NFL abuse of painkillers and other drugs described in court filings

Sealed court documents viewed by The Washington Post describe widespread abuse of painkillers and other drugs by the National Football League.
National Football League
The sealed material, which was reviewed by The Washington Post, provides a rare look into the league’s relationship with drugs and how team doctors manage the pain inherent in a bruising sport to keep players on the field.
Federal law lays out strict guidelines for how teams can handle and dispense prescription drugs. The sealed court filing, which includes testimony and documents by team and league medical personnel, describes multiple instances in which team and league officials were made aware of abuses, record-keeping problems and even violations of federal law and were either slow in responding or failed to comply.
The filing, which was prepared by lawyers for the players suing the league, asserts that “every doctor deposed so far . . . has testified that they violated one or more” federal drug laws and regulations “while serving in their capacity as a team doctor.” Anthony Yates, the Pittsburgh Steelers’ team doctor and past president of the NFL Physicians Society, testified in a deposition that “a majority of clubs as of 2010 had trainers controlling and handling prescription medications and controlled substances when they should not have,” the filing states.
At times, team medical staff displayed a cavalier attitude toward federal guidelines that govern dispensing medicine. In August 2009, for example, Paul Sparling, the Cincinnati Bengals’ head trainer, wrote in an email: “Can you have your office fax a copy of your DEA certificate to me? I need it for my records when the NFL ‘pill counters’ come to see if we are doing things right. Don’t worry, I’m pretty good at keeping them off the trail!”
The Bengals did not make Sparling available for comment or respond to questions about his 2010 email.
NFL spokesman Brian McCarthy said the allegations contained in the court filing “are meritless and the league and its clubs will continue to vigorously defend these claims.”
“The NFL clubs and their medical staffs are all in compliance with the Controlled Substances Act,” McCarthy said in an email. “. . . The NFL clubs and their medical staffs continue to put the health and safety of our players first, providing all NFL players with the highest quality medical care. Any claim or suggestion to the contrary is simply wrong.”
The details and communications were unearthed by lawyers representing more than 1,800 former professional football players who are suing the league in U.S. District Court in Northern California, claiming they suffer long-term organ and joint damage, among other maladies, as a result of improper and deceptive drug distribution practices by NFL teams.
The material was collected by the players’ attorneys as part of the discovery process in the case. The attorneys redacted large portions of the 127-page complaint because both parties had agreed to do so under a court-approved protective order, sealing it from public view. The Post was able to review the redacted information because of an apparent technical error in the filing process but not some of the supporting exhibits and documents.
The filing solely reflects the ex-players’ claims against the NFL’s 32 teams, presenting their legal arguments and evidence to the court. Steven Silverman, the plaintiffs’ attorney, said he could not comment.
The court filing reveals that the teams dispensed painkillers and prescription-strength anti-inflammatories in numbers far beyond anything previously acknowledged or made public. In the calendar year of 2012, for example, the average team prescribed nearly 5,777 doses of nonsteroidal anti-inflammatory drugs and 2,213 doses of controlled medications to its players, according to a March 2013 internal document from Lawrence Brown, the NFL-employed medical adviser who oversees its drug issues.
Those numbers could average out to about six to seven pain pills or injections a week per player over the course of a typical NFL season, but sports medicine experts noted that it’s unlikely the drugs were distributed evenly over the entire roster and just as unlikely that team logs represent the full extent of medications players seek out to manage pain.
“It sounds like an incredible amount of intervention with some pretty risky drugs, some of which, in the case of Vicodin, have a high addiction potential,” said Arthur Caplan, director of the Division of Medical Ethics at New York University’s Langone Medical Center and co-founder of the NYU Sports and Society Program. “It makes you think, are the physicians looking out for the health of the players, or are they just trying to keep them on the field?”
Minnesota Vikings trainer Eric Sugarman, here working with running back Adrian Peterson in 2012 while Peterson recovered from knee surgery, once lamented that his team was not using a painkiller other teams were utilizing. (Jim Mone /Associated Press)
Drug experts who reviewed the data for The Post cautioned that a thorough understanding of the league’s use of pain medication is limited without knowing the exact dosages, types of controlled substances administered and whether all the players on a team were consuming the medications or whether a smaller number accounted for a larger percentage of the drug use.
The filing likens painkillers to performance-enhancing drugs and says while players often felt compelled to use them to contribute to their teams, medical staffs felt pressured to administer them to remain competitive. A February 2006 memo included in the court filing was from the Minnesota Vikings’ head trainer, Eric Sugarman. Writing to then-head coach Brad Childress and the team’s vice president for operations, the trainer said he had met for three hours with team physician David Fischer and lamented that the Vikings were not regularly using a powerful painkiller called Toradol, as other teams were.
“I expressed my concern that [the Vikings] are at a competitive disadvantage. . . . I feel very strongly about this point,” he wrote. “. . . I feel that Dr. Fischer is beginning to see my point of view on many issues. I also feel he is willing to change to improve.”
The Vikings did not respond to requests for comment or to make Sugarman or Fischer available.
Disregarding federal laws
Health and safety practices in the NFL have been under scrutiny in recent years, most notably regarding head trauma from concussions and other long-term health issues faced by former players. The court filing gives a glimpse behind the league’s medical curtain, revealing some of the NFL’s internal discussions and attitudes toward managing pain.
In their filing, the players’ lawyers cite multiple instances in which team executives and league officials were made aware of issues surrounding the handling of pain medication. League medical advisers Brown and Elliott Pellman communicated with team physicians on issues such as medication abuse and attended meetings of the NFL Physicians Society. For example, the complaint cites a 1998 meeting of the society in which Brown reported that during an audit, at least “5 teams were in noncompliance with controlled substances.”
The NFL declined to make the medical advisers available to comment.
Bud Carpenter, the Buffalo Bills’ longtime trainer, “admitted under oath that he witnessed team doctors give players injections of prescription medications without telling them what the drug was they were receiving or its side effects. . . . He further testified that doctors provided prescription medications at places other than where they were allowed to do so in violation of federal and state laws.”
The Bills declined to comment on the remarks or make Carpenter or other team medical personnel available.
The former players say the teams intentionally disregarded federal laws and openly acknowledged their compliance problems. In the complaint, lawyers say “numerous documents obtained during discovery show how Clubs and their doctors and trainers concealed their illegal activities for years.”
Bengals trainer Paul Sparling attends to outside linebacker Vontaze Burfict in a 2014 preseason game. (Tony Tribble/Associated Press)
For example, in a May 2010 email, Pepper Burruss, the Green Bay Packers’ longtime trainer, wrote to his counterpart with the Steelers: “I expect no immediate guidance from Dr. Brown or Dr. Pellman, other than ‘cover your own behind.’ ”
A Packers spokesman declined to comment or to make Burruss available.
The complaint alleges that the NFL has been plagued by prescription drug problems for decades. The league’s former drug adviser, Forrest Tennant, issued a report in May 1990 that stated, in part, “[s]ome Clubs don’t seem to know which drugs are controlled substances, and some don’t apparently understand the necessity (and law) to keep dispensing logs and an internal audit.” Another league document, produced in September 2014, called “NFL Prescription Drug Program Advisory Committee Major Findings and Recommendations,” reported the “non-physician administration and/or dispensing of medications occurs at many Clubs,” the complaint states.
Federal law bars nonlicensed team personnel, such as athletic trainers, from dispensing medication. The complaint cites multiple instances in which clubs were warned about this practice, including letters from Brown to the Bengals, Kansas City Chiefs and Tennessee Titans.
Elliott Pellman , right, helps running back Cedric Houston off the field in 2006 when Pellman was head of the medical department of the New York Jets, along with team orthopedist Elliott Hershman. (Tom Berg/Getty Images)
In 2010, the DEA began a crackdown on the league’s practices after a San Diego Chargers player caught in a traffic stop was found to be in possession of 100 doses of Vicodin. David Chao, the Chargers’ team doctor at the time, operated under a cloud of controversy before leaving the team in 2013 as the NFL Players Association called for his ouster, the DEA scrutinized his practices and the California state medical board revoked his license before deciding to put him on a five-year probation.
In August 2010, seven doctors from the NFL Physicians Society convened on a conference call with Pellman, the league’s medical adviser, to discuss the DEA’s new interest in their practices. The lawsuit quotes an unattributed remark from the minutes of the conference call: “We don’t want to give them the fodder that we have all been doing this wrong. We don’t want to show our deficiencies.”
