Losing The War On Drugs: The Drug War's Health Problem, Part 7

DO OUR DRUG LAWS HARM US MORE THAN THEY HELP?

A growing number of doctors and public health officials say criminal law
is, at best, useless in stopping the damage to health caused by drug use.

Early one morning in 1993, Alan and Eleanor Randell were startled by the
sound of the doorbell in their Victoria home. At the front door were two
police officers. "As soon as I saw them," Eleanor Randell says, her voice
shaking even now, seven years later, "I knew that there was something wrong."

Their 19-year-old son, Peter, had died of a heroin overdose.

It was the nightmarish moment every parent fears. Clear away all the
arguments about drug policy, all the laws, the statistics, the debates, and
you find parents terrified that, one morning, the police will come to tell
them that drugs have taken their child. This visceral fear is the core
reason that drug prohibition continues to enjoy overwhelming public
support. Parents want the criminal law, police, prisons -- and whatever
else it takes -- to keep drugs away from their children.

But not Alan and Eleanor Randell. Perhaps shockingly, these people who have
actually lived every parent's nightmare don't blame drugs so much as the
criminal law itself for Peter's death. They say that drug prohibition, the
very policy designed to protect their child from drugs, turned his risky
decision to try heroin into a deadly one.

The Randells aren't alone in pinning responsibility for drug-related harms
on the criminal law. A growing number of doctors, public health officials
and advocates who work with drug users say that the criminal law is, at
best, useless in stopping the damage to health that drug use can cause. At
worst, they say, drug prohibition actually causes many of the horrific
harms that we blame on drugs. Like medieval surgeons bleeding their
patients, governments may be killing more people with the criminal law than
does the disease they seek to cure.

Before he died, Peter Randell looked nothing like the self-destructive
wreck that is the public's image of a heroin user. He was a bright
19-year-old, an excellent student who had recently graduated from high
school. He was also an independent, creative spirit who read widely,
including Henry Miller, James Joyce, Anais Nin and many others. Peter knew,
his mother says, that many of these authors "used heroin with no ill
effects and he felt it increased their creativity. And I know that was
where Peter was coming from."

Like many other bright teenagers, Peter wanted to try drugs not to escape
emotional pain, but in the romantic, perhaps foolish, hope of opening "the
doors of perception," as Aldous Huxley called his 1954 record of drug
experimentation. An entry in Peter's journal written shortly before he died
describes his first use of cocaine. There is no mention in the journal of
trying heroin, his mother notes, strongly suggesting that the overdose that
killed Peter was his first use of the drug.

Contrary to popular wisdom, most people who use illegal drugs, even cocaine
and heroin, do not go on to become regular users, let alone addicts. It is
especially unlikely that a well-adjusted teenager experimenting with drugs
out of intellectual curiosity will become addicted. Whether that teenager
will get through this experimental phase unscathed is another matter.

Peter Randell didn't, because he broke two basic rules.

Rule No. 1: Never mix heroin with alcohol, or other depressants. Taking
alcohol together with heroin is far more dangerous than taking heroin
alone. Estimates vary, but it is certain that a large proportion of heroin
overdoses is actually the result of taking alcohol and heroin together.

Rule No. 2: Never use heroin alone. Overdose begins with a loss of
consciousness, so it's critical to have someone present to administer help,
or call for it.

Neither Peter nor the friends with whom he took heroin were experienced
users. It's unlikely they knew these basic rules.

They broke the first rule by drinking a large quantity of beer at a bar
before going back to a Vancouver apartment and taking heroin. They all took
the heroin, then separated to sleep in the various rooms of the apartment,
breaking the second rule.

Peter died, alone, in his sleep.

For that, the Randells blame the law. "If he could have gone to the store
and bought (heroin) knowing what he was doing, the way you buy a bottle of
aspirin, this wouldn't have happened," Eleanor Randell explains quietly.
"You buy a bottle of aspirin, it tells you what to do, what not to do. You
buy a bottle of antihistamine, it tells you not to drive, don't mix with
alcohol, all that sort of stuff. Heroin, you don't get that information."

Another place Peter might have been told this is school. But drug education
in most schools does not tell teenagers how to minimize risks. It takes a
"just say no" approach that drills students in the hazards of drug use but
almost never teaches them basic information about how to minimize the risks
of using drugs if they insist on trying them.

