Note: Robert Whitcomb is editor of Health Care Horizon and editorial page
editor and a vice president of The Providence Journal http://www.projo.com

WAR ON DRUGS NEEDS A COMPLETE RETHINKING IN LIGHT OF ITS POOR RESULTS

Do "drug war" advocates really know what they want? Do they really seek to
reduce the overall societal harm of illicit drug use, or do they just want
to make a self-righteous statement about a human weakness?

So far, at least, the overwhelming emphasis has been on "prevention and
enforcement." This has involved massively expensive publicity campaigns,
especially to discourage young people from using drugs, as well as many
billions spent to build new prisons to house people who have problems with
illicit drugs. There is little indication that this investment has paid off.

And the heart of the problem, I think, is that the focus has been on trying
to decrease the general prevalence of use, rather than on those whose
actions cause the most trouble.

We need a far more reasonable damage standard to apply to drug use, one
that weighs the aggregate effects of drug use on society, and that aims at
lowering the worst effects of that use. So far as the health of society
goes, prevalence is really not that important. It's the extreme damage to
society that comes from a small group of users.

As many authorities have noted, most users of most drugs are not
incapacitated by their use. Rather, it is a small hard-core group
accounting for about 80 percent of total consumption that creates the
enormous problems associated with drug use. This small group first became
well known in the crack-cocaine epidemic of the '80s, when it was
responsible for a vicious rash of violence, especially in the inner cities.
Indeed, drug use was more widespread in the 1970s than in the '80s, but it
was primarily marijuana use, which does not have the violence-spawning
physical effects of cocaine.

This hard core, many of whom use crack cocaine or heroin, are those who
have the special set of severe problems associated with drug use -- not the
college kid who smokes an occasional joint.

These problems, of course, include crime, various diseases and injuries,
family violence and breakup and a host of other personal problems that
quickly become societal.

Despite the mantra of prevention, it is obvious that prevention is too late
for the already addicted who are at the root of most societal problems
caused by drug addiction, or for those whose milieu is such that they are
almost certainly going to start using illicit drugs and to stay on them.
The emphasis for these people must be on treatment.

This might have to be mandatory treatment. But we rely far too much on
prison to deal with drug problems. It would be far better to encourage the
establishment of more drug courts and similar bodies that can coerce drug
offenders into repeated testing and treatment in lieu of incarceration,
though the coercion can certainly include the threat of jail time.

There should also be a major expansion of medication therapies for the
addicted. This includes methadone and similar maintenance programs. It is
obvious, from studies here and in Europe, that such programs help decrease
crime and health problems among the hard core of long-term drug addicts.
But laws still unduly restrict the use of methadone, and similar drugs, to
specialized clinics. This should be changed. Methadone needs to be far more
widely available.

A California study found that the benefits of drug treatment were seven
times the costs. Treatment generally costs a mere 10 percent of
incarcerating someone in jail for drug possession. The latter puts hordes
of nonviolent people with no other pathologies languishing behind bars,
depriving society of the contributions of many gifted and hard-working
citizens, and training those whose offense is substance addiction in other,
far more socially destructive criminal arts.

One of the barriers to dealing more effectively with the drug problem is a
preoccupation with trying to get addicts to quit permanently. That may just
be impossible for many or most of them. But society is bound to benefit --
in lower crime, medical costs and family instability -- during any time,
however brief, when addicts are off their drugs. If treatment can keep
people clean for at least a little while, we all benefit. We shouldn't
demand perfection.

The failure to focus on the core of the drug problem means that
universalism becomes the enemy of the effective. Meanwhile, we should never
forget that not only do the hard-core addicts benefit from programs focused
on them, so, of course, do the people who become their victims when
treatment is not offered.

But should illicit drugs be legalized? Perhaps some of them, particularly
marijuana, though total decriminalization of such drugs as cocaine and
heroin might produce such a raft of public health problems, approaching
that of alcoholism, that it wouldn't be worth it. Total decriminalization,
indeed, could be just as foolishly a simple answer as the preposterous
assertion that America can be made "drug-free."

Fighting the drug war will have no end, and its pursuit will require a
constantly adjusted combination of prevention, enforcement and, especially,
treatment modalities. The appearance of new medications to ward off
withdrawal's worst aspects should help. We know enough now to say that
major inroads can be made against the drug problem, if officials are
willing to ignore the rhetoric and start looking at where most of the
ongoing "drug crisis" really resides -- with a relatively small group of
hard-core users.