Tuesday, January 29, 2019
As reported in this local article, "Baltimore State’s Attorney Marilyn Mosby announced Tuesday her office would cease prosecuting people for possessing marijuana regardless of quantity or criminal history." Here is more:
Calling the move monumental for justice in Baltimore, Mosby also requested the courts vacate convictions in nearly 5,000 cases of marijuana possession. “When I ask myself: Is the enforcement and prosecution of marijuana possession making us safer as a city?” Mosby said, “the answer is emphatically ‘no.’”
Mosby follows district attorneys in Manhattan and Philadelphia who have scaled back or outright ended marijuana prosecutions. Maryland lawmakers decriminalized possession of up to 10 grams of marijuana in 2014.
But she also stood alone, politically: No police and no other city officials joined her at the announcement. Hours later, Mayor Catherine Pugh announced her support for Mosby’s plan.
Mosby aims to formalize marijuana policies already in practice. A report released Tuesday by her office shows city prosecutors dropped 88 percent of marijuana possession cases in Baltimore District Court since 2014 — 1,001 cases. [This report is available at this link.]
Still, convictions have saddled thousands in Baltimore with criminal records and frustrated their job searches, Mosby said. The marijuana arrests have disproportionately affected minority neighborhoods in Baltimore. Nationwide, African-Americans are four times more likely than whites to be arrested for possessing marijuana. The ratio jumps to six times more likely in Baltimore, prosecutors wrote in the report.
Such arrests squander scarce police resources, Mosby said, noting 343 people were killed in Baltimore in 2017. Police closed nearly one-third of those cases. Last year, 309 people were killed and police closed closer to one-quarter. “No one,” Mosby said, “thinks spending resources to jail people for marijuana is a good use of our limited time and resources.”
But it remains unclear how the policy will play out in the streets. Mosby made her announcement at the nonprofit Center for Urban Families in West Baltimore while surrounded by her staff, marijuana advocates and neighborhood activists. Police leaders weren’t there....
The department is run by a former agent of the Drug Enforcement Administration, Gary Tuggle; he is interim commissioner. He said his officers wouldn’t quit arresting people for possessing marijuana. “Baltimore Police will continue to make arrests for illegal marijuana possession unless and until the state legislature changes the law regarding marijuana possession,” he said in a statement....
Police leaders have long said they are focused on violent crime and marijuana arrests aren’t a priority. But officers routinely use marijuana as reason to search the pockets or car of someone suspected in more serious crimes....
Mosby has pledged to continue to prosecute anyone suspected of selling marijuana. She said her office would take cases to court when police find evidence of drug sales, such as baggies and scales....
In nearby Baltimore County, State’s Attorney Scott Shellenberger said he had no plans to quit prosecuting marijuana cases. Most first-time offenders are placed in a treatment program in the county, he said.
Mosby also urged state legislators to support a bill that would empower her office to vacate criminal convictions in everything from corrupt cop cases to marijuana prosecutions. The current procedures require action from both prosecutors and defense attorneys to vacate a conviction.
On Tuesday, prosecutors filed papers for marijuana cases dating back to 2011 to be vacated — about 1,000 in Circuit Court and nearly 3,800 in District Court. Judges would rule on the requests.
The press release, titled "Baltimore State’s Attorney Marilyn Mosby To Stop Prosecuting Marijuana Cases, Says Prosecutions Provide No Public Safety Value And Undermine Public Trust In Law Enforcement," discusses the essentials of the policy announced by Baltimore State’s Attorney Marilyn Mosby,
"Impact of Medical Marijuana Legalization on Opioid Use, Chronic Opioid Use, and High-risk Opioid Use"
The title of this post is the title of this notable new article recently published in the Journal of General Internal Medicine and authored by Anuj Shah, Corey Hayes, Mrinmayee Lakkad, and Bradley Martin. Here is the abstract:
To determine the association of medical marijuana legalization with prescription opioid utilization.
A 10% sample of a nationally representative database of commercially insured population was used to gather information on opioid use, chronic opioid use, and high-risk opioid use for the years 2006–2014. Adults with pharmacy and medical benefits for the entire calendar year were included in the population for that year. Multilevel logistic regression analysis, controlling for patient, person-year, and state-level factors, were used to determine the impact of medical marijuana legalization on the three opioid use measures. Sub-group analysis among cancer-free adults and cancer-free adults with at least one chronic non-cancer pain condition in the particular year were conducted. Alternate regression models were used to test the robustness of our results including a fixed effects model, an alternate definition for start date for medical marijuana legalization, a person-level analysis, and a falsification test.
The final sample included a total of 4,840,562 persons translating into 15,705,562 person years. Medical marijuana legalization was found to be associated with a lower odds of any opioid use: OR = 0.95 (0.94–0.96), chronic opioid use: OR = 0.93 (0.91–0.95), and high-risk opioid use: OR = 0.96 (0.94–0.98). The findings were similar in both the sub-group analyses and all the sensitivity analyses. The falsification tests showed no association between medical marijuana legalization and prescriptions for antihyperlipidemics (OR = 1.00; CI 0.99–1.01) or antihypertensives (OR = 1.00; CI 0.99–1.01).
In states where marijuana is available through medical channels, a modestly lower rate of opioid and high-risk opioid prescribing was observed. Policy makers could consider medical marijuana legalization as a tool that may modestly reduce chronic and high-risk opioid use. However, further research assessing risk versus benefits of medical marijuana legalization and head to head comparisons of marijuana versus opioids for pain management is required.
AG-nominee Bill Barr reiterates (with nuance) commitment to non-enforcement of federal marijuana prohibition in reform states
Tom Angell has this effective Forbes report, headlined "Trump Attorney General Pick Puts Marijuana Enforcement Pledge In Writing," spotlighting that the next US Attorney General has made clear his inherent commitment to respecting state-level marijuana reforms. Here are the details:
William Barr, President Trump's nominee to serve as the next U.S. attorney general, made headlines earlier this month when he pledged during his Senate confirmation hearing not to "go after" marijuana companies that comply with state laws.
Now, in response to written questions from senators, Barr is putting that pledge on paper, in black and white. He's also calling for the approval of more legal growers of marijuana for research, and is acknowledging that a recent bill legalizing hemp has broad implications for sale of cannabis products.