The minutes of the call reflect that Pellman and at least two other team doctors met with DEA officials to discuss the investigation and the NFL’s practices, according to the documents. The DEA gave the physicians a 78-slide presentation on laws governing handling of controlled substances — including restrictions on transporting drugs across state lines — and a warning that there were no special exemptions for the league, the plaintiffs’ complaint states.
McCarthy, the NFL spokesman, said the DEA was invited to meet with team medical staffs “to ensure compliance” and “to ensure they are properly educated on federal law and aware of the risk of noncompliance.”
Buffalo Bills team doctor John Marzo testified he traveled and administered controlled substances during road games. (Don Heupel/Associated Press)
Yet even after the DEA began to instruct and pressure the league, the lawsuit charges that doctors still did not come into compliance. According to the sealed court filing, Buffalo’s team physician, John Marzo, testified in a deposition that after the DEA made its presentation to league physicians in 2011, he continued to travel with and administer controlled substances during road games.
In January 2012, Daniel Cooper, the Dallas Cowboys’ team doctor, wrote his congressman, urging a change to the Controlled Substances Act that would accommodate NFL teams. Cooper stated that for “decades under current law, team doctors have illegally [yet unknowingly] transported and administered medications to injured players while covering games away from home.”
The league didn’t bring teams into compliance until 2015, when it instituted the “visiting team medical liaison program,” which allows team physicians to use local doctors to prescribe and distribute controlled substances while on the road. The new program called for a stark departure in the way drugs were administered before, during and after games — and was met with resistance.
In a November 2010 email, Sparling, the Bengals’ trainer, wrote to his counterpart with the Detroit Lions, complaining about the new program. “Until the new [program] is actually in effect,” he said, “we will continue to do as we have done for the past 42 years. . . . I sure would love to know who blew up the system that worked all these years.”
The program did not take effect until 2015, after the DEA again applied pressure. According to the deposition of Yates, the Steelers’ doctor cited in the lawsuit, the impetus was a series of DEA raids conducted in October 2014 to see whether teams were traveling with controlled substances. The lawsuit states that NFL teams were tipped off by a DEA employee in advance of the raids, and “not surprisingly, none of them were carrying controlled substances.”
The Steelers declined to make Yates available for comment.
Packers head athletic trainer Pepper Burruss embraces quarterback Brett Favre in 2015. (Todd Rosenberg/Associated Press)
Reliance on pharmaceuticals
The case marks a rare instance in which the attorneys suing the NFL and seeking damages on behalf of players have gone to discovery. Cases often are preempted by the labor deal between the NFL and its players’ union because the collective bargaining agreement provides other avenues to settle grievances, such as arbitration.
The plaintiffs, though, are suing each of the 32 NFL teams rather than the league as a whole, and in July, U.S. District Judge William Alsup allowed this one to continue on the grounds that the plaintiffs’ allegations fall under the “illegality exception” to the collective bargaining rule. The exception states that parties to a collective bargaining agreement cannot contract for or immunize illegal conduct.
The powerful anti-inflammatory Toradol is often administered to players before games. (Alamy Stock Photo)
Since then, plaintiffs’ lawyers have been interviewing potential witnesses under oath — including at least 11 team and league medical officials — and compiling pertinent documents, such as drug logs and communications between team executives. While the case isn’t scheduled for trial until October, the players’ attorneys say in their filing they already have compiled “hundreds of thousands of pages of documents.”
The complaint recounts specific allegations against each of the 32 teams and details the widespread mishandling and disbursement of medications. “These doctors and trainers dispensed the Medications to their football patients in an amount and manner they would never do with their non-football patients,” the ex-players said in their complaint.
Clubs distributed the drugs not just during and after games but beforehand to blunt the effects of potential injuries, according to the complaint.
A January 2010 email from a New York Jets assistant trainer revealed that team’s use in 2008: 1,031 doses of Toradol and 1,295 doses of Vicodin. The following season the Jets’ use of Toradol increased to 1,178 doses and of Vicodin to 1,564 doses.
Toradol, a nonsteroidal anti-inflammatory often used to manage short-term postoperative pain, deadens feeling and inhibits the body’s ability to sense injury. The opiate Vicodin also relieves and masks pain, but unlike Toradol, it is highly addictive.
According to the March 2013 document from Brown, the Steelers provided its players 7,442 doses of NSAIDs in 2012 — only the 10th most in the league that year — and 2,123 doses of unnamed controlled medications — the 14th most.
“It’s a lot of pills, but there’s also a lot of information we still don’t know,” said Linda Cottler, the founding chair of the Department of Epidemiology at the University of Florida’s College of Public Health and Health Professions.
In 2011, Cottler, who has helped advise the league in the past on prescription drugs, led the most comprehensive study to date on painkiller use in the NFL, surveying 644 retired NFL players. More than half the respondents said they used opioids during their NFL careers, and seven in 10 admitted to misusing the drugs. Of that group, 22 percent said they took six or more pills each day during their playing careers, the highest amount reported in the survey.
That study found that 7 percent of the former players were still actively using opioid drugs in retirement — more than four times the rate of opioid use in the general population at the time.
The sealed documents might not provide a full picture of the league’s use of pain medications, but they do offer snapshots of how much teams rely on pharmaceuticals to put their players on the field each week. According to the court filing: The Atlanta Falcons spent nearly $100,000 on prescriptions in a single year — nearly three times the league average; a Bengals trainer said he’s aware of teams that dispense 90 or more Vicodin pills per game; one drug inventory showed that during seven months of 2004, the Indianapolis Colts administered 900 doses of Toradol and 585 doses of Vicodin.
Representatives for the Falcons, Jets and Steelers declined to comment. The Colts did not respond to a request for comment.
The former players also allege in the complaint that they weren’t always sure what medicines they were taking and weren’t advised of the risks, because team doctors and trainers failed to inform them and keep proper records.
A January 2008 memo from the Vikings’ head trainer documented how sloppy the record-keeping could be. “Here is week 17’s fiasco,” he wrote, according to the sealed documents, before detailing how the team’s logs didn’t match the inventory. And a May 2010 email cited in the court filing showed that the Falcons’ logs didn’t match the league’s audit report for at least four medications. The team was also on the DEA’s “radar” for the large amounts of controlled substances it had ordered, according to court records.
Lining up for the ‘T Train’
One drug in particular is highlighted throughout the lawsuit as a staple for NFL teams. Toradol is available only with a prescription. Though not addictive, it is powerful enough that many countries only administer it in hospitals and only after surgery. The lawsuit claims teams would freely offer it each Sunday to numb existing injuries but also in anticipation of the inevitable aches and pains accrued each Sunday.
A 2002 study found that 28 of the 30 teams that responded to a questionnaire administered Toradol injections — 15 players each game day on average. Though team physicians have been aware that such use was “off label,” the practice continued for more than a decade. In the 2013 Post survey of retired players, 50 percent of those who retired in the 1990s or later reported using Toradol during their careers, including seven out of 10 who retired in 2000 or later.
In 2012, an NFL Physicians Society task force was formed to study the drug and to “formulate a ‘best practice’ recommendation,” according to an email cited in the court filings from Matt Matava, the St. Louis Rams’ team doctor and the society’s former head. The task force was funded by the league office, and the lawsuit cites emails obtained during discovery that show Matava met with league Commissioner Roger Goodell in New York to discuss the task force in January 2012.
Though Matava’s task force recommended that Toradol not be used in anticipation of pain, it cited “unique clinical challenges of the NFL” and stated that each physician should practice medicine “as he or she feels is in the best interest of the patient.”
Toradol continued to be used heavily in the wake of the recommendation. The sealed court filing also cites a 2014 survey that included responses from 27 teams. On average, 26.7 players — more than half the active roster — took at least one dose of Toradol on game day.
According to the sealed court filing, months after the task force issued its recommendations, Matava emailed Yates, the Steelers’ doctor, questioning the team physicians who failed to respond to surveys regarding Toradol usage. “If these guys want to give Toradol because they think it is needed or acceptable, then they should . . . say so. What are they afraid of?” Matava, who did not respond to a request for comment, wrote in the same email that “[c]ontinued use of Toradol in the present climate is not rational.”
But apparently it is still in practice. According to the sealed filing, Yates testified in his deposition that “that even last season, he witnessed players lining up for the ‘T Train’ — Toradol injections before a game.”
Correction
An earlier version of this article reported that David Chao, the San Diego Chargers team doctor, had issued 100 does of Vicodin found in possession of a Chargers player caught in a traffic stop in 2010. Chao has denied issuing the Vicodin to the player. The assertion was included in the filing by lawyers for former players suing the league but The Post does not have corroborating evidence to support it.
From the archives:
The Post’s NFL Medicine Series
Medical care in the NFL is turned on its head
Pain and drugs in the NFL
Who pays for the insurance?
The physical price of an NFL career
Liability for the past


