addiction. Most consider addiction to illicit drugs to be a bigger danger and threat to the public health than alcohol.  The numbers, however, tell a different story.  Alcohol use and abuse causes more physical and economic damage each year than all other substance use and abuse combined.

Some in the addiction advocacy community have “taken sides” on the issue, either for or against the proposed merger. Those in favor believe it is more efficient approach to research. Those opposed to the merger fear that funding for research could end up being decreased. Some opponents of the merger claim the study of alcohol abuse deserves its own institute, since it is legal to purchase and is not an illicit drug. This is a curious argument, since NIDA also studies the abuse of legal substances, such as tobacco, and the abuse of both prescription and over-the-counter medications.  Others claim that the underlying principles of addiction, regardless of what substance to, are similar enough that only one institute should administer research on the subject, just as there is only one cancer institute and one institute for heart disease.

The advocacy community has been clear that a top priority be, at a minimum, maintaining a status quo for the funding of addiction research.  Yet many have assumed that if the merger does take place, research (especially for alcoholism and alcohol use) will suffer as a result, since funding for one institute is cheaper than funding for two.  Opponents of the merger believe that research on alcohol use will be impacted to an even higher degree, that the bigger institute will trump the smaller.  The assumption is that alcoholism research will suffer, since there is the appearance of a smaller institute being absorbed into a larger one. However, nothing produced by SMRB has given this line of thought any credence.  If the two institutes are merged, this will create one new institute, not the absorption of one into the other.

Critics of the merger have also recommended that a better alternative is for the two institutes to simply collaborate.  However, the two institutes collaborate frequently.  Projects funded in FY 2008 alone include: NIDA assisting NIAAA in performing a multicenter trial for quetiapine for the treatment of alcohol dependence through the Veterans Administration Cooperative Study Program; both collaborating along with NIMH on Strategic Planning for Domestic and International NeuroAIDS Research; both collaborating with NIDDK on an Action Plan for liver disease research: and both institutes worked together on an NIH Roadmap Pilot to establish the groundwork for a unified science of behavior change that capitalizes on both the emerging basic science and the progress already made in the design of behavioral interventions in specific disease areas.

One of the most outspoken critics of the merger has been the Research Society on Alcoholism. Both their president, Sara Jo Nixon, and their executive director, Dr. Raymon Anton, have testified before the SMRB, as have several of their members.  Their former president, Dr. Peter Monti, expressed his concerns in a written statement to the SMRB in April, citing the importance of research on issues such as liver disease and fetal alcohol syndrome.  He also cited the importance of NIAAA as a stand-alone institute that fostered interest in the field of alcoholism research. “Prior to the creation of NIAAA, the field of alcohol research had labored in a climate of public denial that alcoholism was even a problem,” he wrote.  ”There was a widespread lack of attention among health professionals to the need for finding ways to treat and prevent alcoholism and alcohol-related illness. NIAAA’s emergence as an Institute brought the importance of alcohol problems to national attention. It also signaled to researchers outside the community that alcohol research was an important area of scientific inquiry and thus attracted the best and brightest investigators to the field.”

The largest organization to openly support the merger is the American Psychiatric Association.  In a recent letter to the SMRB, signed by their CEO and medical director Dr. James Scully, wrote, “Given commonalities in areas such as biology, culture, and frequent use of multiple substances, there are logical reasons to have a single Institute devoted to substance use disorders. The field of addictions research and medicine – and ultimately patients – would be well served if there is greater dialogue and work between current research groups,”

He added, “The science of addiction research, the potential for improved treatments, and the promise for improving the lives of patients and their families, leads the APA to support a proposed merger between NIAAA and NIDA.”  At a recent meeting of the SMRB, APA submitted oral testimony, by Dr. Darrel Regier, their Director of Research.

Even if the SMRB recommends a merger, several complex steps remain in the process.  Their recommendation will be sent to NIH director Dr. Francis Collins.  Dr. Collins may then decide to accept or ignore the recommendation.  If he chooses to ignore the recommendation, he must explain his reasons in writing.  If he accepts the recommendation, he will notify Congress via the Office of the HHS Secretary.  Congress then may refute the recommendation, or accept it by taking no action. This procedure is guided by statute, the aforementioned NIH Reform Act of 2006, which is also responsible for the creation of the SMRB.  The SMRB, it should be noted, has more than two options (merge or leave status quo.)  They can recommend any number of actions, again for Director Collins to accept or deny.

By law, the NIH may contain no more than 27 institutes, the number that currently exists.  Some have speculated that the merger is being investigated so that another institute may be created.   However, such an idea is no more than conjecture at this point, and no NIH or government officials have mentioned this as a possible motive for the merger.

Author’s note: Andrew Kessler currently represents the International Certification and Reciprocity Consortium, which is on the record as a supporter of the merger.