"As discussed at my hearing, I do not intend to go after parties who have complied with state law in reliance on the Cole Memorandum," he wrote, referring to Obama-era cannabis enforcement guidance that then-Attorney General Jeff Sessions rescinded last year.
That said, Barr isn't committing to formally replacing the Cole Memo, which generally directed federal prosecutors not to interfere with state marijuana laws, with new guidance reiterating the approach. "I have not closely considered or determined whether further administrative guidance would be appropriate following the Cole Memorandum and the January 2018 memorandum from Attorney General Sessions, or what such guidance might look like," he wrote in response to a question from Sen. Cory Booker (D-NJ). "If confirmed, I will give the matter careful consideration."
And Barr, who previously served as attorney general under President George H. W. Bush, says it would be even better if Congress got around to addressing the growing gap between state and federal marijuana laws. "I still believe that the legislative process, rather than administrative guidance, is ultimately the right way to resolve whether and how to legalize marijuana," he wrote in a compilation of responses delivered to the Senate Judiciary Committee on Sunday.
But even as Barr reiterated that he wouldn't go after people and businesses that benefited from the Cole memo, he voiced criticism of policy directives like it and of the idea of legalization in general. "An approach based solely on executive discretion fails to provide the certainty and predictability that regulated parties deserve and threatens to undermine the rule of law," Barr wrote in response to a question from Sen. Dianne Feinstein (D-CA). "If confirmed, I can commit to working with the Committee and the rest of Congress on these issues, including any specific legislative proposals. As I have said, however, I do not support the wholesale legalization of marijuana."
Nonetheless, legalization advocates were happy to see the nominee reiterating his non-enforcement pledge when it comes to state-legal businesses. "It’s positive to see Barr make the same commitments on marijuana enforcement in writing as he did in the hearings," Michael Collins, director of national affairs for the Drug Policy Alliance, said. "My hope is that he sends this message to all federal prosecutors so that states are given space to reform their outdated, broken, racist marijuana laws, and the country can turn the page on prohibition."
January 29, 2019 in Campaigns, elections and public officials concerning reforms, Criminal justice developments and reforms, History of Marijuana Laws in the United States, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)
Saturday, January 26, 2019
The title of this post is the headline of this lengthy new commentary piece authored by Jenni Avins appearing in Quartz. I recommend the piece in full, here is its powerful start:
Since California legalized recreational cannabis in January 2018, pot enthusiasts in posh sections of Los Angeles can sleep easily with a few drops of CBD oil under the tongue. They can stroll into dispensaries such as MedMen, the chain touted as the “Apple store of weed,” which recently reported quarterly revenues of $20 million. On Venice Boulevard, shiny sedans toting surfboards drive past posters for Dosist vape pens and billboards for delivery services such as Eaze, a San Francisco-based startup that has raised some $52 million in venture capital.
In places like this, weed is chic. But just a few freeway exits away, in largely black and Latino neighborhoods where cannabis was aggressively policed for decades, people saddled with criminal convictions for possessing or selling the plant still fight to clear criminal records standing in the way of basic necessities: employment, a rental apartment, or a loan. Marijuana legalization and the businesses that profit from it are accelerating faster than efforts to expunge criminal records, and help those affected by them participate in the so-called “Green Boom.” And the legal cannabis industry is in danger of becoming one more chapter in a long American tradition of disenfranchising people of color.
Here is more:
As the US teeters at the tipping point for marijuana going mainstream, it’s increasingly apparent that people and communities who were disproportionately punished for its criminalization were wronged. It’s a cruel footnote to the story of the plant’s legalization that punishment for past involvement with cannabis can remain a bar to entry in the lucrative newly legal industry. Now, policy-makers, entrepreneurs, activists, and everyday consumers are asking what reparations for those wrongs might look like.
Here’s one idea that many agree on: Those disproportionately affected by the War on Drugs—largely, black and Latino communities—should be first in line to benefit from the Green Boom, whether as business owners or beneficiaries of programs funded by earnings from the business.
The US’s legal weed explosion is an incredible story of de-stigmatization, entrepreneurship, and opportunity. It’s also at risk of becoming a staggering tale of hypocrisy, greed, and erasure. But as a deep-pocketed industry with political momentum, American cannabis is uniquely positioned to serve as a model for what racial reparations could look like.
“This is about harnessing the industry to embody the work of repair,” said Adam Vine, the founder of Cage Free Cannabis, an organization that pushes for “drug war reparations” in the form of criminal record expungement, job fairs, voter registration, health care, and social equity programs. “Otherwise,” he said. “Legalization is just theft.”
Go read the rest.
January 26, 2019 in Business laws and regulatory issues, Criminal justice developments and reforms, Race, Gender and Class Issues, Recreational Marijuana Commentary and Debate | Permalink | Comments (0)
NBC News has this new article, headlined "CBD goes mainstream as bars and coffee shops add weed-related drinks to menus," that is worth a read, and I especially liked its closing paragraph. Here are excerpts:
Coffee. Cocktails. Lotion. Dog treats. You name it, CBD is probably in it.
CBD, short for cannabidiol, is a compound found in the cannabis plant. It promises to deliver the calming benefits of marijuana without the high that comes from THC. Companies are adding CBD to just about everything — a trend set to accelerate as regulations ease and consumer interest grows.
Most CBD is now federally legal thanks to the farm bill President Donald Trump signed in December. Companies still aren't supposed to add CBD to food, drinks and dietary supplements, but many are doing it anyway. The Food and Drug Administration has said it plans to continue enforcing this ban but will also look into creating a pathway for such products to legally enter the market.
Some users swear by it, saying it relieves their anxiety, helps them sleep and eases their pain. And forget stoner stereotypes when thinking about CBD. Moms and even pets are experimenting with it. One research firm, Brightfield Group, expects the CBD market to reach $22 billion by 2022.
However, most of our current understanding of CBD is anecdotal — not proven through scientific studies. And because CBD products aren't yet regulated, the quality can vary widely. "There's a lot of interest and excitement, for good reason, but I think people are pushing it too hard, too fast and are overgeneralizing things," said Ryan Vandrey, a professor at Johns Hopkins who studies the behavioral pharmacology of cannabis.