Very often, that's because educators worry that to do so would be condoning
an illegal act. Police officers are particularly sensitive to this, and
they are often the main source of drug education in schools. Police, even
drug education specialists, also tend to have little knowledge of the
scientific reality of drug use and, as a result, they jumble together the
very real dangers of drug use -- that cocaine in large doses can cause
heart attacks, for example -- with common myths -- that crack cocaine or
heroin are "instantly addictive." Not only is it inherently harmful to
teach students scientific falsehoods, but the nature of many drug myths,
especially the idea that a drug can be "instantly addictive," encourages
educators to think it is simply impossible to teach ways of minimizing the
risks of drug use.

Just how unsuccessful this approach is can be seen in the United States.
Despite massive anti-drug campaigns of this sort in schools across the
country -- backed up by expensive national advertising campaigns -- the
U.S. has some of the highest youth drug-use rates in the world. For much of
the last decade, young people's use of most illegal drugs climbed even as
drug education budgets grew.

Many young people, it seems, can't be scared off. "So what do we do?" asks
Eugene Oscapella, an Ottawa lawyer and a director of the Canadian Drug
Policy Foundation. If some teens are going to ignore warnings and threats,
"do we abandon them entirely and leave them to their own devices so they
have absolutely no prospect of doing it relatively safely? Or do we
acknowledge the fact that despite our warnings some people are going to do
things that are risky and we try to minimize the risk?"

One public health official compared drugs with sex education, where
teenagers are told the many good reasons why they shouldn't engage in
sexual activity, but also told how to reduce the risks if they do. Parents
generally support that approach with sex education, but not with drugs. As
a result, schools teach students about condoms but don't tell them
potentially life-saving information about drug use.

Without that information, Peter Randell died.

Since that terrible day in 1993, Alan Randell says, he has "done a lot of
reading" about drugs and prohibition, leading him to conclude that the
ignorance which killed his son is just one of many ways that the criminal
law actually causes the very health harms it is supposed to stop. Many
health officials and activists agree.

Mr. Randell, an accountant with the B.C. Ministry of Health, has a degree
in chemistry. His father was a pharmacist. His brother is a doctor. He
doesn't see drugs as mysterious, frightening things. They can be understood
and dealt with rationally, he says, and the first step toward that is
learning from past mistakes. "More people should know about the prohibition
of alcohol and what happened then," he suggests. "It's just the same thing
happening today."

One striking parallel is the rising potency of drugs that has followed
whenever they have been banned. In 1920, when the U.S. banned alcohol, beer
and wine consumption dropped off precipitously, while the consumption of
spirits rocketed up. At the same time, spirits became more and more potent
as moonshiners created brands like "White Mule Whiskey" that bragged of
their kick. By some estimates, alcohol products sold during Prohibition
were on average 150-per-cent stronger than pre- or post-Prohibition booze.
As a direct result, the number of alcohol-related deaths steadily rose
throughout Prohibition.

The same process is at work today wherever law enforcers have made serious
efforts to suppress illegal drugs. Since 1982, cocaine purity in the U.S.
has risen 30 per cent. Heroin is 40-per-cent stronger. In 1999, the RCMP in
Vancouver seized a major shipment of heroin that was 99-per-cent pure.

The reason illegal drugs get more potent is elementary: They have to be
smuggled and hidden. A case of whiskey may have the same alcohol content as
a dozen kegs of beer, but the whiskey is far easier to smuggle. It's also
easier to smuggle 180-proof booze than 90-proof because it contains the
same amount of alcohol in half the volume. In the same way, low-purity
cocaine and heroin are easier to smuggle than bulky marijuana, and
high-purity cocaine and heroin are easier still to slip across borders. The
more vigorously the police try to stop smugglers, the greater the incentive
smugglers have to make drugs stronger. In effect, law enforcement makes
illegal drugs more potent.

(Marijuana hasn't been replaced like beer and wine during Prohibition, in
part because it contains a different drug than its competitors, so it's not
interchangeable like beer, wine and spirits. Also, at least half of the
marijuana in Canada is grown domestically, so it doesn't have to go through
the rigours of international smuggling.)

