DRUG PROHIBITION AND PUBLIC HEALTH

ADVERSE OUTCOMES

DAWN was established in the mid-1970s by the Federal government to monitor
two important outcomes of drug use--drug-related hospital ER admissions and
deaths in which drugs are implicated. Surprisingly, these data show a
distinctly different time trend from the data on the prevalence of drug use
in the same time period (Figures 5 and 6).

Both drug-related ER visits and deaths climbed steadily after 1979, the
peak year for all drug use, rose most sharply in the mid-1980s just as the
prevalence of use was declining most rapidly, and continued to rise through
the 1990s, despite low and stable drug prevalence among adults. Drug-
related ER visits rose by 60% from 1978 to 1994 (from 323,100 annually to
518,500) while overall ER visits increased by only 26%.[22]

These increases are most strongly associated with the use of cocaine and
heroin (Figure 8), which together account for fewer than 4% of all illegal
drug use but are mentioned in more than 40% of all drug-related ER visits
and more than 90% of deaths due to overdoses. And while there are a growing
number of overdose deaths seen among the new, younger users of heroin,[1]
the age-adjusted death rates show increases in every age group for the
period 1985-1995,22 with the highest rates in the 35-44 age group (an older
cohort of established users).[23]

Overall, drug-related deaths more than quadrupled from 1976 to 1995--from
2136 to 9097 annually.[22,24–38] (See Figure 9.)

It would appear that drug use is becoming more dangerous.

Even as the numbers of drug users have gone down, the per-user rates of ER
visits and fatalities have been much higher since the mid-1980s. If we
measure the success of our drug policy in terms of adverse public health
outcomes instead of prevalence of drug use, it is clear that we are doing
worse, not better.

But if the time trends in drug-related morbidity and mortality do not
correspond to trends in the overall prevalence of adult drug use, as we
would expect them to, what accounts for the sharp climb in both as
prevalence declined? And to what extent is this increase a reflection or
result of our drug policy? To answer these questions it is necessary to
disaggregate the data.

DRUG POLICY IN BLACK AND WHITE

Disaggregating the data on adverse outcomes and drug enforcement by "race"
suggests that the greater the intensity of criminal penalties, the greater
the public health danger of drugs.

The enforcement of drug laws is not applied equally to all groups: despite
comparable rates of drug use, African Americans are disproportionately
represented among imprisoned drug offenders. Figure 10 shows white, black,
and Hispanic drug law violators as a proportion of all state prison inmates
for 1986 and 1991. Today, state prison incarceration rates for African
Americans for drug law violations are almost 20 times those of whites and
more than double those of Hispanics.[14] From 1990 to 1994, incarceration
for drug offenses accounted for 60% of the increase in the black population
in state prisons and 91% of the increase in Federal prisons.[14] This trend
corresponds to the higher proportion of African Americans incarcerated for
all reasons: 6296 per 100,000 adults in 1995, compared with 919 per 100,000
for whites--a ratio of 7.5 to 1. [14] By 1995, 35% of all African American
males ages 25-34 were under the control of the criminal justice
system--behind bars, on probation, or on parole.[39]

Drug enforcement (arrests, incarcerations, probation, parole) may itself be
considered another adverse out-come of drug use--a measure of social
morbidity with enormous negative consequences for those caught up in the
criminal justice system. The damages that a prison record does to a young
person's self-esteem and social and economic prospects are well known. In
addition, a recent study reveals that in 1998, 3.9 million convicted felons
(which includes all drug offenders), were disenfranchised as citizens and
lost the right to vote.[40] Reflecting the disproportionately high rates of
prosecution for drug offenses, disenfranchisement of African Americans
occurs at three to four times the rate of whites. In states with the most
restrictive voting laws, as many as 40% of African American men are likely
to be permanently disenfranchised, according to the study's authors.[40]

I would suggest, however, that drug enforcement can also be viewed as an
independent variable--a causal factor responsible for worsening many of the
social and public health problems that we normally attribute to drug use
per se.

Effects Of Differential Enforcement.

Prohibition criminalizes all drug users, buyers and sellers equally. For
those who are drug-dependent or addicted and cannot gain access to
effective treatment, these laws dictate a life of crime and of degradation,
deceit, and (for the poor) prostitution and drug trafficking to obtain the
money needed to shop in a violent and expensive marketplace. Further, the
drug user is continually exposed to risks to health and life--to infectious
diseases through the re-use of injecting equipment (also criminalized and
still prosecuted under drug paraphenalia laws) and to the unpredictable
effects of illicit substances of unknown purity or potency. The powerful
stigma of addiction relentlessly pushes the addict to the margins of
society, away from family and social supports, medical attention, and
employment--all factors that mitigate the dangers of drug use and promote
recovery.[41]

Although these pervasive influences of prohibition affect all users of
prohibited drugs, the data show that the most negative health consequences
of drug use are not evenly distributed--they fall most heavily on those who
experience the highest rates of drug enforcement, African Americans.