We don't know what exactly CBD interacts with in the brain or the body, but researchers do know that CBD tends to turn down abnormal signaling in the brain, said Ken Mackie, a psychological and brain sciences professor at Indiana University. That's why CBD may help with epilepsy, anxiety and sleep. CBD and other cannabis compounds tweak systems in the body, a process he compares to lowering the volume. Other compounds, like opioids, ketamine and nicotine, simply turn them on and off.
There isn't much clinical research on the safety and efficacy of CBD. Studying cannabis has been challenging because it's technically illegal under federal law, meaning researchers must overcome a number of hurdles in order to study it. We don't know anything about indications like sleep, anxiety or pain, Vandrey said.
We do know it's safe and effective in treating seizures in children with Lennox-Gastaut syndrome or Dravet syndrome. GW Pharma studied its CBD-derived drug, Epidiolex, in numerous clinical trials. After reviewing the company's science, the Food and Drug Administration approved Epidiolex in June.
The lack of clinical evidence hasn't stopped consumers from trying it — and raving about it. "It's always nice to have strong proof in placebo controlled trials, but if someone's taking a drug and feeling any benefit, more power to them," Mackie said....
The farm bill signed in December legalized hemp. Most CBD hitting shelves is derived from the hemp plant, which contains less than 0.3 percent THC, the psychoactive chemical in weed. Hemp's close cousin, marijuana, can contain upwards of 10 percent THC. So you can't get high from CBD products if the proper dosage is followed, but the industry isn't regulated on a federal level so the amount of THC can vary.
Doses can vary, too. Some shops recommend six milligrams of CBD when taken as a tincture or added to food. Others recommend at least 30. Again, since there isn't much clinical research on CBD, most of the recommendations are based on trial and error.
As more people dabble with CBD, more people are following the money, worrying some that bad products will enter the market and taint CBD's allure. Or worse, harm consumers. "There does need to be some sort of regulatory framework for overall product safety and to protect the customer from purchasing products that contain false advertisements or make unsubstantiated claims," said Pamela Hadfield, co-founder of HelloMD, a medical cannabis company, while cautioning against strict regulations that would be "too difficult for most manufacturers to comply."
Joe Masse, beverage director at The Woodstock bar, added a CBD cocktail to the menu in September. Called The White Rabbit, the drink is made with Bombay Dry Gin, sage simple syrup, honey, fresh lemon juice and 1 milligram of CBD oil.... "It's trendy right now, so I don't know how it will be in six months when we redo the menu," Masse said. "A year ago, activated charcoal was popular and now you can't find it anywhere."
Because I am not hip enough to know that "sctivated charcoal" was once, and now is no longer, a big deal, I am not the right person to be predicting the trend lines on the CBD trend. But I do know how important and likely unpredictable it will be to see the FDA and/or state regulatory players take on CBD products and marketing in the wake of the new Farm Bill. Just another important front to watch in the coming months and years and marijuana products and industry players continue to emerge from prohibition's shadow.
January 26, 2019 in Business laws and regulatory issues, Federal Marijuana Laws, Policies and Practices, Food and Drink, History of Marijuana Laws in the United States, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (1)
Thursday, January 24, 2019
The title of this post is the title of this notable new report from the Reason Foundation authored by by Teri Moore and Adrian Moore. Here is part of its executive summary:
Recent wide-spread legalization of medical marijuana and, in many U.S. states, of recreational use of marijuana also, demands that officials must forge a just, coherent and effective law enforcement and legal response to marijuana-impaired driving. More and more states are legalizing marijuana for medical and recreational use, which demands policies toward marijuana-impaired driving that protect public safety without penalizing legal marijuana users who are sober at the time they drive.
Marijuana — or its more technical name, cannabis — and its effects are still quite literally under the microscope. Cannabis containing high levels of THC is typically used recreationally, but may also have therapeutic applications. Because it is the psychoactive component in cannabis, THC is the cannabinoid that impairs driving, and is therefore the focus of this study. This analysis examines the evidence on marijuana-impaired driving and lays the groundwork for a regulatory approach that is scientifically grounded, safetyminded and fair.
In the past 10 years, prevalence of alcohol use by drivers has fallen in the U.S., and use of marijuana has increased dramatically. Alcohol’s composition and effects on drivers have been thoroughly studied over the years and are well understood. It’s tempting to use a similar approach to that used for alcohol — the only other legal intoxicant — and to build policies around per se standards. But since cannabis body fluid levels don’t parallel impairment, that’s not a fair gauge of impairment as it is with alcohol. Indeed, it’s possible for some cannabis users to register above per se levels when completely sober. It’s also tempting to use the easy idea of zero tolerance, but that’s not fair to sober drivers who still have measurable cannabis in their systems.
The only fair solution is for police to assess drivers for impairment as we now do for low blood-alcohol-content impaired drivers and drug-impaired drivers, and to conduct toxicology screens to corroborate that cannabis is present, rather than measuring irrelevant levels in body fluids. Fortunately, screenings are less expensive, quicker and easier to do than measuring body fluid levels. It’s concerning that this means impairment will be assessed entirely by police officers, but that is the most just option currently available. To address this concern, police should use dash- and bodycams to document impairing behavior — such as driving behavior leading to the traffic stop and impairing behavior on field sobriety tests — when possible.
Wednesday, January 23, 2019
I am so very pleased to be able to be a part of an exciting panel discussion taking place next week, the "Ohio State Cannabiz Roundtable." The event is described at this website, where one can and should register ASAP. Here is the event description and expected participants:
With cannabis being illegal at the federal level but many states moving to legalize it for both medical and recreational purposes, how does one navigate this new emerging market properly? The birth of this new multi-billion industry is being accompanied by a lot of unusual challenges, risks, and opportunities. Please join us for a discussion of the various aspects of this market – dealing with regulations and legal questions, raising funds, working through a financial system that is disinclined to serve them, and running a new business in an unchartered territory. After our panel discussion, students and attendees will have a chance to speak to each panelist in a small group setting to ask questions and network. This is a unique opportunity to better understand the rapidly rising market of cannabis, don’t miss out!