Rising potency can be deadly. Dean Wilson, the vice-president of the
Vancouver Area Network of Drug Users (VANDU), a support group for drug
users, says "purity is a huge issue" for addicts trying to survive on
Vancouver's streets. Because drugs aren't tested and labelled, only
experience can tell a drug user what single dose, or "flap," is safe. But
that experience is only good as long as the purity of drugs on the market
doesn't rise. When it does, users "put the same $10 flap in and die."

A similar threat is posed by tainted drugs. Because alcohol is legal,
government regulators can inspect the facilities of brewers and distillers
and test their products. If they sell products that aren't precisely what
they claim to be, and those products do harm, sellers risk criminal
negligence charges. And customers can sue. None of this is true of illegal
drugs.

When the U.S. banned alcohol in 1920, it immediately unleashed a flood of
tainted, fraudulent and poisonous alcohol. Drinkers in speakeasies
swallowed moonshine made from unknown substances and distilled in rusty
equipment. Huge numbers of drinkers unwittingly quaffed wood alcohol. One
concoction, known as "Jamaica Ginger," or "Jake," caused partial paralysis
in thousands of drinkers, giving them a distinctive shuffle known in
popular culture as the "Jake walk."

Estimates vary, but it's likely that tens of thousands of Americans were
killed by poisonous alcohol in the 13 years of Prohibition. Even greater
numbers were left blind, paralysed or otherwise damaged.

Prohibition officials and supporters acknowledged the carnage but rather
than seeing it as an indictment of their policy, they blamed drinkers. One
official dismissed anyone who died of tainted alcohol as a "deliberate
suicide," and Prohibition Commissioner Roy Haynes piously declared, "Who
drinks bootleg drinks with death."

Like suppliers of alcohol during Prohibition, traffickers of illegal drugs
cannot be regulated or sued. As a result, illegal drugs sold on the black
market are often tainted, fraudulent and poisonous.

This is "one of the main reasons we have overdose deaths," says Diane
Riley, deputy director of the International Harm Reduction Association and
a board member of UNAIDS, the United Nations body directing the
international effort against AIDS. Ms. Riley cites the example of Ecstasy
(3,4-Methylenedioxymethamphetamine, or MDMA), popular among teenagers
attending raves. "When people think they're getting Ecstasy, they're in
fact often getting many other synthetic drugs that aren't Ecstasy." An
American organization that tests pills sold as Ecstasy at raves has found
that one in five contains no MDMA at all. Many of the bogus pills are made
of DXM, a cheap cough suppressant that also suppresses sweating -- which
can easily cause heatstroke if the consumer is doing something strenuous,
such as dancing. These and other frauds are the actual cause of many -- no
one's sure how many -- of the deaths linked to Ecstasy.

Another type of dangerous fraud often occurs when drugs have been moved to
the street level. Sellers often maximize profits by diluting their drugs
with other substances, such as talcum powder, baking soda or anything else
that's on hand. Some adulterants have no effect on the user. But others do
serious harm. Heroin, for example, is sometimes cut with quinine, which can
produce pulmonary edema (fluid in the lungs) and a quick death. Only by
using the drugs can purchasers discover if the adulterants are harmful, and
by then, of course, it's too late.

Unable to test and regulate illegal drugs, the usual way public health
officials spot bad drugs is to follow the corpses. In one case last May,
heroin addicts turned up in hospitals in Glasgow bearing abscesses of up to
30 centimetres in diameter. They were treated with antibiotics but many
people still grew sicker and died. Similar outbreaks appeared all over
Britain and Ireland. Officials eventually traced the deaths to a batch of
heroin infected with a bacterium found in soil. By the time the bad drugs
had been identified and warnings issued, more than 30 people were dead.

These outbreaks are far from uncommon. Ms. Riley points to Vancouver, where
researchers have done extensive work in tracking drug-related deaths. "What
you'll see," she says, "is a wave of deaths when there is a particular
contaminant in the product. Or you'll see a wave of deaths when there's
suddenly a surge of very high purity."

The public generally writes off these deaths as "drug overdoses," as if
they are the inevitable result of drug use. They are not. They are the
result, Ms. Riley insists, of using "unregulated, unknown products."
Untainted drugs of constant purity can and do kill users, of course, and
it's not known precisely how many drug-related deaths are actually the
result of rising purity or adulteration. But it is "certainly" the
majority, says Ms. Riley.