Find information about the popularity of traditional painkillers, anti-anxiety medications and anti-nausea drugs in states that adopted medical marijuana laws.

Studies indicate that medical marijuana is effective in treating chronic pain; PTSD; anxiety; AIDS; and spasms. Overall, most of the same studies report that there has been a decrease in a variety of drugs, especially pain-killers, in states that have adopted medical marijuana laws. Among the older population, medical marijuana is reportedly improving their quality of life, making them less dependent widely prescribed opioid painkillers and other drugs. Documents mentioning Washington are relevant.

Find scholarly articles that support this question's claims.

Medical marijuana initiative likely headed for Florida ballot

Kristi Kelly, co-founder of medical-marijuana dispensary Good Meds Network. (Matthew Staver/The Washington Post.)
Backers of a constitutional amendment to allow Florida patients to use marijuana for medical purposes say they will turn in enough signatures to qualify for the fall ballot by next week.
Supporters of the measure have until Feb. 1 to submit just over 683,000 valid signatures of registered voters. Realistically, backers are shooting for about 1 million signatures, to account for any deemed invalid; organizers say they will hit the million-signature mark by next week.
“As of tomorrow, we should be right at, maybe a little bit under, a million” signatures, said Ben Pollara, who runs the People United for Medical Marijuana campaign that’s spearheading the initiative. “By this time next week, we should have more than enough to give us some comfort that we should be on the ballot.”
So far, the Florida Department of Elections says the group has submitted 265,000 valid signatures. The group says it has hundreds of thousands of signatures still being processed by county elections officials.
Once the signatures are submitted and verified, Florida’s Supreme Court will rule on whether the amendment’s ballot title and summary meet legal requirements, a decision likely to come before the beginning of April (See the proposed summary language here).
And if the measure makes the ballot, organizers say poll results show they will start the fall campaign in strong position.
A Quinnipiac University poll conducted in November showed a huge majority of Florida voters, 82 percent, backed allowing adults to use marijuana for medical purposes if their doctor prescribes the drug. Just 16 percent of voters said they opposed marijuana for medical use.
The same poll showed a slim plurality — 48 percent — supported allowing adults to possess small amounts of marijuana for personal use. Forty-six percent said they opposed recreational marijuana use.
But backers are still preparing for a big fight. Pollara said his group will aim to raise at least $10 million for the fall campaign, which will share the stage with a high-profile race between Gov. Rick Scott (R) and his eventual Democratic challenger.
“We’re a big state. We have a lot of media markets. They’re going to be expensive, given the governor’s race,” Pollara said.
At present, 18 states and the District of Columbia allow patients to use marijuana for medical purposes, while two states — Colorado and Washington — allow legal purchases for non-medical use. Eleven of those states legalized marijuana for medical use through ballot initiatives.


One striking chart shows why pharma companies are fighting legal marijuana

(Sarah L. Voisin/The Washington Post) They found that, in the 17 states with a medical-marijuana law in place by 2013, prescriptions for painkillers and other classes of drugs fell sharply compared with states that did not have a medical-marijuana law. The drops were quite significant: In medical-marijuana states, the average doctor prescribed 265 fewer doses of antidepressants each year, 486 fewer doses of seizure medication, 541 fewer anti-nausea doses and 562 fewer doses of anti-anxiety medication. But most strikingly, the typical physician in a medical-marijuana state prescribed 1,826 fewer doses of painkillers in a given year. These conditions are among those for which medical marijuana is most often approved under state laws. So as a sanity check, the Bradfords ran a similar analysis on drug categories that pot typically is not recommended for — blood thinners, anti-viral drugs and antibiotics. And on those drugs, they found no changes in prescribing patterns after the passage of marijuana laws. "This provides strong evidence that the observed shifts in prescribing patterns were in fact due to the passage of the medical marijuana laws," they write. In a news release In what may be the most concerning finding for the pharmaceutical industry, the Bradfords took their analysis a step further by estimating the cost savings to Medicare from the decreased prescribing. They found that about $165 million was saved in the 17 medical marijuana states in 2013. In a back-of-the-envelope calculation, the estimated annual Medicare prescription savings would be nearly half a billion dollars if all 50 states were to implement similar programs. "That amount would have represented just under 0.5 percent of all Medicare Part D spending in 2013," they calculate. Cost-savings alone are not a sufficient justification for implementing a medical-marijuana program. The bottom line is better health, and the Bradfords' research shows promising evidence that medical-marijuana users are finding plant-based relief for conditions that otherwise would have required a pill to treat. "Our findings and existing clinical literature imply that patients respond to medical marijuana legislation as if there are clinical benefits to the drug, which adds to the growing body of evidence suggesting that the Schedule 1 status of marijuana is outdated," the study concludes. The Bradfords will next look at whether similar patterns hold for Medicaid. Anne McDonald Pritchett, Vice president of policy and research for PhRMA, discusses prescription drug abuse. The discussion took place during Coffee@WaPo: A policy

(Sarah L. Voisin/The Washington Post)
There's a body of research showing that painkiller abuse and overdose are lower in states with medical marijuana laws. These studies have generally assumed that when medical marijuana is available, pain patients are increasingly choosing pot over powerful and deadly prescription narcotics. But that's always been just an assumption.
Now a new study, released in the journal Health Affairs, validates these findings by providing clear evidence of a missing link in the causal chain running from medical marijuana to falling overdoses. Ashley and W. David Bradford, a daughter-father pair of researchers at the University of Georgia, scoured the database of all prescription drugs paid for under Medicare Part D from 2010 to 2013.
They found that, in the 17 states with a medical-marijuana law in place by 2013, prescriptions for painkillers and other classes of drugs fell sharply compared with states that did not have a medical-marijuana law. The drops were quite significant: In medical-marijuana states, the average doctor prescribed 265 fewer doses of antidepressants each year, 486 fewer doses of seizure medication, 541 fewer anti-nausea doses and 562 fewer doses of anti-anxiety medication.
But most strikingly, the typical physician in a medical-marijuana state prescribed 1,826 fewer doses of painkillers in a given year.

These conditions are among those for which medical marijuana is most often approved under state laws. So as a sanity check, the Bradfords ran a similar analysis on drug categories that pot typically is not recommended for — blood thinners, anti-viral drugs and antibiotics. And on those drugs, they found no changes in prescribing patterns after the passage of marijuana laws.
"This provides strong evidence that the observed shifts in prescribing patterns were in fact due to the passage of the medical marijuana laws," they write.
In a news release
One interesting wrinkle in the data is glaucoma, for which there was a small increase in demand for traditional drugs in medical-marijuana states. It's routinely listed as an approved condition under medical-marijuana laws, and studies have shown that marijuana provides some degree of temporary relief for its symptoms.
The Bradfords hypothesize that the short duration of the glaucoma relief provided by marijuana — roughly an hour or so — may actually stimulate more demand in traditional glaucoma medications. Glaucoma patients may experience some short-term relief from marijuana, which may prompt them to seek other, robust treatment options from their doctors.
The tanking numbers for painkiller prescriptions in medical marijuana states are likely to cause some concern among pharmaceutical companies. These companies have long been at the forefront of opposition to marijuana reform, funding research by anti-pot academics and funneling dollars to groups, such as the Community Anti-Drug Coalitions of America, that oppose marijuana legalization.
Pharmaceutical companies have also lobbied federal agencies directly to prevent the liberalization of marijuana laws. In one case, recently uncovered by the office of Sen. Kirsten Gillibrand (D-N.Y.), the Department of Health and Human Services recommended that naturally derived THC, the main psychoactive component of marijuana, be moved from Schedule 1 to Schedule 3 of the Controlled Substances Act — a less restrictive category that would acknowledge the drug's medical use and make it easier to research and prescribe. Several months after HHS submitted its recommendation, at least one drug company that manufactures a synthetic version of THC — which would presumably have to compete with any natural derivatives — wrote to the Drug Enforcement Administration to express opposition to rescheduling natural THC, citing "the abuse potential in terms of the need to grow and cultivate substantial crops of marijuana in the United States."
The DEA ultimately rejected the HHS recommendation without explanation.
In what may be the most concerning finding for the pharmaceutical industry, the Bradfords took their analysis a step further by estimating the cost savings to Medicare from the decreased prescribing. They found that about $165 million was saved in the 17 medical marijuana states in 2013. In a back-of-the-envelope calculation, the estimated annual Medicare prescription savings would be nearly half a billion dollars if all 50 states were to implement similar programs.
"That amount would have represented just under 0.5 percent of all Medicare Part D spending in 2013," they calculate.
Cost-savings alone are not a sufficient justification for implementing a medical-marijuana program. The bottom line is better health, and the Bradfords' research shows promising evidence that medical-marijuana users are finding plant-based relief for conditions that otherwise would have required a pill to treat.
"Our findings and existing clinical literature imply that patients respond to medical marijuana legislation as if there are clinical benefits to the drug, which adds to the growing body of evidence suggesting that the Schedule 1 status of marijuana is outdated," the study concludes.
One limitation of the study is that it only looks at Medicare Part D spending, which applies only to seniors. Previous studies have shown that seniors are among the most reluctant medical-marijuana users, so the net effect of medical marijuana for all prescription patients may be even greater.
The Bradfords will next look at whether similar patterns hold for Medicaid.
Anne McDonald Pritchett, Vice president of policy and research for PhRMA, discusses prescription drug abuse. The discussion took place during Coffee@WaPo: A policy conversation about addiction in America.