January 31, 2019 at 9am -- 2nd Floor Rotunda, Mason Hall
Tuesday, January 22, 2019
In prior posts, I have noted here and here commentaries by the author of the new book by Alex Berenson, "Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence," as well as the lengthy Malcolm Gladwell New Yorker essay about the book. And in this post, I rounded up some of the major commentaries expressing concerns about Berenson's claims that more marijuana use is leading to more mental illness and more violence. In addition to collecting all these posts via links below, I also wanted to spotlight a few more notable commentaries in this space:
From Dave Levitan, "Reefer Madness 2.0: What Marijuana Science Says, and Doesn’t Say. A new book and New Yorker feature are filled with cherry-picked data, oversimplified studies, and scientific errors."
From Carl Hart and Charles Ksir, "Does marijuana use really cause psychotic disorders?: Alex Berenson says the drug causes ‘sharp increases in murders and aggravated assaults’. As scientists, we find his claims misinformed and reckless"
Prior related posts:
- Flagging concerns about potential links between marijuana, mental illness and violence
- Another notable commentary about the risks of marijuana legalization (without accounting for harms of prohibition)
- Malcolm Gladwell rightly highlights how much we do not know about marijuana (but still ignores what we know about prohibition)
- Rounding up commentary pushing back on efforts to link marijuana, psychosis and violence
The question in the title of this post is prompted by this USA Today story headlined "CBS rejects Super Bowl ad on benefits of medical marijuana." (And if you do not know what prop bets are, here is a primer: "Prop bets popular for Super Bowl, but NFL wants them gone.") Here are excepts from the ad story:
CBS rejected a Super Bowl ad that makes a case for medical marijuana. Acreage Holdings, which is in the cannabis cultivation, processing and dispensing business, said it produced a 60-second ad that shows three people suffering from varying health issues who say their lives were made better by use of medical marijuana.
Acreage said its ad agency sent storyboards for the ad to the network and received a return email that said: “CBS will not be accepting any ads for medical marijuana at this time.”
A CBS spokesperson told USA TODAY Sports that under CBS broadcast standards it does not currently accept cannabis-related advertising....
“We’re not particularly surprised that CBS and/or the NFL rejected the content,” Acreage president George Allen said. “And that is actually less a statement about them and more we think a statement about where we stand right now in this country.”...
“One of the hardest parts about this business is the ambiguity that we operate within,” Allen said. “We do the best we can to navigate a complex fabric of state and federal policy, much of which conflicts.”
Allen said the company had not decided whether to run its 60-second ad or a 30-second version when it learned that CBS would not accept any ads for medical marijuana. CBS is charging an average of $5.2 million for a 30-second ad in this year's game between the Los Angeles Rams and New England Patriots on Feb. 3.
“It’s a public service announcement really more than it is an advertisement,” said Harris Damashek, Acreage’s chief marketing officer. “We’re not marketing any of our products or retail in this spot.”
An unfinished version of the 60-second ad introduces a Colorado boy who suffers from Dravet syndrome; his mother says her son would have dozens to hundreds of seizures a day and medical marijuana saved his life. A Buffalo man says he was on opioids for 15 years after three back surgeries and that medical marijuana gave him his life back. An Oakland man who lost part of his leg in military service says his pain was unbearable until medical marijuana.
“The time is now,” say words on the screen near the end of the ad. Then the screen shifts and viewers are asked to call on their representatives in the U.S. House and Senate to advocate for change. Fine print at the bottom says the testimonials in the ad come from the experiences of the individuals and have not been evaluated by the FDA. The fine print also says marijuana is a Schedule I controlled substance and medical use has not been approved in some states....
Acreage expects to post the ad online at some point so people can see it, even if they can’t see it on the Super Bowl. “It’s not quite ready yet,” Damashek said, “but we anticipate and look forward to getting the message out far and wide.”
I have to admit to being a bit suspect of the idea that the Acreage folks were really planning to spend $10 million to run "a public service announcement" during SuperBowl LIII. Dare I speculate that they knew full well that their ad would be rejected, but also knew that simply asking and getting rejected would result in beneficial attention. And I suppose I am now guilty of giving them some of this desired attention (but I am at least asking a fun question along the way).
Speaking of that question, I will answer by foolishly predicting that there will be a marijuana ad during Super Bowl LVI in February 2022.
Sunday, January 20, 2019
The title of this post is the headline of this provocative Wall Street Journal commentary authored by Peter Bach, "a pulmonary physician at Memorial Sloan Kettering Cancer Center in New York [who] directs the Center for Health Policy and Outcomes." Here are excerpts:
Ten states and the District of Columbia have legalized recreational marijuana use, and another eight look likely to do so in 2019. I favor the move but am troubled by the gateway to it: All these jurisdictions first passed laws permitting the use of “medical” marijuana. We should set the record straight, lest young people (and old ones) think marijuana is good for you because it is wrongly labeled a medication.
Actual medicines have research behind them, enumerating their benefits, characterizing their harms, and ensuring the former supersedes the latter. Marijuana doesn’t. It’s a toxin, not a medicine. It impairs judgment and driving ability. It increases the risk of psychosis and schizophrenia. Smoking it damages the respiratory tract. A 2017 report from the National Academy of Medicine called the evidence for these harms “substantial.”
Claims that marijuana relieves pain may be true. But the clinical studies that have been done compare it with a placebo, not even a pain reliever like ibuprofen. That’s not the type of rigorous evaluation we pursue for medications. What’s more, every intoxicant would pass that sort of test because you don’t experience pain as acutely when you are high. If weed is a pain reliever, so is Budweiser.
Some advocates say marijuana is better than opiates for pain. Yet while opiates have risks, there are no studies comparing them to marijuana, and untested claims in medicine don’t get the benefit of the doubt. Testing such a hypothesis often disproves it.
Decades ago, several studies suggested that marijuana might relieve nausea in chemotherapy patients. But again most compared it with a placebo, while a few compared it with older nausea treatments not used today. None were very convincing. More important, no study has compared marijuana to today’s Neurokinin-1 antagonists. While such treatments are sometimes ineffective, that shortcoming doesn’t impart efficacy on marijuana either.
In writing medical-marijuana laws, state lawmakers and initiative authors have gone well beyond pain and nausea control, lauding the plant as an effective treatment for a long list of conditions, including hepatitis, Alzheimer’s and Parkinson’s. Beyond the lack of data, what these conditions have in common isn’t biology, but modern medicine’s failure to treat them satisfactorily. Heartbreaking as that is, marijuana isn’t the answer....
