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The authors discuss a debate in the U.S. and Canada about providing a safer supply to people who use drugs. Topics include an approach to safer supply which involves offering medications to people who use drugs, how policy debates about reducing harms posed by the increasingly dangerous drug supply would be more productive, and an example of interventions sometimes referred to as safer supply.

Background and aims: Synthetic opioids, mostly illegally manufactured fentanyl (IMF), were mentioned in 60% of United States (US) drug overdose deaths in 2020, with dramatic variation across states that mirrors variation in IMF supply. However, little is known about IMF markets in the United States and how they are changing. Researchers have previously used data from undercover cocaine, heroin, and methamphetamine purchases and seizures to examine how their use and related harms respond to changes in price and availability. This analysis used US Drug Enforcement Administration (DEA) data to address two questions: (i) "To what extent does IMF supply vary over time and geography?" and (ii) "What has happened to the purity‐adjusted price of IMF?" Methods: We developed descriptive statistics and visualizations using data from 66 713 observations mentioning IMF and/or heroin from the DEA's System to Retrieve Information from Drug Evidence (STRIDE; now STARLIMS) from 2013 to 2021. Price regressions were estimated with city‐level fixed effects examining IMF‐only powder observations with purity and price information at the low‐to‐medium wholesale level (>1 g to ≤100 g; n = 964). Results: From 2013 to 2021, the share of heroin and/or IMF observations mentioning IMF grew from near zero to more than two‐thirds. The share of heroin observations also containing IMF grew from <1% to ~40%. There is important geographic variation: in California, most IMF seizures involved counterfeit tablets, whereas New York and Massachusetts largely involved powder formulation. The median price per pure gram of IMF powder sold at the >10 to ≤100 g level fell by more than 50% from 2016 to 2021; regression analyses suggested an average annual decline of 17% (P < 0.001). However, this price decline appears to have been driven by observations from the Northeast. Conclusions: Since 2013, the illegally manufactured fentanyl problem in the United States has become more deadly and more diverse. [ABSTRACT FROM AUTHOR]

Background and aim: In Uruguay, residents age 18 and older seeking legal cannabis must register with the government and choose one of three supply mechanisms: self‐cultivation, non‐profit cannabis clubs or pharmacies. This is the first paper to measure the association between type of legal cannabis supply mechanism and traffic crashes involving injuries. Design Ecological study using ordinary least squares regression to examine how department‐level variation in registrations (overall and by type) is associated with traffic crashes involving injuries. Setting: Uruguay. Cases 532 department‐quarters. Measurements Quarterly cannabis registration counts at the department level and incident‐level traffic crash data were obtained from government agencies. The analyses controlled for department‐level economic and demographic characteristics and, as a robustness check, we included traffic violations involving alcohol for departments reporting this information. Department‐level data on crashes, registrations and alcohol violations were denominated by the number of residents ages 18 and older. Findings From 2013 to 2019, the average number of registrations at the department‐quarter level per 10 000 residents age 18 and older for self‐cultivation, club membership and pharmacy purchasing were 17.7 (SD = 16.8), 3.6 (SD = 8.6), and 25.1 (SD = 50.4), respectively. In our multivariate regression analyses, we did not find a statistically significant association between the total number of registrations and traffic crashes with injuries (β = −0.007; P = 0.398; 95% CI = −0.023, 0.01). Analyses focused on the specific supply mechanisms found a consistent, positive and statistically significant association between the number of individuals registered as self‐cultivators and the number of traffic crashes with injuries (β = 0.194; P = 0.008; 95% CI = 0.058, 0.329). Associations for other supply mechanisms were inconsistent across the various model specifications. Conclusions: In Uruguay, the number of people allowed to self‐cultivate cannabis is positively associated with traffic crashes involving injuries. Individual‐level analyses are needed to assess better the factors underlying this association. [ABSTRACT FROM AUTHOR]