Marijuana legalization on ballot in 3 states, but Justice Department remains silent

Marijuana plants grow at the Northwest Patient Resource Center medical marijuana dispensary in Seattle.  (Ted S. Warren/AP)
Voters are set to cast their ballots in three Western states next month on whether to legalize the sale of marijuana for recreational use, initiatives that would directly violate federal law but that have drawn only silence from the Justice Department.
Despite the urging of drug enforcement experts, officials in Washington have not said how the federal government would deal with possible state laws in Colorado, Washington and Oregon that would conflict with the federal Controlled Substances Act. Federal law prohibits the production, possession and sale of marijuana and classifies marijuana as a Schedule 1 drug, putting it in the same category as LSD and heroin.
Nine former administrators of the Drug Enforcement Administration wrote a letter last month to Attorney General Eric H. Holder Jr., urging him to publicly oppose the ballot initiatives that, if passed, would make the states the first in the nation to decriminalize marijuana for recreational use by adults.
“To continue to remain silent conveys to the American public and the global community a tacit acceptance of these dangerous initiatives,” wrote the former administrators, who oversaw the DEA under both Democratic and Republican presidents from 1973 to 2007. “We urge you to take a public position on these initiatives as soon as possible.”
Holder has not responded to the letter. The former officials are planning to hold a news conference Monday to press their concerns more publicly.
“The Justice Department should speak out ahead of the ballot initiatives to avoid immediate court action,” said Peter Bensinger, the DEA administrator from 1976 to 1981. “The initiatives will be in direct conflict with federal law, international treaty obligations and Supreme Court rulings.”
The Justice Department can file suit to try to block state laws that it deems to have violated federal statutes. It did that, for example, after Arizona passed a law in 2010 that the state said was aimed at cracking down on illegal immigrants but that the Obama administration believed was unconstitutional. In other cases, officials have simply made the Justice Department’s stance clear ahead of ballot initiatives, as Holder did in 2010 when he said that officials opposed a California measure to legalize marijuana.
But with the upcoming initiatives over legalization, Justice Department spokeswoman Allison W. Price said the department would not comment. “We are not going to speculate on the outcome of various ballot initiatives state by state,” she said.
Colorado’s measure, known as Amendment 64, is the most likely to pass, according to observers and local polls. Under the measure, retail stores would be allowed to sell marijuana, and it would be taxed and regulated like tobacco and alcohol.
Growing operations would be legalized, as would “infusion factories” that could blend marijuana into brownies, candy bars and lollipops, according to Tom Gorman, the director of the federal Rocky Mountain High-Intensity Drug Trafficking Area.
“If this passes, Colorado would have the most liberal marijuana laws in the developed world, more liberal than the Netherlands,” said Gorman, whose group brings together local, state and federal law enforcement officials. “It’s illegal for a state to pass a constitutional measure that allows its citizens to violate federal law.”
The initiative has the support of 51 percent of state voters, according to a poll conducted for the Denver Post. More than 300 physicians in the state have joined the campaign for legalization.
“As physicians, we have a professional obligation to do no harm,” Bruce Madison, former associate medical director of the faculty at the University of Colorado School of Medicine, said in a statement. “But the truth is that the Colorado marijuana laws do just that, by wasting hundreds of millions of dollars in a failed war on marijuana, by ruining thousands of lives by unnecessary arrest and incarceration, and by causing the deaths of hundreds of people killed in black-market criminal activities.”
In a letter to President Obama, four former White House drug czars said the administration’s “non-discussion” stance “is sending a message that you and your administration are indifferent to the legalization issue.”
“We stand united against any efforts . . . to legalize marijuana or any other currently illegal substances and urge you to respond . . . expressing unequivocal opposition to marijuana legalization generally and these initiatives specifically,” the former National Drug Control Policy directors wrote.
Along with the Colorado ballot proposal, Initiative 502 in Washington and Measure 80 in Oregon would allow people who are 21 and older to buy marijuana from shops regulated by the state.
All three ballot initiatives are a step beyond the laws that have legalized marijuana for medical purposes. Starting with California in 1996, the District and 17 states, including the three with these ballot proposals, have passed laws making it legal to manufacture, distribute and possess marijuana for such purposes. Arkansas has a similar measure on the ballot this year.
In 2009, David Ogden, then the deputy attorney general, wrote a memo to U.S. attorneys, advising that the prosecution of significant traffickers of illegal drugs, including marijuana, remained a core priority. Marijuana distribution was the largest source of revenue for the Mexican cartels, Ogden said.
But he also addressed the growing number of states legalizing marijuana for medicinal purposes.
“Prosecution of individuals with cancer or other serious illnesses who use marijuana as part of a recommended treatment regimen consistent with applicable state law, or those caregivers . . . who provide such individuals with marijuana, is unlikely to be an efficient use of limited federal resources,” Ogden wrote.
Last year, in a memo to U.S. attorneys, Deputy Attorney General James M. Cole reiterated Ogden’s position on medical marijuana but indicated that there was a growing increase in scope of commercial cultivation, sale, distribution and use of marijuana for “purported medical purposes.”
“The Ogden Memorandum was never intended to shield such activities from federal enforcement action and prosecution, even when those activities purport to comply with state law,” Cole wrote.
In recent months, federal authorities have cracked down on the sale of marijuana from dispensaries near schools.
The DEA warned in August that about two dozen marijuana dispensaries operating in school zones in Washington state would face possible prosecution if they didn’t shut down. That same month, U.S. Attorney John Walsh in Colorado sent out 10 letters to medical marijuana dispensaries within 1,000 feet of schools, ordering them to close.
Julie Tate contributed to this report.


Even where it’s legal for parents to smoke pot: What about the kids?

Candace Junkin is the founder and head of the International Women's Cannabis Conference, which works to share the voices of women and mothers for the legalization of marijuana. She is photographed at her St. Mary's County, Md., home. (Reza A. Marvashti / For the Washington Post)
Like the parent of any toddler and kindergartner, Jared wants to keep certain things out of reach.
Liquor is stored out of sight in a cupboard. The household cleaners are safely kept behind childproof locks. And the marijuana is stashed high on a shelf in a fireproof lockbox.
Evenings fall into a familiar routine. Family dinner. Baths. Then, after their daughters are snuggled in for the night, Jared slips out onto the back deck of their District apartment and smokes a now-legal bowl of marijuana.
“It relaxes me. And it helps me get perspective to see the big picture. I find that enjoyable,” said Jared, a rare parent in the District who was willing to talk openly about his marijuana use. He asked that his full name not be used because he is concerned about the impact on his children.
Jared said he and other pot-smoking parents he knows have one ironclad rule: They don’t smoke in front of their kids. Yet what will happen once the kids figure out Dad’s on the balcony getting high?
Marijuana sold by a local dealer in Washington. (Evelyn Hockstein/For The Washington Post)
More than half the country supports legalizing marijuana, according to polls. But it’s this question — What about the kids? — that provokes unease, even outrage, and keeps many pot- using parents uncertain about how to navigate the “new normal” of legalized marijuana.
The stakes are high for both parents and kids. Even where the drug is legal, parental pot-smoking can be considered as a factor in child-neglect cases, just like alcohol. As a result, some parents have been accused of endangering their children and had them taken away by child protective service agencies.
There are fears that if parents reveal their use, teens will be more likely to give it a try, a phenomenon supported by research. And although the science is fairly new, some studies have found heavy marijuana use in adolescence can permanently disrupt key networks in the developing brain associated with memory and processing information.
“For parents, this is a confusing time. If they’re users, how are they going to talk to their kids?” said Matthew Kuehlhorn, founder of Community Thrive, a new organization in Colorado that helps facilitate such talks in an effort to prevent youth substance use. “This is a social culture change we haven’t seen the likes of since alcohol prohibition ended.”
Kathy Henderson, who leads a Parents Against Pot effort in her Trinidad neighborhood in Northeast Washington, said she has noticed that legalization has led to a higher incidence of children “walking around the street openly smoking marijuana and thinking it’s okay.”
“It’s very, very disheartening,” she said. “Our children have so many challenges to begin with, this has really set us back. It’s crazy.”
Playing it straight
Jared said he doesn’t want his daughters to use marijuana as minors, but he plans to be straight with them when they’re older.
“When they get to the age of 21, and can make a legal choice, they need to know, honestly, ‘What’s alcohol like? What’s it going to do to me? What are the risks? And what’s cannabis like?’ ”
In Jared’s mind, cannabis — advocates’ preferred term — is the substance of lesser harm. It’s less addictive, studies have found, causes fewer health problems and, unlike alcohol, no one has ever died using it.
And he likes the idea that regulating the marijuana trade should make marijuana harder for teens to acquire.
In time, he hopes smoking a joint will be as unremarkable for parents as cracking open a beer at the end of the day. But that’s not today.
Even Jared, who made the decision to “out” himself as a pot smoker because he works for the pro-legalization Marijuana Policy Project, is nervous. He hastens to say that he never smokes so much he couldn’t quickly respond to an emergency with the kids.
“There’s still so much stigma,” he said. “If I worked anyplace else, I wouldn’t be talking openly.”
Finding connections
Advocates for legalizing marijuana say there are more pot-smoking parents than most people think. The Pew Research Center reported that 47 percent of Americans — about 150 million people — have tried marijuana.
A group of mothers in Beverly Hills, Calif., made headlines as the “Marijuana Moms” not long ago when they came clean about using marijuana to deal with chronic pain. And the Global Drug Policy Observatory found that women between the ages of 30 and 50 were among the biggest supporters of legalization in Washington state and Colorado.
“Marijuana, of all the mind- altering substances, is probably the only one that helps you cope with being a parent,” said Adam Eidinger, a cannabis activist in the District, who said he smokes marijuana regularly for medical reasons. “It gives you patience.”
Like Jared, Eidinger keeps his stash in a safe locked away from his 11-year-old daughter, and he smokes on his condominum’s roof deck. But he’s been pushing the District to amend the new law, which permits the drug to be used inside one’s home, in order to allow pot smoking at special clubs, roof decks, beer gardens or bars. “I don’t know how that’s any better for children — having friends come over to my house and smoking weed around my kid,” he said.
Yvonne Maguire, a stay-at-home mother of young children, was terrified that her District neighbors would find out she smoked marijuana to deal with insomnia and migraines. But since she moved to Colorado, where the recreational use of marijuana has been legal since January 2014, she and her husband have joined groups that activists have put together for parents who smoke pot.
“It’s really nice,” she said. “It’s a way for parents to feel more comfortable.”
Brittany Driver, mother of a 3-year-old and regular medical marijuana user, dispenses advice in her Pot and Parenting column for the Denver Post .
She’s also helping to promote an app, called High There, that will help pot-smoking mothers find each other.
“Even in Colorado, there’s still such a stigma for parents, it’s still hard to talk about openly,” Driver said.
Legal questions
Because of that stigma, even when it’s legal, some pot-smoking parents worry that their use will be met with the disapproval of others, who might ostracize their children.
But what keeps many parents underground, they say, is their terror of someone calling Child Protective Services. A pot-smoking couple who ran a medical marijuana dispensary in Washington state, where medical and recreational marijuana use is legal, had their 5-year-old taken away and placed in CPS protective custody in November when he tested positive for THC, the psycho-active chemical in marijuana.
And in April, CPS took away the 11-year-old son of Shona Banda, who uses marijuana to manage Crohn’s disease and is an outspoken advocate for medical marijuana in Kansas, where legalization bills failed this year. After her son spoke out about medical marijuana in school, police investigated and found marijuana, drug paraphernalia and a lab for extracting cannabis oil in the kitchen, within easy reach of children. Banda faces the possibility of child endangerment and other charges.
Mindy Good, spokeswoman for Child and Family Services in the District, said officials have been having serious conversations about what marijuana’s new legal status in the District will mean.
“Whether a substance is legal or illegal is of less concern to us than whether or not it’s affecting someone’s ability to parent,” she said. “For instance, alcohol is totally legal. But if it’s impairing the ability to protect and care for your child, that’s when we step in.”
Sara Arnold co-founded the Family Law & Cannabis Alliance, a Massachusetts-based group that monitors and advocates for pot-smoking parents’ legal rights, in part because she herself, a medical marijuana user, has been investigated by CPS three times.
“We have actually had instances of medical marijuana patients in states where medical marijuana is legal facing termination of their parental rights,” Arnold said. “If a parent had a bottle of wine, no one would be coming to check that out.”
Changing demographics
Though studies show that the majority of marijuana users tend to be lower-income and those with less than a high school education, Max Simon, with Green Flower Media, sees that changing. Green Flower is sponsoring a “Coming Out Green” campaign of reports and videos of personal stories to rehabilitate pot’s outlaw image.
“One of the fastest growing markets we’re seeing is the baby-boom generation,” who smoked pot in college then quit when they got jobs and now want to use it again, he said. And most of them are parents. The group is releasing a new report, “Be Askable,” with advice for setting family rules and a “just wait” message to help teens delay any substance use until their brains are developed.
Candace Junkin, co-founder of the International Women’s Cannabis Coalition, is a mother of four and grandmother of three who lives in St. Mary’s County, Md., where medical marijuana has been legal since 2014. (Virginia recently passed a bill legalizing medical marijuana for epilepsy, glaucoma and cancer.) She suffers from trigeminal neuralgia, a condition that causes excruciating shooting pains in her face. Her doctors initially prescribed painkillers, but they made her so disoriented her children called her “Mombie.” In 2002, she found marijuana eased the pain and began smoking or vaporizing up to six times a day.
At first, she was so ashamed that she hid her use from her children. “But over the years, the kids started to see that when Mommy would be hurting, she would go in her bedroom, and she would come out and she would be better,” Junkin said.
She decided to share the research she’d done on the health benefits of cannabis with them. None of her children, the youngest of whom is 17, smoke pot.
“One kid is about to go to college. Another is about to graduate. One owns her own business,” she said. “For a pothead mom, I think I’ve done okay.”