Marijuana belongs in the same category as alcohol and tobacco — harmful products that adults can choose to enjoy.... Decades passed before we took on smoking and drinking with education, labeling and other forms of regulation. But it worked, and deaths from lung cancer, heart disease and alcohol-associated accidents are in sharp decline. We need this same approach with marijuana. Acknowledging that it is not a medicine is a necessary first step.
I think it valuable and important to highlight ways in which many of the forms of the plant cannabis, at least right now, is not comparable to the kinds of medicines we access at a drug store. But it is also important to highlight ways in which medical marijuana laws do not treat marijuana as comparable to other medicines. For starters, public and private health insurance systems general do not help cover the cost of marijuana used medicinally and there are all sorts of distinctive limits on the whos and hows of medical marijuana access. In many ways, all modern medical marijuana laws are still just elaborate variations on the original law created by California in 1996, which simply created a limited exception to marijuana prohibition for those eager to try marijuana for various therapeutic purposes. Had marijuana never been criminalized, there would have been no need to seek exceptions from prohibition for medical uses (and, it bear recalling, there was much discussion and special laws around alcohol access for medical use during the Prohibition era).
January 20, 2019 in History of Alcohol Prohibition and Temperance Movements, History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (2)
Wednesday, January 16, 2019
Speculating about impact on the opioid crisis as Ohio finally sees its first legal medical marijuana sale
Here is a silly trivia question: How did some people in Ohio celebrate the 100-year anniversary of the ratification of the alcohol prohibition amendment?
Answer: By finally being able to purchase medical marijuana in the state legally.
Remarkably, it has taken more than 30 months form the Buckeye State to go from the passage of a medical marijuana law to the opening up of the first legal dispensaries. And, not surprisingly, this new NBC News piece is already asking whether this development will help with the state's opioid problems. Here are excerpts:
Leaning on her cane, Joan Caleodis stepped gingerly into history on Wednesday as one of the first people to legally purchase medical marijuana in the state of Ohio.
Caleodis, who is 55 and suffers from multiple sclerosis, paid $150 for three containers, each holding 2.83 grams of dried cannabis flowers, at the CY + Dispensary in the town of Wintersville.
“I’m feeling ecstatic,” Caleodis told reporters as other pain sufferers waiting in line applauded. “The patients no longer have to wait for relief. We can get rid of this opioid issue we have in this country.” Caleodis said she felt even better when she got home and tried out her purchase. “I was curious and I am very happy with the quality,” she told NBC News. “Some days are worse than others, but I am pretty much in constant pain and right now I am not.”
A former state worker who went on disability after 27 years on the job, Caleodis said she was prescribed opioids for pain after she was diagnosed with multiple sclerosis more than eight years ago. “I found myself taking double the amount prescribed and told myself, ‘I’m not going that route’,” she said. “This is definitely better.”
While medical marijuana is now available in the Buckeye State, it is unclear if the change will put a dent into the state's opioid epidemic. Ohio is one of “the top five states with the highest rates for opioid-related overdose deaths,” according to the National Institute on Drug Abuse.
Medical marijuana dispensaries are regulated in Ohio by the state Board of Pharmacy. When asked if the state views legal pot as a potential weapon in the battle against the deadly opioid epidemic, a Board spokesman replied, “The state has no official policy on this.”
The same question was posed to newly-installed Gov. Mike DeWine, who as attorney general sued the pharmaceutical companies for flooding his state with prescription painkillers. His team referred a reporter to the state Board of Pharmacy....
“There’s some suggestive evidence that marijuana may help to reduce opioid use,” Dr. Caleb Alexander, co-founder of the Center for Drug Safety and Effectivenesss at the Bloomberg School posted. “There’s also some evidence to the contrary.”
Rosalie Liccardo Pacula, co-director of the Drug Policy Research Center at the RAND Corporation said in the same forum that she was in favor of expanding medical marijuana programs, but added, “I do not believe that doing so will substantially impact the opioid epidemic. “
“Most people substituting cannabis for opioids are not using either drug medicinally,” she wrote. “Moreover, research does not suggest that cannabis is a substitute for heroin or fentanyl, the major drivers of the epidemic today.”
Mark Parrino of the American Association for the Treatment of Opioid Dependence said, “It is counterintuitive to advocate for the legalization of marijuana while our nation is struggling with an opioid use disorder epidemic.” “While medical use of marijuana may be beneficial in some cases, I do not think that it is reasonable to promote marijuana as a positive medical treatment,” he wrote.
Caleodis said anyone who thinks marijuana doesn’t help should take a walk in her shoes. She said she has used other “black market” cannabis products to easy her anguish over the years. “My symptoms are always there, I feel a burning in my feet just about all the time,” she said. “And at night it is way worse. Sometimes I just can’t sleep. But tonight I think I will.”
January 16, 2019 in History of Marijuana Laws in the United States, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (1)
Tuesday, January 15, 2019
The title of this post is the title of this great new book chapter authored by Lewis Grossman now available via SSRN. Here is its abstract:
The struggle for access to medical marijuana differs from most other battles for therapeutic freedom in American history because marijuana also has a popular, though controversial, nontherapeutic use — delivery of a recreational high. After considering struggles over the medical use of alcohol during prohibition as a precedent, this chapter relates the history of medical marijuana use and regulation in the United States. The bulk of the chapter focuses on the medical marijuana movement from the 1970s to present. This campaign has been one of the prime examples of a successful extrajudicial social movement for freedom of therapeutic choice. With the exception of a single promising decision in 1975, courts have uniformly rejected arguments for medical marijuana access. But the 1996 passage of Proposition 215 in California triggered a tremendous wave of state measures legalizing medical cannabis, as well as a dramatic change in American attitudes about the issue.
The chapter recounts this history in light of the special legal, political, and rhetorical challenges medical cannabis advocates have faced. First, many officials have opposed the legalization of medical marijuana, regardless of whether it offers therapeutic benefits, because of the public health harms and moral degradation they associate with the use of pot. Second, marijuana’s designation as a Schedule I substance under the Controlled Substances Act of 1970, and the DEA’s rejection of multiple citizen petitions to reclassify it, has placed extremely high obstacles in the way of researchers interested in scientifically assessing marijuana’s therapeutic efficacy. Third, federal government policies have lagged behind public preference and state law. Finally, medical marijuana supporters have had to negotiate an invaluable but fraught relationship with advocates for comprehensive marijuana legalization. The perspectives and goals of these two groups have overlapped and conflicted in fascinating and unexpected ways.