Overdose deaths are higher than ever across Canada, but the toll is worst
in British Columbia. Drug-related fatalities in that province rose steadily
throughout the 1990s until, in 1998, drug users were dying at a rate of
more than one a day. After a small decline in 1999, the number of overdose
deaths is rising again. "We're predicting that they're going to be up again
this year in the 300 to 400 range," says Dr. Perry Kendall, British
Columbia's Provincial Health Officer. As of mid-July, 177 had died.

Horrific as this is, Ms. Riley says the health damage inflicted by the
criminal prohibition of drugs is even more profound, if not so readily
apparent. For instance, shooting drugs with needles, she insists, "is
itself a manifestation of the criminalization of drugs."

By the mid-19th century, the syringe was perfected and much of that era's
medical use of drugs like cocaine and morphine was by injection.
Non-medical injection was also not uncommon. But the widespread abandonment
of other drug-taking methods in favour of needles only developed after
drugs were banned in the first half of the 20th century.

The explanation lies partly in economics. Drug prohibition makes drugs
extremely expensive. Experience shows this doesn't deter use, particularly
by addicts who, almost by definition, will sacrifice other priorities to
pay for drugs. But it does strongly encourage heavy users -- especially
teenagers, the poor, and addicts bankrupted by the inflated cost of drugs
- -- to seek out drugs that give the best "bang for the buck" and to use
those drugs in the most cost-efficient way.

Further encouraging this attitude is the fear of arrest: Faster drug-taking
methods minimize the risk of getting caught in possession of drugs. Even
drug interdiction contributes by encouraging smugglers to favour more
potent forms of drugs over less potent, more natural forms.

All these factors lead users toward more potent forms of drugs and more
dangerous methods of ingestion. At the end of that line is the needle.

Take the drugs derived from the opium poppy: opium, morphine (first
produced in 1806), and heroin (first produced in 1883). For centuries, even
millennia, people in societies around the world smoked opium. They also
stirred it into liquids (mixed with alcohol, it was called "laudanum") and
swallowed it. After opium was banned, both practices became rare, and opium
itself became increasingly scarce at the consumer level. Heroin has taken
its place. And instead of swallowing or smoking the heroin as they had for
centuries with opium, most users inject it.

This happened because heroin is far more potent than opium. And injection
is faster and more "cost-efficient" than smoking, and far more so than
swallowing.

Unfortunately, heroin's greater potency also gives it much greater
potential for overdose than opium. And injection, by delivering the biggest
drug load in the fastest possible way, also maximizes the chance of overdose.

Thus, by banning drugs, governments actually pressed users toward the most
dangerous form of the drug and the most dangerous method of taking it.

This perverse progression can also be seen with cocaine. For centuries,
South American aboriginals chewed coca leaves, a practice that safely and
slowly delivers a modest amount of cocaine. Similarly, tea, wine and soft
drinks can be made with cocaine content. These fairly benign uses of
cocaine were very popular in the 19th century -- especially the
cocaine-laced drink called Coca Cola.

In 1860, Europeans discovered how to extract pure cocaine from coca in
powder form, allowing it to be snorted, a more potent and quicker method of
delivery. Smoking cocaine is an even quicker way to deliver more of the
drug to the body. Injecting cocaine is the fastest way to deliver the
heaviest drug hit.

Each step in that progression is more dangerous than the last, yet exactly
this slide has taken place.

Coca is still chewed in pockets of South America where the coca bush is
grown, but nowhere else. Cocaine drinks are gone.

It was difficult at first to smoke cocaine because the powder doesn't burn
properly. One solution was "freebasing," which involved the addition of
some dangerously combustible chemicals. But then in the early 1980s, users
learned that just by adding baking soda, cocaine could be made smokable,
giving a bigger, faster rush than inhaling the same amount of powder cocaine.

It was, in other words, very "cost-efficient." This form of cocaine could
therefore be sold in tiny hits that cost only $5 or $10 each, making it
highly attractive to the urban poor. Thus was born "crack" cocaine.

And then, finally, there is cocaine by injection. Once little-known, the
injection of cocaine is an increasingly popular option, even the leading
method of taking the drug in some parts of the world. Addicts even inject
crack.