U.S. affirms its prohibition on medical marijuana

Marijuana plants growing at a Minnesota Medical Solutions greenhouse in Otsego, Minn., last year. The crop is part of the state's medical marijuana supply.  (Glen Stubbe/Star Tribune/AP)
This post has been updated.
The government refused again Thursday to allow the use of marijuana for medical purposes, reaffirming its conclusion that the drug’s therapeutic value has not been proved scientifically and defying a growing clamor to legalize it for the treatment of a variety of conditions.
In an announcement in the Federal Register and a letter to petitioners, the Drug Enforcement Administration turned down requests to remove marijuana from “Schedule I,” which classifies it as a drug with “no currently accepted medical use” in the United States and precludes doctors from prescribing it.
The decision keeps the federal government at odds with 25 states and the District of Columbia, which have passed laws allowing medical use of marijuana to some degree. Members of  Congress have called for its reclassification and on Wednesday, the National Conference of State Legislatures adopted a resolution asking the federal government to remove marijuana from Schedule I.
"Right now, the science doesn't support it," Chuck Rosenberg, acting administrator of the Drug Enforcement Administration, said in an interview Thursday. Citing a lengthy analysis conducted by the Food and Drug Administration, he said the decision "is tethered to the science."
The agency announced one policy change that could increase the amount of research conducted on marijuana: the DEA will expand the number of places allowed to grow marijuana for studies of its value in chronic pain relief, as a treatment for epilepsy and for other purposes. Currently, only the University of Mississippi,which holds an exclusive contract with the National Institute on Drug Abuse, is federally licensed to grow marijuana for research purposes.
The latest development in the 46-year legal and policy battle over the status of marijuana disappointed advocates of looser restrictions on the drug, who had hoped that the government would carve out a special place for marijuana in the controlled-substance regulations or move it to a less tightly regulated category, Schedule II.
In the words of a 2015 Brookings Institution report, a move to Schedule II “would signal to the medical community that [the Food and Drug Administration and the National Institutes of Health] are ready to take medical marijuana research seriously, and help overcome a government-sponsored chilling effect on research that manifests in direct and indirect ways.”
But as it has in previous reviews, marijuana again failed an analysis conducted by the FDA and NIDA. The FDA concluded that medical and scientific data do not yet prove that marijuana is safe and effective as a medicine. Legally, that prohibits the DEA from reclassifying the drug.
“We’re pleased to see that the Obama Administration … understands the science the way we and almost every single medical association in the country understand it,” said Kevin Sabet, president of Smart Approaches to Marijuana, which opposes loosening restrictions on marijuana.
Rep. Earl Blumenauer (D-Ore.) praised the decision to allow more facilities to cultivate marijuana for research, but said the decision doesn’t go far enough. “This decision ... is further evidence that the DEA doesn’t get it. Keeping marijuana at Schedule I continues an outdated, failed approach — leaving patients and marijuana businesses trapped between state and federal laws,” Blumenauer said.
PostTV travels to the county in West Virginia with the highest-rate increase in marijuana possession arrests to see how pot laws have affected communities.
Schedule I drugs — which include LSD and heroin, as well as marijuana — have “no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.” Schedule II drugs, such as the powerful narcotic painkillers that have caused an epidemic of addiction over the past decade, have medicinal value but “a high potential for abuse which may lead to severe psychological or physical dependence.” Marijuana was placed in Schedule I in 1970, when Congress passed the Controlled Substances Act.
Research has shown that some components of marijuana have promise as a treatment for epilepsy and chronic pain. Some people use it to relieve the symptoms of post-traumatic stress disorder, although research has not been conducted to prove its value for that condition.
Rosenberg said that while individual researchers may have shown that marijuana or its extracts are helpful for certain conditions, the FDA has the most comprehensive view of the state of scientific research on the drug.
"The FDA knows this better than anyone on the planet," he said, though he acknowledged that "a lot of people will disagree with that."
He also noted that many people misconstrue the controlled substance scheduling regime as a ranking of drugs' relative dangers. Clearly, he said, marijuana is not as dangerous as heroin, LSD and perhaps some of the opioids in Schedule 2. "It's not the Richter Scale," he said. But that doesn't mean cannabis and its extracts are safe for medical use and not prone to abuse, he added.
Academic researchers have complained that registration and application requirements to work with Schedule I drugs make studying their purported benefits difficult. The DEA, however, says the number of researchers registered to study marijuana and its components has doubled in the past two years.
The governors of Rhode Island and Washington, and a New Mexico resident, Bryan A. Krumm, petitioned the DEA to remove marijuana from Schedule I. The agency most recently rejected a similar request in 2011, touching off a legal battle to force reclassification in which the DEA ultimately prevailed.
With so many states allowing the use of cannabis components for health reasons, Rosenberg acknowledged the conflict with the federal government's posture. But he said prescribers need not fear that the announcement signals a federal crackdown.
"We are not changing our enforcement priorities," he said.
It is unclear how many more facilities would be allowed to grow marijuana for researchers under the new rules. But the government signaled its intent to end the effective monopoly on cultivation maintained by NIDA and the University of Mississippi, officials said. That would allow a greater supply and a wider variety of products for research. Growers would apply to DEA, not NIDA, for permission to cultivate.
"If petitioners meet our criteria, and they can assure us that this stuff can be handled safely and securely," they likely will be given permission to cultivate marijuana for research purposes, he said.
The new policy also contains a “statement of principles” that reminds growers of the provisions of a 2014 law that governs the use of industrial hemp. The plant is a cannabis variant that contains a low concentration of tetrahydrocannabinol, or THC, the chemical responsible for most of marijuana’s impact on the brain.
Christopher Ingraham contributed to this report.
Read more:
The DEA's latest stance on marijuana, explained