January 15, 2019 in History of Alcohol Prohibition and Temperance Movements, History of Marijuana Laws in the United States, Medical Marijuana Commentary and Debate, Medical Marijuana State Laws and Reforms | Permalink | Comments (1)
I have noted the new book by Alex Berenson, "Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence," through his recent commentaries spotlighted here and here, as well as through Malcolm Gladwell's New Yorker essay about the book. The core message of Berenson's book, namely that more marijuana use thanks to legal reforms is leading to more mental illness and more violence, is now generating a whole lot of push back. Here is just a partial round-up of new commentary expressing concerns about Berenson's claims:
By Aaron E. Carroll, "The Reasonable Way to View Marijuana’s Risks: Cannabis has downsides, but speculation and fear should be replaced with the best evidence available."
Also by Aaron E. Carroll, "A more thorough analysis of marijuana use and homicide in Colorado and Washington"
By James Hamblin, "If Legal Marijuana Leads to Murder, What’s Up in the Netherlands?: A terrifying argument that cannabis causes homicides sparks a debate over whether the drug is more dangerous than its criminalization."
By German Lopez, "What Alex Berenson’s new book gets wrong about marijuana, psychosis, and violence: The book, Tell Your Children, has received a lot of media attention, but it’s essentially Reefer Madness 2.0."
By Jesse Signal, "Did Marijuana Legalization Really Increase Homicide Rates?"
The debates over the data and how to respond to what we know and do not know is fascinating. And, helpfully, this morning The Marshall Project has this great new piece headlined "How Dangerous is Marijuana, Really? A Marshall Project virtual roundtable." Here is how the Marshall Project sets up a fascinating discussion:
On Jan. 7, The Marshall Project published an interview with Alex Berenson, a former New York Times reporter and author of "Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence," which warns that the rush to legalize the drug has obscured evidence of its dangers. The interview stirred up a storm on social media, so we decided to enlarge the discussion.
What follows is a conversation, conducted by email and moderated by Bill Keller, editor-in-chief of The Marshall Project. Berenson is joined by three other panelists. Maria McFarland Sánchez-Moreno is the executive director of the Drug Policy Alliance, a non-profit that advocates ending the war on drugs, including the "responsible regulation" of marijuana. Its donors include companies in the legal, for-profit cannabis industry, whose gifts, the group reports, made up less than 1 percent of the alliance’s 2018 revenue. Keith Humphreys is the Esther Ting Memorial Professor at Stanford University. He has been deeply involved in drug policy as a researcher and White House advisor. Mark A.R. Kleiman is a professor of public policy at the New York University Marron Institute of Urban Management, where he leads the crime and justice program. He is also chairman of BOTEC Analysis, which advises Washington State and Maine on cannabis regulation.
The discussion has been lightly edited for length and clarity.
The Marshall Project: This first question is for all of you. Let's start with the core question Alex set out to answer in reporting his book: What do we know about the connection between marijuana and mental illness? What would you say is established medical science, and what is still unresolved?
Monday, January 14, 2019
The title of this post is the title of this new Guardian piece. I have reprinted some excerpts of the piece below, though the piece does not make all that serious an effort to figure out whether and why marijuana may be proving more popular with the AARP crowd. But, in all likelihood, I have flagged this piece because I wanted an excuse to reprint here the remarkably curious graphic that goes with it. I am thinking that the old-looking television in the graphic is supposed to be showing Mr. Ed, but I cannot figure out what is up with the smiling clown. In any event, here is some of the text that follows this trippy picture:
As attitudes towards cannabis shift, the fastest-growing group of users is over 50 – and marijuana’s popularity among seniors is beginning to change the American experience of old age.
Why are more seniors getting high? It might make more sense to ask: “Why not?” As adults reach retirement, they age out of drug tests and have far more time on their hands. Some feel liberated to abandon long-held proprieties.
Elegant vape pens and other attractive, discreet products have helped de stigmatize the drug among older Americans. “Legalization seems to make non-users seem a little less scared of it, and perhaps less judgmental,” says Jo, a 56-year-old cannabis user who preferred not to use her real name.
The seniors using cannabis today aren’t your parents’ grandparents. The generation that camped out at Woodstock is now in its seventies. They’ve been around grass long enough to realize it’s not going to kill them, and are more open to the possibility it will come with health benefits....
Seniors’ affinity for weed is beginning to ripple across the US healthcare system. A 2016 study found that in states with access to medical marijuana, those using Medicare part D – a benefit primarily for seniors – received fewer prescriptions for other drugs to treat depression, anxiety, pain, and other chronic issues....
While some doctors have expressed concerns about seniors self-medicating with weed, virtually everyone agrees the public health consequences of opioids are far worse. And the most serious health concerns associated with marijuana, such as impaired brain development, tend to affect younger people.
For the industry, seniors’ newfound interest in cannabis is a business opportunity. The Colorado edibles company Wana Brands, among many others, sells cannabis products reminiscent of medicines familiar to seniors. Wana sells extended release capsules as well as products with different ratios of THC and CBD, which intoxicate users to different degrees and can have a variety of effects on ailments.
For someone who hasn’t seen a joint in 40 years, the modern dispensary can be a dizzying experience replete with dozens of products – topicals (lotions), tinctures, sprays – all promising to help you feel better, but also to get you stoned. Whether or not marijuana helps seniors to alleviate their conditions, many may enjoy a sense of control over their own wellbeing. Meanwhile, dispensaries in California and elsewhere cater to older clientele with discounts and shuttle busses. Dispensary owners like to brag about how many older women come in as evidence that they’re created an attractive and welcoming store.