Unlike heroin, the high from injected cocaine doesn't last long, so a
cocaine addict will have to shoot up more frequently -- even 20 times a day
or more. Every puncturing of the skin carries a risk of infections, even if
clean needles and syringes are used.

But drug users often don't use clean needles. In part, that's because
paying black market prices for drugs often bankrupts addicts, leaving them
living in chaotic circumstances without the cash to pay for a steady supply
of clean equipment. In some jurisdictions, it's also because the law
forbids not only drugs but the devices for using them, and thus makes users
reluctant to keep needles in their possession. (In Canada, it is illegal to
distribute drug paraphernalia, but not possess it. Needle distribution
isn't banned, however, because devices for stopping the spread of disease
are exempted. This likely includes needles and syringes, though the law
isn't entirely clear.)

So users will often share needles and syringes. In doing so, they also
share infections, including hepatitis and HIV.

Alternatively, users will often go to a shooting gallery where the gallery
will supply the syringe and the drug, notes lawyer Eugene Oscapella. "In a
situation like that, the shooting gallery may not provide clean equipment.
(But) even if they give you a clean syringe, if you end up rinsing your
syringe in a bowl of water that's turned pink with the blood of other
people using that same bowl of water, you're at great risk of infection."

Needle exchanges have helped to reduce this damage in Canada, but only
modestly. Among Canada's estimated 50,000 to 100,000 injection drug users,
blood-borne infections are rampant. In many parts of the country, 80 to 90
per cent of injectors are infected with HIV or hepatitis B or C. By one
estimate, half of new AIDS cases are related to injection drug use. Up to
25 per cent of Vancouver's injection drug users are infected with HIV. In
Ottawa, two studies have found that about one in five injection drug users
has HIV -- after Vancouver, the highest rate of infection in Canada. (It
is, incidentally, a myth that needle exchanges actually increase infection
or increase injection drug use, accusations commonly heard in the media.
Exchanges have been studied exhaustively and experts reject these claims.)

The story is at least as bad, and often much worse, around the world. In
some countries, more than two-thirds of injection drug users are infected
with HIV. In the United States, where the federal government has opposed
needle exchanges and many states have laws forbidding even privately funded
exchanges, 250,000 people have contracted HIV by sharing needles.

"You can see the course of HIV following the drug route," says Diane Riley.

The criminal law makes this dire situation even worse by imprisoning drug
users. That puts "a whole wash of people in your correctional system who
are HIV-positive," notes Ms. Riley. In Canadian prisons, like most prisons
around the world, there are no needle exchanges and possession of needles
is strictly forbidden. So prisoners share needles, "some of which have been
used hundreds of times over 10 years." And it's not just existing injection
drug users who use these needles. Prison life is so monotonous it
encourages prisoners who either hadn't used drugs before going to prison,
or hadn't injected, to shoot up.

In these conditions, HIV and other infections can spread like the plague.
One study in Scotland found that in a two-week period, as many as 40
prisoners involved in needle-sharing got HIV. By one estimate, 40 per cent
of Canadian prisoners have hepatitis C.

When their sentences are over, newly infected convicts leave prison and
take their infections with them. In effect, drug prohibition has turned
prisons into vectors for the transmission of blood-borne diseases. Prisons
also loom large in the thoughts of that blighted minority of drug users who
become serious addicts. Bud Osborn, an award-winning poet and recovering
heroin addict who spent decades shooting drugs in various North American
cities, sums up the core activity of an addict's life: "Primarily, you're
trying to avoid arrest and identification by the police."

Fear dominates addicts' thoughts and changes their behaviour in numerous,
destructive ways. Dr. Kendall, British Columbia's provincial health officer
and the former president of the Addiction Research Foundation, cites the
crucial moments that follow a drug user's overdose. "There is a reluctance
to stay with somebody" after an overdose occurs and help is called, he
says. Calling 911 about a drug overdose brings the police, and that means
possible arrest. Users know this and get away as fast as they can, leaving
no one to offer "mouth-to-mouth resuscitation or help to the person."
Worse, users will often waste precious time getting rid of drugs and other
evidence before they call for help.

Or they won't call at all. One study of actions taken by drug users
immediately after overdoses occurred found that in just 14 per cent of
cases was calling an ambulance the first thing they did; in half of the
overdoses, an ambulance was never called.