One-third of long-term users say they’re hooked on prescription opioids

UNNATURAL CAUSES | SICK AND DYING IN SMALL-TOWN AMERICA:
Respondents who took part in The Washington Post-Kaiser Family Foundation survey on long-term, opioid painkiller use share their experiences of living with pain.
One-third of Americans who have taken prescription opioids for at least two months say they became addicted to, or physically dependent on, the powerful painkillers, according to a new Washington Post-Kaiser Family Foundation survey.
Virtually all long-term users surveyed said that they were introduced to the drugs by a doctor’s prescription, not by friends or through illicit means. But more than 6 in 10 said doctors offered no advice on how or when to stop taking the drugs. And 1 in 5 said doctors provided insufficient information about the risk of side effects, including addiction.
The survey raises sharp questions about the responsibility of doctors for an epidemic of addiction and overdose that has claimed nearly 180,000 lives since 2000. Opioid deaths surged to more than 30,000 last year, according to new data from the U.S. Centers for Disease Control and Prevention, with deaths from heroin alone surpassing the toll from gun homicides.
Doctors have been widely blamed for sparking the crisis by overprescribing highly addictive opioids to treat everyday pain. The survey suggests that they are still doing too little to stop it.
“Why isn’t it 100 percent?” demanded Gary Mendell, founder of Shatterproof, a grass-roots group dedicated to reducing addiction in the United States, referring to the share who say doctors have counseled them on stopping the medication. “It’s unbelievable that it’s not 100 percent.”

Patrice A. Harris, chairwoman of the American Medical Association’s Board of Trustees and chair of its task force to reduce opioid abuse, acknowledged that doctors could do more to counsel patients on avoiding addiction.
“The doctors that I have talked to are discussing this with their patients,” Harris said. But, citing the survey, she added: “We could certainly do a better job.”
Despite the high rate of dependence, the poll finds that a majority of long-term opioid users say the drugs have dramatically improved their lives. Opioids relieve pain that is otherwise intractable, they said in follow-up interviews, allowing them to walk, work and pursue other activities. Fully two-thirds of users surveyed said relief is well worth the risk of addiction.
People living with opioid users tend to have a darker view of the drugs’ effects. While one-third of users say they are hooked, more than half of people living with them suspect addiction, the survey found. Family members are also far more likely to say the drugs have damaged the users’ physical and mental health, finances and personal relationships.

Still, the survey’s findings highlight a fundamental conflict: While the drugs are a scourge for many, they are a godsend to others, especially the estimated 100 million Americans who live in chronic pain. Efforts by policymakers to restrict use have been met with outrage.
“We’re not saying that no one should ever be on these pills,” but most people would be “healthier and more functional if they were off them,” said CDC Director Tom Frieden, who this spring urged doctors to sharply limit the number of pills they prescribe.
“The bottom line here is that prescription opiates are as addictive as heroin. They’re dangerous drugs,” Frieden said. “You take a few pills, you can be addicted for life. You take a few too many and you can die.”
Opioid abuse — both prescription painkillers and their chemical cousins, heroin and fentanyl — is the main cause of rising death rates among middle-aged white Americans, particularly women in rural areas. It also has contributed to the first overall decline in U.S. life expectancy at birth in more than two decades, the government reported Thursday.
In 2014, U.S. doctors wrote 240 million prescriptions for opiates, enough for every adult to have their own bottle of pills. The CDC estimated that about 2.1 million Americans are addicted to legal narcotics.
In the first-ever guidelines on opioids for physicians, the CDC in March urged doctors to try nonnarcotic methods before offering patients pills containing oxycodone, hydrocodone and other opioids. The guidelines noted that there is little evidence that opioids are effective beyond 12 weeks.
“Three days or less will often be sufficient; more than seven days will rarely be needed,” the guidelines say.
But many people take the drugs much longer. In the past two years, about 5 percent of American adults have used prescription opioids for at least two months, the poll found; about half of those report taking the drugs for two years or more.

For the survey, one of the most comprehensive polls of long-term opioid users to date, The Post and Kaiser interviewed 622 people who said that they had taken narcotic painkillers for at least two months over the past two years. The survey also included 187 people who said they share a household with an opioid user, usually a spouse or a parent.
The survey did not include people who were treated for cancer or a terminal illness. At the time of the interview, 45 percent of long-term users were no longer taking the drugs, while 55 percent were still taking them. Users were slightly more likely than the general public to be white and far more apt to be middle-aged.
Nearly all long-term users (95 percent) said that they began taking the drugs to relieve pain from surgery, an injury or a chronic condition. Just 3 percent said that they started as recreational users.
More than 8 in 10 said that they tried to manage their pain with nonnarcotic medication; about 7 in 10 said that they tried alternative treatments, such as physical therapy and acupuncture. More than half (57 percent) found those methods ineffective.

Charles Stonesifer, 74, a former bricklayer who lives in Baltimore, has taken Tylenol with codeine and then Tramadol over the past two years. “Both my knees are shot,” he said, adding that he would be unable to walk without narcotics.
Stonesifer said that he had no trouble giving up the drugs when he tried, but his pain returned and he was forced to resume taking them.
“If they actually stopped you from getting the [drugs], it would be very difficult for me,” Stonesifer said. “It would put me in a wheelchair instead of being able to get around. And once you’re in a wheelchair, you never get up.”
Nancy Horton, 62, of Martinsburg, W.Va., admits that she is addicted to the 190 milligrams of oxycodone she takes daily to dull the pain of rheumatoid arthritis. Without the drugs, “I get the shakes. I am very anxious,” she said. “I just pace constantly. I can’t get comfortable.”
After 15 years on opioids, she said, “I look back now and think, ‘What could I have done differently?’ ”
Sizable minorities of respondents report using the drugs for purposes other than managing pain. Such behavior is much more common among people who say they are addicted or physically dependent on opioids. Among this group, 47 percent say they sometimes take the drugs for “fun or to get high”; 38 percent use them to “deal with day-to-day stress”; and 30 percent use them to “relax or relieve tension.”
Side effects are widespread. Over half of long-term users said that they have experienced constipation; almost as many felt indigestion, dry mouth or nausea; and 15 percent said that they have had breathing problems. One in 5 (21 percent) have taken additional medications to treat those symptoms.
More than half (52 percent) of long-term users said that they have taken other prescription medications for anxiety, depression and sleeplessness while on opioids, and 1 in 6 said that they have consumed the drugs along with alcohol — risky combinations that could have dire consequences. Overall, nearly 6 in 10 said that they take at least four prescription drugs, and about one-third said that they take seven or more medications.

The survey revealed a largely positive relationship between opioid consumers and their doctors. Large majorities said doctors have warned them to avoid alcohol, cautioned them about possible side effects and explained the risk of addiction.
But 61 percent said that their doctors did not suggest a plan for getting off the drugs when they were first prescribed, and more than half said doctors have not altered their dose or frequency. Among long-term users who stopped taking opioids, 34 percent said the termination of their prescription was a reason.
Just 4 percent said that they have a prescription for naloxone, the drug that can be administered by someone else in an emergency to reverse the effect of an overdose.

While about a quarter of long-term users said a friend or family member has suggested they stop taking the drug, two-thirds said that they are “not too” or “not at all” concerned about becoming addicted. And about 6 in 10 of those who report being addicted have not sought treatment or other help.
Yngvild Olsen, chair of the American Society of Addiction Medicine’s public policy committee, said doctors “have a vital role to play in addressing the epidemic, not only by changing their prescribing patterns and learning a lot more about chronic pain management and addiction, but also by stepping up to the plate in learning how to treat addiction.”
Emily Guskin, Monica Akhtar and Erin Patrick O’Connor contributed to this report.