For another recent press piece related to this topic, Forbes ran over the weekend this article headlined "Cannabis Club Fills Info Gap For California Seniors"
Sunday, January 13, 2019
Maryland Medical Cannabis Commission report explores treatment of opioid use disorder by using medical cannabis
The debate over the relationship between the opioid crisis and marijuana reforms is so very interesting and, of course, so very important. Advocates for and against marijuana reform seem ever eager to leverage the opioid crisis (and everything else) to support their prior conclusions about the virtues or vices of marijuana reform. Against this backdrop, I think information from non-partisans is especially valuable, and thus I was pleased to see this notable new report from the Maryland Medical Cannabis Commission titled "Treatment of Opioid Use Disorder with Medical Cannabis." I recommend the full report, which mostly just reports on the state of the law in many jurisdictions and research on these topics. Here are excerpts:
Since 2016, at least nine states have considered legislation or regulations to allow medical cannabis as an opioid replacement therapy to help ease withdrawal symptoms and aid in relapse prevention.... In 2018, Pennsylvania, New Jersey, and New York became the first states to expressly allow medical cannabis for the treatment of OUD. Each state permits the use of medical cannabis to treat OUD, but with significant restrictions....
From 2016-2018, at least seven state legislatures considered bills that would expressly add OUD to the list of medical cannabis qualifying conditions. Of these, the majority rejected the legislation seeking to add OUD to the list of qualifying conditions. [T]hree states – Hawaii, Maine, and New Mexico – passed legislation authorizing the use of medical cannabis to treat OUD; however, the State’s Governor vetoed the legislation in each instance following significant pressure from health care providers, health care organizations, and addiction specialists....
Data suggest that cannabis legalization reduces prescription opioid use by serving as an alternative pain treatment. Medical cannabis laws may also have downstream policy effects on reducing opioid-related hospitalizations, overdose deaths, and traffic fatalities. The following section examines existing literature on the association between medical cannabis and opioid use, including as a treatment for opioid use disorder....
[But] a study was published in the “To the Editor” section of JAMA Internal Medicine in September 2018, which found that the opioid-related overdose death rate was accelerating in states where medical and/or adult use cannabis laws had been implemented. Moreover, the death rate surpassed that of nonlegalizing states. The study reviewed opioid-related overdose death data from 2010 to 2016, and determined that the age-adjusted death rate was higher in states with cannabis legalization and that the age-adjusted death rate was increasing at a faster rate than in non-legalizing states. While several researchers have challenged the methodology of this study – including the inaccurate assessment of states that have legalized medical and adultuse cannabis – the results call attention to the need for further investigation of the association between cannabis legalization and opioid-related overdose deaths....
In December 2018, the Commission received two petitions requesting the addition of OUD to the list of medical cannabis qualifying conditions. If the Commission determines that either or both of these petitions are “facially substantial” then it must conduct a public hearing within the next 12 months to evaluate whether the medical condition or disease should be included in the list of qualifying conditions. The Commission’s Research Committee, which includes two physicians, a scientist, addiction specialist, and horticulturist, is currently evaluating the petitions to determine whether they are facially substantial and require a public hearing. The Commission will provide the General Assembly with updates on the status of the OUD petitions, including information on any public hearings to consider adding OUD as a qualifying medical condition.
January 13, 2019 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)
Saturday, January 12, 2019
The title of this post is the headline of this recent commentary in USA Today authored by DJ Jaffe, who is the executive director of Mental Illness Policy Org. Here is an excerpt:
Before legislators legalize marijuana, they should require bold and direct warning labels to be placed on the packaging as is done with tobacco products. If the states fail to act, then the Food and Drug Administration should step in and require it.
In early 2017, after exhaustive review, the National Academies of Sciences, Engineering, and Medicine found that there are significant health risks associated with using cannabis and cannabinoids. Yet none of the 33 states that have legalized medical marijuana, or the 10 states that have legalized recreational use, gives adequate warnings of those risks.
The situation is similar to when cigarettes first became extensively marketed. The health risks were known but not disclosed, leading to disease and lives being lost. In addition to appearing on the packaging, the warning labels should be displayed prominently wherever the product is sold, in advertising and in mandated public service announcements funded by the marijuana industry.
The academies, founded by Congress, comprise the country’s leading researchers. They have become the nation’s most reputable arbiters of the science that should guide policy. The findings of the report, "The Health Effects of Cannabis and Cannabinoids," were particularly disturbing for people prone to mental illness and those who have a mental illness.
The report found either substantial or moderate evidence of an association between cannabis use and the development of schizophrenia or other psychoses; increased symptoms of mania and hypomania in individuals diagnosed with bipolar disorders; increased risk for the development of depressive disorders; and increased incidence of suicidal ideation, attempts and completions.
Schizophrenia and bipolar disorders are two of the most devastating neurobiological disorders and the ones that are often associated with homelessness and incarceration. If there is an association with using legalized marijuana, shouldn’t the public be warned?...
Washington and Colorado were the first states to legalize recreational marijuana. While both warn pregnant mothers not to use it, the only other significant warning on the packaging is that there “may be health risks,” a watered-down mealy mouthed warning that fails to give consumers the concrete information they need to avoid danger.
While the National Academies found "association," association is not the same as causality. Perhaps the increased risk of schizophrenia developing is because those who are prone to schizophrenia also are prone to use these products.
But until we know the chicken-or-egg answer, we should not follow the example of the tobacco regulation where the product was allowed to be marketed unencumbered by warnings, leading to more than 480,000 deaths a year, and subsequently the spending of millions of dollars re-educating consumers who had been misled in the first place.
Thursday, January 10, 2019
The title of this post is the title of this notable new study just published in the journal Drug and Alcohol Dependence. Here is its abstract:
Driving under the influence of cannabis (DUIC) is a public health concern among those using medical cannabis. Understanding behaviors contributing to DUIC can inform prevention efforts. We evaluated three past 6-month DUIC behaviors among medical cannabis users with chronic pain.
Adults (N = 790) seeking medical cannabis certification or recertification for moderate/severe pain were recruited from February 2014 through June 2015 at Michigan medical cannabis clinics. About half of participants were male (52%) and 81% were White; their Mean age was 45.8 years. Participants completed survey measures of DUIC (driving within 2 h of use, driving while “a little high,” and driving while “very high”) and background factors (demographics, alcohol use, etc.). Unadjusted and adjusted logistic regressions were used to examine correlates of DUIC.
For the past 6 months, DUIC within 2 h of use was reported by 56.4% of the sample, DUIC while a “little high” was reported by 50.5%, and “very high” was reported by 21.1%. G reater cannabis quantity consumed and binge drinking were generally associated with DUIC behaviors. Higher pain was associated with lower likelihood of DUIC. Findings vary somewhat across DUIC measures.