Background and Aims: The US state of South Dakota's 24/7 Sobriety Program (24/7) requires individuals charged or convicted of alcohol‐involved offenses to avoid alcohol and submit to twice‐daily or continuous alcohol testing. We evaluated the impact of the 24/7 program in the US state of Montana. Methods: Using data from everyone in Montana who was convicted of their second driving under the influence (DUI) offense from 2009 to August 2013, we described program violations among 24/7 participants and then estimated the effect of 24/7 participation on the probability of DUI re‐arrest. To address potential selection issues related to individual‐level 24/7 participation, we used an instrumental variables approach that exploits county‐level variation in program adoption. Results: Among 2768 people convicted of a second DUI in our analytical sample, 356 participated in 24/7 and were monitored for an average of 173 days (median = 112 days). Among the 332 participants monitored by breath test, 95.5% of scheduled alcohol breath tests were completed and did not lead to a program violation. After controlling for individual‐ and community‐level covariates as well as year and county fixed effects, our instrumental variable models suggested that participation in 24/7 reduced the 1‐year DUI re‐arrest probability by at least 80% (preferred model: 86% decrease; 8.9 percentage points) compared with a counterfactual group of people convicted of a second DUI over the same period but not assigned to the program. Conclusions: South Dakota USA's 24/7 Sobriety Program appears to work in Montana as well. Certain delivery of immediate but modest sanctions for repeat driving under the influence (DUI) arrestees who violate alcohol abstinence orders appears to be able to reduce future DUI arrests. [ABSTRACT FROM AUTHOR]

Background: Overdose deaths related to illegal drugs in North American markets are now dominated by potent synthetic opioids such as fentanyl, a circumstance foreshadowed by often‐overlooked events in Estonia since the turn of the century. Market transitions generate important and far‐reaching implications for drug policy. Argument and analysis: The supplier‐driven introduction of illegally manufactured synthetic opioids into street opioids is elevating the risk of fatal overdose. Using the most recent overdose mortality and drug seizure data in North America, we find that overdose deaths and seizures involving synthetic opioids are geographically concentrated, but this might be changing. Examination here suggests that in some places fentanyl and its analogues have virtually displaced traditional opioids, such as heroin. The concealing of synthetic opioids in powders sold as heroin or pressed into counterfeit medications substantially increases harms. The nature and scale of the challenge posed by synthetic opioids is unprecedented in recent drug policy history. Conclusions: There is urgent need for policy and technological innovation to meet the challenges posed by illegally produced synthetic opioids. Novel interventions worth examining include supervising drug use, proactively deterring on‐line distribution and new technologies aimed at improving transparency, such as point‐of‐use drug content testing. Continuing to approach this problem only with existing policies and available methods, such as naloxone, is unlikely to be enough and will result in many premature deaths. [ABSTRACT FROM AUTHOR]

Background and aims: Debates regarding lowering the blood alcohol concentration (BAC) limit for drivers are intensifying in the United States and other countries, and the World Health Organization recommends that the limit for adults should be 0.05%. In January 2016, Uruguay implemented a law setting a zero BAC limit for all drivers. This study aimed to assess the effect of this policy on the frequency of moderate/severe injury and fatal traffic crashes. Design A quasi‐experimental study in which a synthetic control model was used with controls consisting of local areas in Chile as the counterfactual for outcomes in Uruguay, matched across population counts and pre‐intervention period outcomes. Sensitivity analyses were also conducted. Setting: Uruguay and Chile. Cases Panel data with crash counts by outcome per locality‐month (2013–2017). Intervention and comparator: A zero blood alcohol concentration law implemented on 9 January 2016 in Uruguay, alongside a continued 0.03 g/dl BAC threshold in Chile. Measurements Per‐capita moderate/severe injury (i.e. moderate or severe), severe injury and fatal crashes (2013–2017). Findings Our base synthetic control model results suggested a reduction in fatal crashes at 12 months [20.9%; P‐value = 0.018, 95% confidence interval (CI) = −0.340, −0.061]. Moderate/severe injury crashes did not decrease significantly (10.2%, P = 0.312, 95% CI = −0.282, 0.075). The estimated effect at 24 months was smaller and with larger confidence intervals for fatal crashes (14%; P = 0.048, 95% CI = −0.246, −0.026) and largely unchanged for moderate/severe injury crashes (−9.4%, P = 0.302, 95% CI = −0.248, 0.058). Difference‐in‐differences analyses yielded similar results. As a sensitivity test, a synthetic control model relying on an inferior treatment–control match pre‐intervention (measured by mean squared error) yielded similar‐sized differences that were not statistically significant. Conclusions: Implementation of a law setting a zero blood alcohol concentration threshold for all drivers in Uruguay appears to have resulted in a reduction in fatal crashes during the following 12 and 24 months. [ABSTRACT FROM AUTHOR]