Drug users are reluctant to seek help in other situations as well. A report
issued jointly by the Canadian Centre on Substance Abuse and the Centre for
Addiction and Mental Health (formerly the Addiction Research Foundation)
stated that the "illegal status of street drugs makes users reluctant to
discuss their drug use or seek treatment when they need it." That point was
underlined by the HIV, AIDS, and Injection Drug Use National Action Plan, a
1997 report funded by Health Canada. Fear of the law, the report states,
makes drug users "afraid to go to health or social services."

That fear even dogs addicts when they personally suffer medical
emergencies. Ann Livingston, the director of VANDU, works closely with
addicts in the sad streets of east Vancouver. She describes addicts who
will "go in the hospital, and the cops will be in emerg, so they use an
assumed name. Someone doubled over in pain, like dying, and they're worried
about getting busted."

The criminal law is worse than useless in helping drug users, the National
Action Plan stated. It only contributes to the "marginalization and
stigmatization" of addicts.

(The federal official responsible for the criminal law, Justice Minister
Anne McLellan, declined to be interviewed for this series. So did her
predecessor and current federal minister of health, Allan Rock.)

Marginalization is key to understanding the predicament of drug addicts. In
the public's mind, drug addicts are derelicts who live in squalid ghettoes.
But drug addiction alone is highly unlikely to reduce people to that
miserable state. It is the criminalization of what the addict needs, and
the labelling of addicts as criminals, that turns them into human wreckage.
The millions of prescription drug addicts worldwide do not live in slums,
and relatively few alcoholics look like the walking dead of Vancouver's
east side. But "if you're dependent on something illegal, whether it's a
drug or whatever," says Diane Riley, "that's the way you're going to look."

Ms. Riley points to the experience of the United Kingdom, which allowed
doctors to prescribe pharmaceutical heroin, or other drugs, to addicts from
the 1920s until the stricter American approach was picked up in the late
1960s (the U.S. approach led to disastrous results, including soaring
addiction, crime and death rates.) Without fear of arrest and the
debilitating cost of black-market drugs, these addicts typically lived
stable, middle-class lives. "You see them functioning perfectly well with
their families and so on," Ms. Riley says, "and you get quite a different
picture." (Throughout this 40-year period, addiction, death and crime rates
also remained a small fraction of what they were in the U.S.)

This simply confirms what historians have known all along: Many people who
become addicted to drugs can continue to maintain homes, families and
reasonable careers -- if they have safe, legal access to the drugs they
need. Many of the famous examples of successful addicts are doctors,
including Dr. William Halsted, the renowned turn-of-the-century surgeon and
co-founder of Johns Hopkins Hospital, who was secretly addicted to cocaine,
and later morphine, for most of his life.

A Swiss project gave modern support for this perspective. From 1994 to
1997, the Swiss government gave prescription heroin to 1,100 addicts who
each had made at least two failed attempts at conventional forms of
treatment. The results were startling. There were no deaths from overdoses.
The physical health of addicts improved enormously. The percentage of
income from illegal activity fell from 69 to 10 per cent while the number
of unemployed fell from 44 to 20 per cent. The percentage of those with
permanent employment jumped from 14 to 32 per cent. The use of cocaine and
heroin dropped and 83 people gave up drugs altogether -- suggesting that
when addicts' lives are stabilized by removing the fear of arrest and the
constant hunt for cash to pay for expensive drugs, they are more likely to
reduce drug use and perhaps give it up altogether.

Despite stiff opposition from the U.S., numerous other countries are
conducting or considering similar heroin maintenance trials. Other policies
that make minimizing the risks of drug use, not abstention, their top
priority, are popping up in numerous countries.

If a thaw in drug war attitudes does come, it will be far too late for so
many victims of drug prohibition and their families. But that hasn't
stopped Alan and Eleanor Randell from going to conferences, joining
advocacy groups opposed to prohibition and writing letters denouncing the
policy they are sure killed their son.

It's been seven years since the Randells took the long ferry ride across to
Vancouver to identify their son's body, but even talking of that day
wounds. Mrs. Randell pauses, a long silence filled with loss. She concludes
softly, "It's a terrible looking thing to see, to see your young child dead
like that."