The prevalence of DUIC is concerning, with more research needed on how to best measure DUIC. Prevention messaging for DUIC may be enhanced by addressing alcohol co-consumption.
Another exciting time to be discussing (too many) international, federal, state and local developments as I start fifth iteration of my Marijuana Law, Policy & Reform seminar
I have lately been gearing up to start teaching today the fifth(!) iteration of my Marijuana Law, Policy & Reform seminar at The Ohio State University Moritz College of Law. When I first started teaching this course, way back in Fall 2013, the prospect of significant marijuana reforms in Ohio seemed like a pipe dream (see what I did there!). But here are just some of the notable headlines from some local Ohio outlets just this week:
The last of these links is, technically, a federal marijuana reform story. But I included it here, and picked the lengthy title for this post, because I feel like this year I am "drinking out of a fire hose" even more than usual when teaching about Marijuana Law, Policy and Reform. In prior years, there were a few stories in a few jurisdictions to follow on a weekly basis; now it seems like there are important developments in dozens of jurisdictions every single day. I am extra exciting to see what topics are of special interests to my students, and blog readers will get to come along for the ride when student being their projects and presentations in a few months.
Wednesday, January 9, 2019
The title of this post is the title of this new Civilized piece with an interesting factoid about employment in the marijuana industry. Here are the particulars (with links from the original to a notable infographic):
If there's any marker that the cannabis industry isn't slowing down, it's just how many people are now working in it.
In 2018 there were somewhere between 125,000 and 160,000 working in the legal cannabis industry, according to an infographic released by Cali Extractions using data from Statista and Marijuana Business Daily. That's no small jump up from just last year where there were only 90,000–110,000 cannabis industry workers.
That means there are more people working in state-legalized cannabis industries than there are pilots or librarians in America. And next year cannabis jobs look like they'll overtake the number of kindergarten teachers and bus drivers.
"Since 2016, revenue from cannabis has almost doubled—not many industries can show that kind of growth, even in the salad days," reads the a statement released with the infographic.
Tuesday, January 8, 2019
Malcolm Gladwell rightly highlights how much we do not know about marijuana (but still ignores what we know about prohibition)
Malcolm Gladwell has this new extended essay in The New Yorker asking "Is Marijuana as Safe as We Think?". The piece is somewhat focused on the forthcoming book by Alex Berenson (whose recent commentaries I have covered here and here), but it is most effective when it highlights that research on the public health consequences of marijuana remains incomplete and inconclusive. Here is how the piece starts:
A few years ago, the National Academy of Medicine convened a panel of sixteen leading medical experts to analyze the scientific literature on cannabis. The report they prepared, which came out in January of 2017, runs to four hundred and sixty-eight pages. It contains no bombshells or surprises, which perhaps explains why it went largely unnoticed. It simply stated, over and over again, that a drug North Americans have become enthusiastic about remains a mystery.
For example, smoking pot is widely supposed to diminish the nausea associated with chemotherapy. But, the panel pointed out, “there are no good-quality randomized trials investigating this option.” We have evidence for marijuana as a treatment for pain, but “very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.” The caveats continue. Is it good for epilepsy? “Insufficient evidence.” Tourette’s syndrome? Limited evidence. A.L.S., Huntington’s, and Parkinson’s? Insufficient evidence. Irritable-bowel syndrome? Insufficient evidence. Dementia and glaucoma? Probably not. Anxiety? Maybe. Depression? Probably not.
Then come Chapters 5 through 13, the heart of the report, which concern marijuana’s potential risks. The haze of uncertainty continues. Does the use of cannabis increase the likelihood of fatal car accidents? Yes. By how much? Unclear. Does it affect motivation and cognition? Hard to say, but probably. Does it affect employment prospects? Probably. Will it impair academic achievement? Limited evidence. This goes on for pages.
We need proper studies, the panel concluded, on the health effects of cannabis on children and teen-agers and pregnant women and breast-feeding mothers and “older populations” and “heavy cannabis users”; in other words, on everyone except the college student who smokes a joint once a month.
Gladwell later provides some context for how we should approach modern marijuana reform in light of all this uncertainty:
Drug policy is always clearest at the fringes. Illegal opioids are at one end. They are dangerous. Manufacturers and distributors belong in prison, and users belong in drug-treatment programs. The cannabis industry would have us believe that its product, like coffee, belongs at the other end of the continuum. “Flow Kana partners with independent multi-generational farmers who cultivate under full sun, sustainably, and in small batches,” the promotional literature for one California cannabis brand reads. “Using only organic methods, these stewards of the land have spent their lives balancing a unique and harmonious relationship between the farm, the genetics and the terroir.” But cannabis is not coffee. It’s somewhere in the middle. The experience of most users is relatively benign and predictable; the experience of a few, at the margins, is not. Products or behaviors that have that kind of muddled risk profile are confusing, because it is very difficult for those in the benign middle to appreciate the experiences of those at the statistical tails. Low-frequency risks also take longer and are far harder to quantify, and the lesson of “Tell Your Children” and the National Academy report is that we aren’t yet in a position to do so. For the moment, cannabis probably belongs in the category of substances that society permits but simultaneously discourages. Cigarettes are heavily taxed, and smoking is prohibited in most workplaces and public spaces. Alcohol can’t be sold without a license and is kept out of the hands of children. Prescription drugs have rules about dosages, labels that describe their risks, and policies that govern their availability. The advice that seasoned potheads sometimes give new users — “start low and go slow” — is probably good advice for society as a whole, at least until we better understand what we are dealing with.
I am not inclined to dispute much of what Gladwell has to say in this piece especially when he stresses uncertainty, but I am again eager to highlight what he ignores about the certain harms of prohibition. Notably, we still send a whole lot of drug users to prison rather than to treatment programs because of the "drug war" approach to criminalizing drug prohibitions, and we still arrest a whole lot of marijuana users. Moreover and even more importantly, the certain harms of marijuana prohibition are borne disproportionately by people of color and the poor.
I am supportive of a "start low and go slow” approach to the commercialization of marijuana based on all the uncertainty that Gladwell is eager to stress. But given the certain harms of prohibition and who is disproportionately subject to them, I do not think we can end the criminalization of marijuana soon enough.