Background and Objectives: To expand on epidemiologic studies examining associations between the legalization of recreational cannabis and use among young adults, we examined the associations between licensed and unlicensed cannabis outlet density and cannabis outcomes. Methods: A total of 1097 young adults aged 21 and older living in Los Angeles County were surveyed before licensed recreational cannabis outlets opened (Time 1: July to December 2017) and after (Time 2: July 2018 to June 2019). Using a database of open licensed and unlicensed cannabis retailers to calculate individual‐level cannabis outlet density measures, we examined associations between outlet density within a 4‐mile radius of participants' residences with Time 2 outcomes of any past‐month use, daily use, intentions to use, quantity used, consequences, and cannabis use disorder (CUD) symptoms. Results: After controlling for demographic factors and cannabis outcomes at a time point prior to their opening (Time 1), licensed cannabis outlets were associated with young adults' cannabis use, heavy use, and intentions, and unlicensed outlets were associated with young adults' heavy cannabis use and CUD symptoms. Conclusion and Scientific Significance: This study expands beyond studies of outlet prevalence to find that, after controlling for outcomes 1 year prior, licensed and unlicensed outlets were associated with young adults' cannabis outcomes. The current study is among the first to find associations between cannabis use outcomes and density of cannabis outlets among young adults using data from two time points: preopening and postopening of recreational cannabis retailers. Findings can inform policies around the density and placement of cannabis outlets. (Am J Addict 2020;00:00–00) [ABSTRACT FROM AUTHOR]

The authors discuss Hawaii’s Opportunity Probation with Enforcement, a program for the reduction of substance abuse by convicted persons. They mention the success of the initial program in modifying the behavior of participants, the less-successful results in other locations, and the reasons for the program's failure.

Decisionmakers continue to search for new ways to deter criminal behavior that do not rely on increasing the severity of punishment. This paper evaluates South Dakota's 24/7 Sobriety Program—a novel, large‐scale intervention requiring those arrested for or convicted of an alcohol‐related offense to abstain from alcohol and submit to alcohol tests multiple times daily. Those testing positive or missing a test receive a swift,certain, and moderate sanction; typically, a night or two in jail. To estimate the causal effect of the 24/7 program on the probability of rearrest or probation revocation for those arrested for a second or third driving under the influence (DUI) offense, we instrument an individual's 24/7 participation with program availability in the county of arrest. We estimate that the individual‐level probability of rearrest or probation revocation is 13.7 percentage points (49 percent; p = 0.002) lower for 24/7 participants than non‐participants 12 months after their DUI arrest. We detect substantive decreases at 24 and 36 months, but the precision of those estimates depends on model specification. These findings provide empricial support for applying "swift‐certain‐fair" sanctions to deter noncompliance in community supervision settings. This paper also provides policymakers with evidence for a new approach to reduce criminal activity among those whose alcohol use leads them to repeatedly threaten public health and safety. [ABSTRACT FROM AUTHOR]

Background and Aims: Supervised consumption sites (SCS) operate in more than 10 countries. SCS have mostly emerged as a bottom‐up response to crises, first to HIV/AIDS and now overdose deaths, in ways that make rigorous evaluation difficult. Opinions vary about how much favorable evidence must accumulate before implementation. Our aim was to assess the nature and quality of evidence on the consequences of implementing SCS. Methods: We reviewed the higher‐quality SCS literature, focusing on articles evaluating natural experiments and mathematical modeling studies that estimate costs and benefits. We discuss the evidence through the lens of three types of decision‐makers and from three intellectual perspectives. Results: Millions of drug use episodes have been supervised at SCS with no reported overdose deaths; however, uncertainties remain concerning the magnitude of the population‐level effects. The published literature on SCS is large and almost unanimous in its support, but limited in nature and the number of sites evaluated. It can also overlook four key distinctions: (1) between outcomes that occur within the facility and possible spillover effects on behavior outside the SCS; (2) between effects of supervising consumption and the effects of other services offered, such as syringe or naloxone distribution; (3) between association and causation; and (4) between effectiveness and the cost‐effectiveness of SCS compared to other interventions. Conclusions: The causal evidence for favorable outcomes of supervised consumption sites is minimal, but there appears to be little basis for concern about adverse effects. This raises the question of how context and priors can affect how high the bar is set when deciding whether to endorse supervised consumption sites. The literature also understates distinctions and nuances that need to be appreciated to gain a rich understanding of how a range of stakeholders should interpret and apply that evidence to a variety of decisions. [ABSTRACT FROM AUTHOR]