The American Legion wants the federal government to change course on marijuana

Army veteran Perry Parks of Rockingham, N.C., attends a demonstration in front of the White House in November to bring awareness to the overmedication of veterans and advocate for federal legalization of medical marijuana. (Ricky Carioti/ The Washington Post)
The American Legion, a group representing 2.4 million U.S. military veterans, has called on Congress to remove marijuana from Schedule 1 of the federal Controlled Substances Act and "reclassify it in a category that, at a minimum will recognize cannabis as a drug with potential medical value."
In a resolution passed at the Legion's annual convention last week, the organization said it hopes that better research into marijuana and an official acknowledgment of its potential medical benefits will hasten the development of new treatments for post-traumatic stress disorder and traumatic brain injuries, ailments that have plagued veterans returning from the wars in Iraq and Afghanistan.
The Legion's resolution, published online by Marijuana.com, noted that the federal Drug Enforcement Administration recently approved the country's first randomized, controlled trial using whole-plant, smoked marijuana to treat PTSD symptoms. That study will be conducted by Sue Sisley, an Arizona researcher who tried for nearly a decade to get a green light for the research but struggled to find an academic institution to sponsor it. The University of Colorado ultimately agreed to fund the research.
During an address at the Legion's convention in Cincinnati, Sisley told members that "veterans are exhausted and feel like guinea pigs; they’re getting desperate” and that traditional medications didn't seem to be providing adequate relief to many vets suffering from PTSD.
The DEA recently reaffirmed its decades-old policy of classifying marijuana among the most dangerous drugs, citing its "high potential for abuse" and "no currently accepted medical use." That position has faced increasing criticism from federal and state lawmakers, physicians, researchers and even some law enforcement groups.
Medical marijuana is extremely popular with voters: A June Quinnipiac University poll found that 89 percent supported the use of marijuana with a doctor's recommendation. A separate survey by the Iraq and Afghanistan Veterans of America found that 68 percent of responding members supported legalizing medical marijuana in their state, and 75 percent said that the Department of Veterans Affairs should allow medical marijuana as a treatment option.
A DEA position paper from 2013 states that "smoked marijuana has not withstood the rigors of science — it is not medicine, and it is not safe."
More from Wonkblog:
Legal marijuana is doing what the drug war couldn't
An unprecedented number of states will vote on marijuana this fall
The ‘mostly false’ argument that could derail legal weed in California
Middle-aged parents are now more likely to smoke weed than their teenage kids


Justin Trudeau may have made the best case for legal pot ever

Justin Trudeau says legalizing marijuana is the best way to keep this baby from smoking marijuana. (Paul Chiasson/Canadian Press via AP)
Speaking Wednesday at an economic conference, Canadian Prime Minister Justin Trudeau made one of the more buttoned-down, straight-edged arguments for marijuana legalization I've heard in recent years. It's worth quoting at length so I've done that below:
Look, our approach on legalizing marijuana is not about creating a boutique industry or bringing in tax revenue, it’s based on two very simple principles:
The first one is, young people have easier access to cannabis now, in Canada, than they do in just about any other countries in the world. [Of] 29 different countries studied by the U.N., Canada was number one in terms of underage access to marijuana. And whatever you might think or studies seen about cannabis being less harmful than alcohol or even cigarettes, the fact is it is bad for the developing brain and we need to make sure that it’s harder for underage Canadians to access marijuana. And that will happen under a controlled and regulated regime.
The other piece of it is there are billions upon billions of dollars flowing into the pockets of organized crime, street gangs and gun-runners, because of the illicit marijuana trade, and if we can get that out of the criminal elements and into a more regulated fashion we will reduce the amount of criminal activity that’s profiting from those, and that has offshoots into so many other criminal activities. So those are my focuses on that.
I have no doubt that Canadians and entrepreneurs will be tremendously innovative in finding ways to create positive economic benefits from the legalization and control of marijuana, but our focus is on protecting kids and protecting our streets.
Trudeau made these remarks in response to a conference participant who said that "Canada could be to cannabis as France is to wine." These enthusiastic predictions about the burgeoning marijuana industry — billions of dollars in revenue and taxes, thousands of jobs created -- should be familiar to anyone who's followed efforts to legalize pot here in the United States.
But Trudeau's argument for legalization is concerned less with creating benefits, and more with reducing harms. He starts from the same place that many legalization opponents start from — concern for the safety of children.
Opponents of legalization have always argued that relaxing marijuana laws will inevitably lead to increased use among teens and adolescents. This would obviously be a problem, because younger users are more at risk for marijuana dependency than adults, and heavy use among teens has been linked to a whole host of social and mental health problems.
But Trudeau points to an easy-to-overlook fact: It's already incredibly easy for teenagers to get high if they want to. In 2015, for instance, nearly 80 percent of U.S. 12th-graders said it would be easy for them to obtain marijuana. It's clear, in other words, that current policies centered on making the drug completely illegal are doing little to keep it out of the hands of kids who want to use it.
Trudeau argues that taking pot out of the black market and putting it under the aegis of a regulatory structure will actually make it harder for kids — those most susceptible to the drug's harms — to obtain it. We don't really know yet if that's the case. Legalization experiments in Colorado and elsewhere are still too young to draw sweeping conclusions about the effects of legalization on teen use and access.
That said, the early data is encouraging. A recent study published in Lancet Psychiatry found that the over the past decade or so — as 13 states passed medical-marijuana laws, 10 states relaxed penalties for marijuana use, and Colorado and Washington became the first states to fully legalize recreational pot use — not only have national teen marijuana use rates declined, but problems associated with teen marijuana use, like dependency, have fallen too.
Beyond that, the latest federal data shows no significant year-over-year change in marijuana use among teens in Colorado and Washington in the year after marijuana became legal there.
Experts say none of this is particularly surprising. "Most of the legal changes have pertained only to those 21 and over, so the absence of a big increase in teens is exactly what you’d expect," Jonathan Caulkins of Carnegie Mellon University told me late last year.
In short, it may be the case that marijuana legalization will have a much smaller impact on teen use rates than once feared. This doesn't mean that legalization doesn't bring risks of its own, however. If marijuana is more widely available, more people will use it, and a certain percent of them will develop a dependency on the drug. And another subset of users will end up doing incredibly stupid or dangerous things while high.
But the question is weighing these very real risks of harm against the harms that are already occurring because of prohibition. Marijuana prohibition ruins lives — lives of the hundreds of thousands of people arrested for possessing the drug each year, or the lives of thousands of people put behind bars for years on account of simple marijuana possession, or the lives of people living in the communities wracked by violence when rival drug gangs fight over turf and put innocents in the crossfire.
Trudeau is saying that this current approach isn't working, and that people legitimately concerned over the harms of the drug trade should consider a radically different approach. So far, the evidence is backing him up.
Canadian Prime Minister Justin Trudeau arrived in Washington for the White House state dinner, and Twitter users remarked on the "bromance" friendship between Trudeau and President Obama.


These are the states that could legalize pot next

Since late 2012, marijuana legalization questions have been asked in at least 38 states. In 25 of those states, majorities supported legalization. In another 5 states, there wasn't majority support for or opposition against legalization -- results were very close, in other words. And in 8 states, majorities opposed legalization. Methodology is important here. Most of these state results shouldn't be directly compared to each other, which is why I'm simply sorting states into qualitative categories rather than doing a numeric comparison of support. The reason is that question wording across these surveys varies considerably, and we know that question wording has a strong effect on marijuana survey results. But each of the surveys I included were scientifically conducted by credible polling firms. They offer representative samples of the populations of their respective states. They all ask about support for the full legalization of marijuana -- not just support for medical marijuana, or for decriminalization, but for legalizing recreational use. I've included all the detailed information, including question wording, survey firm, sample size, survey date, and a link to the raw results in a table below, so you can check it out for yourself. For Alaska, D.C. and Oregon, I used the actual results of last fall's ballot initiatives, since those represent the most recent (and most accurate!) barometer of support in those states. It's important to remember that majority support in a state now doesn't equal sure-fire victory. Some of these measures may not even quality for the ballot. In other cases, voters may sour on the details of specific proposals as they learn more about them. And in just about all of these cases, the public is closely divided between support on opposition. Even given these caveats, however, it's useful to get an assessment of the lay of the land as we head in to 2016. The full list of state polls is below. Did I miss anything? Let me know. State Legalization support (%) Question wording Source and link Sample size Population surveyed Date Alabama -- Alaska 53 Ballot measure: "This bill would tax and regulate the production, sale, and use of marijuana in Alaska. The bill would make the use of marijuana legal for persons 21 years of age or older. The bill would allow a person to possess, use, show, buy, transport, or grow set amounts of marijuana, with the growing subject to certain restrictions."

Marijuana legalization now enjoys majority support in the U.S. -- 52 percent of Americans support legalization, 42 percent oppose it, and 7 percent remain undecided, according to the latest General Social Survey.
But most changes to marijuana law aren't happening at the federal level, they're happening in the states. In some, possession and use remains a crime. Other states have decriminalized possession of small amounts, 24 have legalized marijuana for medical use, and 4 states plus Washington, D.C., have gone fully legal. There are as many shades of grey (or green) between these policies as there are states.
So it's useful to have some sense of public attitudes toward marijuana at the state level, especially considering marijuana will be on the ballot in many states in 2016. No polling outlet that I'm aware of has released comprehensive state-level results for attitudes toward marijuana legalization. But the question has been asked in most states by a variety of polling firms in recent years, and I thought it might be useful to compile all those results in once place. So here they are.

