Marijuana, Opioid ‘Low-Hanging Fruit’ Of Drug Decriminalisation, Says Yale Expert

People jailed for drug abuse are 8x more likely to die the year after release than those with the same risk factors who weren’t incarcerated, says Prof Dr Frederick Altice.

KUALA LUMPUR, August 5 – Efforts to decriminalise some drug offences in Malaysia should include the use and possession of marijuana and opioids for adults, said Prof Dr Frederick Altice, founder of the Yale School of Medicine’s HIV in Prisons programme.

Dr Altice, a clinical epidemiologist at Yale University in the United States, said any effort to decriminalise drugs would mean separating criminalisation from “things that are treatable”.

“Alcohol is treatable. Opioids are treatable. Amphetamines are going to be a problem here, stimulants are tough, and they’re also associated with violent things. So this is where the rubber is going to hit the road in Malaysia. For us (in the US), it’s cocaine. So that’s our stimulant,” Dr Altice told CodeBlue in an hour-long interview here in Kuala Lumpur last June.

“So I would say that opioids are really easy. For marijuana, people don’t, you know, harm anybody. They don’t break major laws. They get mellow, whether it’s to relax or whatever. But we have treatable things.

“I think stimulants are going to be a bit of a problem, so our treatments are expensive. They’re more expensive than other sorts of methadone, costing six cents a day, the cheapest treatment. I mean, I can’t treat anything else for that price.

“So I suppose we should sort of prioritise – pick the low-hanging fruit, do it, study it, evaluate it, and go with the next sort of thing. You don’t have to fix everything. You have to have a plan to fix it all, but you can do it incrementally,” Dr Altice said.

Opioids are a class of drugs found naturally in the opium poppy plant that works in the brain to produce a variety of effects, including the relief of pain. Opioids can be prescription medications often referred to as painkillers or in the form of “street” drugs, such as heroin.

In Malaysia, heroin is still the primary illicit drug used. Methadone maintenance treatment, or methadone replacement therapy, was established in 2005 as a harm reduction programme for opioid abusers.

Drug substitution therapy is intended to substitute more potent drugs such as heroin with prescribed medication of similar action with a lower level of addiction and craving.

Amphetamines are stimulant drugs. They make the messages between a person’s brain and body move faster, making them more alert and physically active.

Ecstasy is an empathogen drug that contains methylenedioxymethamphetamine (MDMA), a derivative of amphetamine. The effects of ecstasy are similar to amphetamines, such as feeling energetic and euphoric and having an increased heart rate.

Empathogens are a class of psychoactive drugs that induce feelings of empathy and emotional openness.

The term “marijuana” is often used interchangeably with cannabis, a type of plant in the Cannabaceae family. In the US, marijuana legally refers to cannabis that has more than 0.3 per cent THC, one of the psychoactive chemicals found in the cannabis plant that produces a “high”.

Malaysia’s drug policies are historically grounded on harsh punitive measures, including arresting and incarcerating users and using the death penalty for trafficking offences.

However, in recent years, the government has become more open to addressing the nation’s drug epidemic through a public health approach rather than a criminal justice approach.

In 2019, former health minister Dzulkefly Ahmad announced federal plans to remove criminal penalties for possessing and using a small quantity of drugs for personal use. The trafficking of drugs, however, remains a crime.

Under existing laws, anyone found with 200 grams of cannabis, 40 grams of cocaine, and 15 grams of heroin or morphine risks being charged with drug trafficking – a crime that carries a mandatory death sentence. About two-thirds of over 68,000 inmates in Malaysian prisons are there after conviction for drug possession.

Earlier this year, current health minister Khairy Jamaluddin announced a review of the Dangerous Drugs Act 1952 and the Poisons Act 1952 to regulate the medical use of marijuana and ketum.

The Ministry of Health (MOH) will also introduce a framework later this year to register prescription drugs containing cannabidiol (CBD). However, the framework will only apply to prescription CBD, not for self-medication or recreational use, Khairy stressed.

Malaysia currently has no registered CBD-infused treatment, although existing legislation does not prohibit the use of cannabis for medicinal purposes.

CodeBlue previously reported the National Pharmaceutical Regulatory Agency (NPRA) confirming the approval of a prescription medicine derived from cannabis in 2014 to treat muscle spasms and spasticity from multiple sclerosis.

Despite its approval, Sativex — an oromucosal spray of a formulated cannabis extract with CBD and THC, the psychoactive chemical component in cannabis — was taken off the Malaysian market three years later as it was not commercially viable. Sativex was developed by GW Pharmaceuticals, a maker of cannabinoid therapeutics based in Ireland.

Around the world, attitudes towards cannabis, or marijuana, have been gradually shifting as governments from Mexico to New Zealand consider relaxing their laws to allow the use of the drug either medically, recreationally or both.

In the US, 38 states have legalised medical marijuana to varying degrees, while 18 states and Washington DC have approved recreational cannabis use.

Drug Abuse Prisoners Eight Times More Likely To Die A Year After Release

For drug-dependent individuals who go to prison, Dr Altice said they are eight times more likely to die in the year after release than those with the same risk factors but who have never been incarcerated.

“So, if you’re a person who uses drugs, and you go to prison, and you get released, you are eight times more likely to die because the person is interrupted,” said Dr Altice, who has conducted extensive studies on substance abuse and infectious diseases involving vulnerable populations, including prisoners and sex workers, in Malaysia.

“Let’s just say that I’m using heroin, and I’m using it every day, and I’m developing tolerance – I can tolerate more and more and more.

“So let’s just say you have a bag of heroin, and you’re doing 10 bags of heroin before you come in. You go to prison, detox, and they do nothing. Your tolerance goes back down. And then you leave (prison). When you restart back again, your body is not used to it, and you will break.

“That is one of the reasons people with HIV – if they don’t get treatment in prison, their health deteriorates. So they’ve spent two years in prison with no treatment, and their T cells are going down. And they’re really at risk of dying because there is no access to treatment. So these are all factors. So that interruption, taking people out.

“And then the other thing that happens is that people who leave prison, the people they used to buy drugs from, the people who they hang out with, their families, their networks, their support networks are all disrupted. So all of that comes to play,” Dr Altice said.

T cells are white blood cells that are part of the immune system. T cells help protect the body from infection and may help fight cancer. One of the indicators of HIV infection is a gradual loss of CD4 T cells. CD4 T cells are considered “helper” cells because they do not neutralise infections but instead trigger the body’s response to infections.

“I think that the justice system has been harmed by the way that things are set up. So you typically have a Ministry of Justice or Law that handles prisons and a Ministry of Health that handles health. But there’s a grey zone where there’s the expectation that the prison department that doesn’t have money for health is going to do it.

“They don’t have the resources, and they don’t have the pharmacies, they don’t have any of that. And the health system says, ‘Oh, we’re going to help you with that.’ But in reality, it doesn’t happen because the prison is supposed to do that.

“So it’s kind of like you’re saddling another land. Basically, you’re forgotten about, so everybody thinks the other person is supposed to do it.

“And so when you talk to the people in the justice system, they are very committed to getting help, but their hands are strapped because they are not a health delivery programme.

“And then you have the people in health like, oh, I can’t go into prison. That’s a dangerous place or, you know, you have to send your people to my clinic, which is not realistic.

“So this balance of health and safety, there’s a tension there, and you have to redefine your systems, so those come together,” Dr Altice said.

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