Aims To (1) assess trends and variation in the market share of product types and potency sold in a legal cannabis retail market and (2) estimate how potency and purchase quantity influence price variation for cannabis flower. Design Secondary analysis of publicly available data from Washington State's cannabis traceability system spanning 7 July 2014 to 30 September 2016. Descriptive statistics and linear regressions assessed variation and trends in cannabis product variety and potency. Hedonic regressions estimated how purchase quantity and potency influence cannabis flower price variation. Setting Washington State, USA. Participants (1) A total of 44 482 176 million cannabis purchases, including (2) 31 052 123 cannabis flower purchases after trimming price and quantity outliers. Measurements Primary outcome measures were (1) monthly expenditures on cannabis, total delta-9-tetrahydrocannabinol (THC) concentration and cannabidiol (CBD) concentration by product type and (2) excise tax-inclusive price per gram of cannabis flower. Key covariates for the hedonic price regressions included quantity purchased, THC and CBD. Findings Traditional cannabis flowers still account for the majority of spending (66.6%), but the market share of extracts for inhalation increased by 145.8% between October 2014 and September 2016, now comprising 21.2% of sales. The average THC-level for cannabis extracts is more than triple that for cannabis flowers (68.7% compared to 20.6%). For flower products, there is a statistically significant relationship between price per gram and both THC [coefficient = 0.012; 95% confidence interval (CI) = 0.011-0.013] and CBD (coefficient = 0.017; CI = 0.015-0.019). The estimated discount elasticity is −0.06 (CI = −0.07 to −0.05). Conclusions In the state of Washington, USA, the legal cannabis market is currently dominated by high-THC cannabis flower, and features growing expenditures on extracts. For cannabis flower, both THC and CBD are associated with higher per-gram prices, and there are small but significant quantity discounts. [ABSTRACT FROM AUTHOR]

Background and aims Prohibitions on producing, distributing and selling cannabis are loosening in various jurisdictions around the world. This paper describes the diversification of cannabis supply laws and discusses the challenges to and opportunities for learning from these changes. Methods We document changes in cannabis supply laws that de jure legalized cannabis production for medical and/or non-medical purposes (excluding industrial hemp) in Australasia, Europe, North America and South America. We also highlight challenges to evaluating these legal changes based on our experiences studying cannabis laws and policies in the United States. Findings As of August 2016, two countries have passed laws to legalize large-scale cannabis production for non-medical purposes at the national (Uruguay) or subnational level (four US states). At least nine other countries legally allow (or will soon allow) cannabis to be supplied for medicinal purposes. Most of the changes in cannabis supply laws have occurred since 2010. The data available in most countries are inadequate for rigorously evaluating the changes in cannabis supply laws. Conclusion The evidence base for assessing changes in cannabis supply laws remains weak. Efforts should focus upon collecting information about quantities consumed and market transactions as well as validating self-report surveys. [ABSTRACT FROM AUTHOR]

Background and Aims In 2014 the legislature of Vermont, USA passed a law requiring the Secretary of Administration to report on the consequences of legalizing marijuana. The RAND Corporation was commissioned to write that report. This paper summarizes insights from that analysis that are germane to other jurisdictions. Method Translation of key findings from the RAND Corporation report to the broader policy debate. Results Marijuana legalization encompasses a wide range of possible regimes, distinguished along at least four dimensions: which organizations are allowed to produce and supply the drug, the regulations under which they operate, the nature of the products that can be distributed and taxes and prices. Vermont's decriminalization had already cut its costs of enforcing marijuana prohibition against adults to about $1 per resident per year. That is probably less than the cost of regulating a legal market. Revenues from taxing residents' purchases after legalization could be many times that amount, so the main fiscal cost of prohibition after decriminalization relative to outright legalization may be foregone tax revenues, not enforcement costs. Approximately 40 times as many users live within 200 miles of Vermont's borders as live within the state; drug tourism and associated tax revenues will be important considerations, as will be the response of other states. Indeed, if another state legalized with lower taxes, that could undermine the ability to collect taxes on even Vermont residents' purchases. Conclusions Analysis of possible outcomes if Vermont, USA, legalized marijuana reveal that choices about how, and not just whether, to legalize a drug can have profound consequences for the effects on health and social wellbeing, and the choices of one jurisdiction can affect the options and incentives available to other jurisdictions. [ABSTRACT FROM AUTHOR]