Since late 2012, marijuana legalization questions have been asked in at least 38 states. In 25 of those states, majorities supported legalization. In another 5 states, there wasn't majority support for or opposition against legalization -- results were very close, in other words. And in 8 states, majorities opposed legalization.
Methodology is important here. Most of these state results shouldn't be directly compared to each other, which is why I'm simply sorting states into qualitative categories rather than doing a numeric comparison of support. The reason is that question wording across these surveys varies considerably, and we know that question wording has a strong effect on marijuana survey results.
But each of the surveys I included were scientifically conducted by credible polling firms. They offer representative samples of the populations of their respective states. They all ask about support for the full legalization of marijuana -- not just support for medical marijuana, or for decriminalization, but for legalizing recreational use. I've included all the detailed information, including question wording, survey firm, sample size, survey date, and a link to the raw results in a table below, so you can check it out for yourself. For Alaska, D.C. and Oregon, I used the actual results of last fall's ballot initiatives, since those represent the most recent (and most accurate!) barometer of support in those states.
According to Ballotpedia, a legislation-tracking website, legalization initiatives may appear on the ballot in 11 states in 2016, as well as Ohio this year. Among those 12 states, the latest survey results show majority support for legalization in six -- Arizona, California, Nevada, Massachusetts, Michigan and Ohio. In two states -- Maine and Missouri -- there isn't a majority for or against legalization. And in four states -- Arkansas, Mississippi, Montana and Wyoming -- state-level polling hasn't been done.
It's important to remember that majority support in a state now doesn't equal sure-fire victory. Some of these measures may not even quality for the ballot. In other cases, voters may sour on the details of specific proposals as they learn more about them. And in just about all of these cases, the public is closely divided between support on opposition.
Even given these caveats, however, it's useful to get an assessment of the lay of the land as we head in to 2016. The full list of state polls is below. Did I miss anything? Let me know.
State
Legalization support (%)
Question wording
Source and link
Sample size
Population surveyed
Date

Alabama
--

Alaska
53
Ballot measure: "This bill would tax and regulate the production, sale, and use of marijuana in Alaska. The bill would make the use of marijuana legal for persons 21 years of age or older. The bill would allow a person to possess, use, show, buy, transport, or grow set amounts of marijuana, with the growing subject to certain restrictions."
Ballot measure
all
voters
Nov-14

Arizona
53
“Do you favor or oppose legalizing the possession of small amounts of marijuana for personal use?”(% who favor)
Behavior Research Center's Rocky Mountain Poll
701
voters
May-15

Arkansas
--

California
54
“Next, in general, do you think the use of marijuana should be legal, or not?"(% saying "Yes, legal")
Public Policy Institute of California
1706
adults
May-15

Colorado
62
"Do you support or oppose allowing adults in {{STATE}} to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
894
voters
Apr-15

Connecticut
63
"Do you support or oppose allowing adults in Connecticut to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
1235
voters
Mar-15

DC
70
Ballot measure: "Legalization of Possession of Minimal Amounts of Marijuana for Personal Use Act of 2014"
Ballot measure
all
voters
Nov-14

Delaware
56
"Do you think the use of marijuana should be made legal, or not?"
University of Delaware's Center for Political Communication
902
adults
Sep-14

Florida
55
"Do you support or oppose allowing adults in {{STATE}} to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
1087
voters
Apr-15

Georgia
49
"Should the general assembly in Georgia legalize the use of marijuana by adults, or not?" (% saying "yes")
Atlanta Journal-Constitution
905
adults
Jan-15

Hawaii
66
"What if Hawaii decided to legalize the use of marijuana by adults and regulated its sale and collected tax money from the sale? … yes, to tax and regulate; or no, to leave marijuana use by afdults a crim?" (percent saying "yes")
Q-mark research
400
voters
Jan-14

Idaho
31
"Do you support or oppose the legalization of marijuana in Idaho?" (% who "strongly" or "somewhat" support)
Idaho Politics Weekly
605
adults
Jan-15

Illinois
--

Indiana
52
"Marijuana use is currently illegal in Indiana. Would you favor or oppose a change in the law that makes marijuana a regulated substance much like the way we regulate the use of alcohol and tobacco products?" (% saying "favor")
Bowen Center for Public ffairs
600
adults
Oct-13

Iowa
47
"Do you support or oppose allowing adults in {{STATE}} to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
948
voters
Apr-15

Kansas
--

Kentucky
38
"Do you favor or oppose the Commonwealth of Kentucky allowing residents to buy and use marijuana in the following situations?" (percent favoring "under any circumstances")
Kentucky Health Issues Poll
1,680
adults
Oct-12

Louisiana
45
"Would you favor or oppose legalizing the possession of small amounts of marijuana for personal use?" (% saying "favor")
Louisiana State University
514
adults
Jan-15

Maine
48
"Do you think marijuana usage should be legal or illegal in Maine?" (% saying "legal")
Public Policy Polling
953
adults
Aug-13

Maryland
52
"In general, do you support or oppose making the use of marijuana legal in Maryland?" (% saying "support" or "strongly support")
Goucher Poll
619
adults
Feb-15

Massachusetts
53
"In general, do you favor or oppose the legalization of marijuana? " (% saying "favor")
Suffolk University/Boston Herald
600
likely voters
Feb-14

Michigan
51
"Would you support or oppose the legalization of marijuana for recreational use if it was regulated and taxed like alcohol?" (% saying "strongly" or "somewhat" support)
Marketing Research Group
600
likely voters
Apr-15

Minnesota
46
"Do you think marijuana should be made legal or not?" (% saying "yes")
St. Cloud State University Survey
626
adults
Oct-13

Mississippi
--

Missouri
45
Full text of proposed ballot measure to legalize, tax and regulate marijuana (percent supporting ballot measure)
Greenberg Quinlan Rosner Research
500
likely voters
Feb-14

Montana
--

Nebraska
--

Nevada
54
"Would you support or oppose the legalization of marijuana for recreational use if it was regulated and taxed like alcohol?" (% saying "strongly" or "somewhat" support)
Moore Information
500
voters
Sep-13

New Hampshire
54
"Do you support or oppose legalizing the possession of small amounts of marijuana for personal recreational use in New Hampshire?" (% saying "strongly" or "somewhat" support)
The WMUR Granite State Poll
567
adults
May-15

New Jersey
58
"Thinking about the issue in general, to what extent do you personally support or oppose legalizing, taxing, and regulating marijuana for adults 21 and over? Do you strongly support it, somewhat support it, somewhat oppose it, or strongly oppose it?"
Rutgers-Eagleton Poll
860
adults
Apr-15

New Mexico
44
“Do you support or oppose legalizing recreational marijuana use for adults in New Mexico, with a tax and regulation system, similar to Colorado?”(% saying "support")
Albuquerque Journal poll
500
likely voters
Sep-14

New York
51
"Do you support or oppose allowing adults in New York State to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
1129
voters
Apr-14

North Carolina
37
"Do you think the use of marijuana should be made legal, or not?"
Public Policy Polling
845
voters
Jan-15

North Dakota
--

Ohio
52
"Do you support or oppose allowing adults in {{STATE}} to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
1077
voters
Apr-15

Oklahoma
--

Oregon
56
A ballot initiative that "Allows possession, manufacture, sale of marijuana by/to adults, subject to state licensing, regulation, taxation"
Ballot initiative
all
voters
Nov-14

Pennsylvania
51
"Do you support or oppose allowing adults in {{STATE}} to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
1036
voters
Apr-15

Rhode Island
57
"Since 2012, four states - Colorado, Washington, Alaska and Oregon - have changed their laws to regulate and tax marijuana similarly to alcohol for legal use by adults who are 21 and older. Would you support or oppose changing Rhode Island law to regulate and tax marijuana similarly to alcohol?" (% saying "support")
Public Policy Polling
763
voters
Apr-15

South Carolina
--

South Dakota
--

Tennessee
32
"Which comes closer to your view about the use of marijuana by adults? It should be legal for personal use, it should be legal only for medicinal use, or it should not be legal?" (% saying it should be legal for personal use)
Vanderbilt University
1505
adults
May-14

Texas
58
"The voters in Colorado and Washington changed their laws to allow marijuana to be regulated similarly to alcohol for adults age 21 and older. Would you support or oppose changing Texas law to regulate and tax marijuana similarly to alcohol, where stores would be licensed to sell marijuana to adults 21 and older?" (% who "strongly" or "somewhat" support)
Public Policy Polling
860
voters
Sep-13

Utah
--

Vermont
54
"Do you support or oppose passing a similar law (to legalize recreational marijuana) in Vermont to legalize and regulate marijunana for recreational use?" (% saying "support")
Castleton Polling Institute
700
adults
Feb-15

Virginia
54
"Do you support or oppose allowing adults in {{STATE}} to legally possess small amounts of marijuana for personal use?" (% saying "support")
Quinnipiac University Poll
961
voters
Apr-15

Washington
56
"In general, do you think marijuana usage should be legal or illegal?" (% saying "legal")
Public Policy Polling
879
voters
May-15

West Virginia
46
"Two states -- Colorado and Washington -- recently changed their laws to regulate and tax marijuana similarly to alcohol, for legal use by adults age 21 and older. Would you support or oppose changing West Virginia law to regulate and tax marijuana similarly to alcohol, so stores would be licensed to sell marijuana to adults 21 and older?" (% who support)
Public Policy Polling
614
voters
Dec-13

Wisconsin
46
"Do you think the use of marijuana should be made legal, or not?" (% saying "yes")
Marquette Law School Survey
800
voters
Sep-14

Wyoming
CORRECTION: An earlier version of this post contained an incorrect result for Louisiana. The percentage of Louisiana residents who favor marijuana legalization is 45 percent.