When the data are adjusted for the correct population denominators, they
reveal a huge discrepancy in rates of adverse outcomes. While we see an
overall rise in drug-related ER admissions for the total population
throughout a long period of declining drug use (especially declines in the
use of cocaine), these rates are very different across "racial" subgroups.
African Americans fare dramatically worse than whites; in 1996, African
Americans had 7.5 times the white rate of heroin-related emergency
department visits and 11.5 times the white rate of cocaine-related visits
(Table 2).

In 1996, African Americans, who represent only 12% of the US adult
population [42] and a similar percentage of drug users, accounted for 57%
of ER drug admissions while whites (75% of the population 26 and a
proportionate number of drug users) accounted for 31%.[12]

A similar pattern is seen in the racially disaggregated data on overdose
deaths in this period. African Americans have 3.5 times the rate of drug
fatalities of whites,36 and while the overall trend is an increase for all
groups, from 1980 to 1993 there was a 326% increase in drug abuse deaths
for blacks but a 129% increase for whites and others (Figure 11).

CONCLUSION: DRUG PROHIBITION VS PUBLIC HEALTH

Large disparities in drug-related morbidity and mortality appear to be a
powerful consequence of prohibition drug policies and their unequal
application in our society. (See Table 3.) But they also point to a set of
larger problems, evident in the historic relationship of US drug policies
to public health. In the United States we have a long history of strong
public sentiment about the use of all intoxicating substances--we alone in
the Western world altered our national Constitution to ban alcohol for 14
years. Today's drug policies may be understood as the expression of an
(almost) innocent wish to make dangerous drugs disappear by legislating
their prohibition.

A plausible case can be made that as drug use rose in the 1960s and 1970s,
extending more widely and more openly into middle-class America,
increasingly severe criminal penalties for the use of prohibited drugs and
more rigorous enforcement was a predictable response. While the avowed
motive of this policy, restraining the damages that can be caused by drugs,
was (and is) a legitimate social goal, the cure has only worsened the disease.

Drug laws and their massive, cruel imposition on millions of young men and
women--not simply the use of drugs--have stigmatized and estranged our most
disadvantaged minorities, creating a "new American Gulag"[18] with its own
archipelago of prisons, jails, courts, probation, parole, and, most
recently, compulsory treatment as an alternative to incarceration, blurring
the boundary between treatment and punishment. As we build prisons instead
of schools, the images of young black men being arrested and imprisoned for
drug offenses continue to fill the news media. While all the data suggest
little systematic difference in the prevalence of drug use by "race" or
ethnicity, these images foster the belief that nonwhite Americans use drugs
more than other Americans--an assumption that goes largely unexamined by a
public systematically frightened about our children's almost inevitable
exposure to drugs.43 At the same time, our prejudicial enforcement of drug
laws and the wholesale criminalization of a large cohort of young
inner-city residents serves to sustain and reinforce this stereotype while
fostering social, economic, and political disenfranchisement [44] and
increasing the health and life risk associated with use of drugs.

Drugs can certainly cause harm, but our selective application of punitive
drug prohibition laws are at least as dangerous. These laws have spawned a
lethal biosocial ecology in which the poorest nations and communities are
ravaged by uncontrolled criminal drug markets,[45] emerging infectious
diseases,46 and the widespread corruption of civil society.[47]

Drugs are cheaper, more powerful, and more available today then at any time
in the past 25 years. This new and complex political reality cries out for
effective policies based on sound science, public health priorities and
human rights.[48-50] Yet, after nearly a century of a bankrupt approach to
drug control, we see no end in sight. In June 1998, delegates from all over
the world heard Pino Arlacchi, Executive Director of the UN Office for Drug
Control and Crime Prevention, address the General Assembly's Special
Session on International Drug Control with calls "to start the real war
against drugs and convince nations and people that there could be a
drug-free world."[51]

Effective and publicly acceptable alternatives to a prohibition- based
policy are now available to us in the form of harm reduction approaches
(including needle exchange programs, low threshold treatment, and improved
access to housing and health care for drug users). Harm reduction is
already national policy in a score of countries throughout the world.[52]
But in the US the very use of the term harm reduction is still banned from
the Federal policy lexicon and denied funding because it is seen as
"condoning drug use." Its proponents are vilified as supporters of drug
legalization,[53,54] and critics within the government are cowed into
silence (or anxiously whispered support at AIDS conferences). And there can
be severe penalties for open dissent--as we saw in the case of Surgeon
General Joycelyn Elders.

These are not-so-early warning signs of a great American failure--not only
in drug policy but in our native capacity for creative, compassionate, and
above all open discourse about issues vital to our well-being. It is time
that we move beyond this drug fundamentalism and abandon our unhappy
history of prohibition for more humane and pragmatic policies that protect
public health and support our democratic values.

The author thanks Jennifer McNeely for assistance with this article.

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