Aims Drug policy strategies and discussions often use prevalence of drug use as a primary performance indicator. However, three other indicators are at least as relevant: the number of heavy users, total expenditures and total amount consumed. This paper stems from our efforts to develop annual estimates of these three measures for cocaine (including crack), heroin, marijuana and methamphetamine in the United States. Methods The estimates exploit complementary strengths of a general population survey ( National Survey on Drug Use and Health) and both survey and urinalysis test result data for arrestees ( Arrestee Drug Abuse Monitoring Program), supplemented by many other data sources. Results Throughout the 2000s US drug users spent in the order of $100 billion annually on these drugs, although the spending distribution and use patterns changed dramatically. From 2006 to 2010, the amount of marijuana consumed in the United States probably increased by more than 30%, while the amount of cocaine consumed in the United States fell by approximately 50%. These figures are consistent with supply-side indicators, such as seizures and production estimates. For all the drugs, total consumption and expenditures are driven by the minority of users who consume on 21 or more days each month. Conclusions Even for established drugs, consumption can change rapidly. The halving of the cocaine market in five years and the parallel (but independent) large rise in daily/near-daily marijuana use are major events that were not anticipated by the expert community and raise important theoretical, research, and policy issues. [ABSTRACT FROM AUTHOR]

The authors present their thoughts on desistance mandates as a method of treating drug addicts within a criminal justice setting. They detail how such mandates do not prevent individuals from receiving formal treatment or participating in self-help groups but avoids forcing participants into treatment against their will.

ABSTRACT Aims No modern jurisdiction has ever legalized commercial production, distribution and possession of cannabis for recreational purposes. This paper presents insights about the effect of legalization on production costs and consumption and highlights important design choices. Methods Insights were uncovered through our analysis of recent legalization proposals in California. The effect on the cost of producing cannabis is largely based on existing estimates of current wholesale prices, current costs of producing cannabis and other legal agricultural goods, and the type(s) of production that will be permitted. The effect on consumption is based on production costs, regulatory regime, tax rate, price elasticity of demand, shape of the demand curve and non-price effects (e.g. change in stigma). Results Removing prohibitions on producing and distributing cannabis will dramatically reduce wholesale prices. The effect on consumption and tax revenues will depend on many design choices, including: the tax level, whether there is an incentive for a continued black market, whether to tax and/or regulate cannabinoid levels, whether there are allowances for home cultivation, whether advertising is restricted, and how the regulatory system is designed and adjusted. Conclusions The legal production costs of cannabis will be dramatically below current wholesale prices, enough so that taxes and regulation will be insufficient to raise retail price to prohibition levels. We expect legalization will increase consumption substantially, but the size of the increase is uncertain since it depends on design choices and the unknown shape of the cannabis demand curve. [ABSTRACT FROM AUTHOR]

The article notes the benefits of evaluating medical articles with essay commentaries, exploring commentaries written in the issue about the articles "Supervised consumption sites: a nuanced assessment of the causal evidence," "The unmaking of 'evil': claiming space for rational discourse on US drug policy," and "How much do we need to know about supervised consumption sites? It depends who's asking."

The author discusses a study by L. Bainbridge on the transfer of 24/7 Sobriety, the Mayor's Office for Policing And Crime (MOPAC) alcohol abstinence monitoring requirement pilot, from South Dakota to South London, England. The author questions which aspects of the program have the greatest impact on reducing alcohol consumption and improving other outcomes for participants, their families and society.

A response is provided to articles in the same issue of the journal which address additional data sources for cannabis markets, the legalization of the cannabis industry, and changes in cannabis policies as of 2017. The economic profitability of marijuana as a commodity is examined, along with the structure, performance, and conduct of an industrial organization. Company loyalty and frequent buyer programs are assessed, along with data mining and smart vaporizer pens.

Commentary to: Understanding and learning from the diversification of cannabis supply laws [ABSTRACT FROM AUTHOR]

Commentary to: Considering marijuana legalization carefully: insights for other jurisdictions from analysis for Vermont [ABSTRACT FROM AUTHOR]

In this article Jonathan P. Caulkins, Beau Kilmer, Peter H. Reuter and Gregory Midgette respond to commentaries within the issue which focus on their article "Cocaine’s Fall and Marijuana’s Rise: Questions and Insights Based on New Estimates on Consumption and Expenditures in US Drug Markets". In the article they offer opinions on several points which are raised within the commentaries and on several aspects of their own article which are discussed in the commentaries.

The author discusses the legalization of commercial production and sale of cannabis in the first two states, namely, Colorado and Washington in the November's 2012 elections. The author mentions that the greatest change that has occurred following the passage of cannabis measures is the ability for individuals over the age of 21 to legally possess and grow cannabis products in those states. The author provides that the consequences of the legalization are yet unclear.

In this article, researcher Johnathan P. Caulkins responses to the commentatries made on his study related to the issue of legalizating cannabis. He mentions that his study focused on design choices for implementing legalization of cannabis. He also mentions that the production costs after legalization process can drop below the current wholesale prices. Further he mentions the Kettil Bruun Society has reveals the difficuties in regulation right for drugs as they have been conforting the nuances of alcohol control for 25 years.