AN INFORMED APPROACH TO SUBSTANCE ABUSE

DRUGS AND DRUG POLICY: THE CASE FOR A SLOW FIX

The main policy goal should be to minimize the aggregate societal damage
associated with drug use.

"Fanaticism," says Santayana, "consists of redoubling your efforts when you
have lost sight of your aim." An old Alcoholics Anonymous adage defines
insanity as "continuing to do the same thing and expecting to get a
different result." Between them, these two aphorisms define the condition
of U.S. drug policy and the public debate about it.

Our current policies, largely misconceived, are doing much more harm than
they should and much less good than they might. Part of the problem is
simply the formidable complexity of the phenomena we are trying to manage.
The heterogeneity of drugs and drug users defies simple categorization. As
a result, the serious policy questions refuse to line up along the easily
comprehended polarity that fits two-party politics and point/counterpoint
journalism. Yet the discussion of drug policy remains unproductively
polarized between the "drug warriors" who advocate stricter controls and
harsher punishments and the "legalizers" who favor more relaxed controls.
As a result, a wide variety of sensible policy modifications that fail to
fit the ideological predilections of either extreme simply do not get
discussed.

The only way to close the gap between what we know how to do and what we
are actually doing is to develop a "third way" of thinking about drug
policy. Using only existing knowledge and resources, the nation could have
a much smaller drug problem five years from now than it has today.
Repairing our broken policies, however, will require a clearer vision of
what the drug problem is and more moderate expectations about what public
policy in this area can actually accomplish.

Pushing enforcement

Current policies, which reflect the drug warrior philosophy, aim to reduce
drug use through stricter controls, increased enforcement, harsher
punishment, and school-based and mass media efforts to stigmatize the use
of illicit drugs. Treatment is very much an afterthought, both rhetorically
and budgetarily. At least three-quarters of the roughly $40 billion spent
by governments at all levels on the control of illicit drug use now goes
into enforcement; the size of that effort and the number of people
incarcerated for drug law violations have grown approximately 10-fold
during the past 20 years. Yet hard drug prices are currently near their
all-time lows.

By contrast, critics of current policies focus not on use reduction but
"harm reduction"-that is, making the consumption of illicit drugs less
harmful to those who consume them and to nonusers. The most widely debated
example is needle exchange, which aims to reduce the transmission of HIV
and other infectious organisms that can occur when intravenous drug users
share needles. Some advocates of harm reduction also assert that diminution
or elimination of legal penalties for drug use and distribution would
decrease addicts' need to steal to buy drugs and the violence associated
with the drug trade.

The question always is whether and to what extent such reductions in risk
would be offset or more than offset by increases in the extent of illicit
drug taking. Reducing the risk of harm associated with any given pattern of
drug-taking is not the same thing as reducing the aggregate level of harm.
By reducing the risks associated with drug use, policies aimed at harm
reduction may actually increase the number of users and/or the intensity of
drug use, which could result in increasing the total level of drug-related
damage to users and others.. Thus, whether a given harm reduction policy
increases or decreases total damage depends on the details of the program
and the circumstances.

So far, the advocates of use reduction have had very much the better of the
political confrontation. Harm reduction approaches have consistently failed
to capture the public's imagination. Even methadone maintenance for opiate
addicts, despite its amply demonstrated success, remains politically
controversial, as illustrated by New York City Mayor Rudolph Giuliani's
recent proposal to abolish it. And legalization remains the great bogeyman
of the drug policy debate.

The dominance of the use-reduction viewpoint is illustrated and reinforced
by the extent to which measures of prevalence-the total number of drug
users-dominate public discussion of the effectiveness of current drug
policies. The two big national surveys paid for the federal government, the
Monitoring the Future study of high school students done by the University
of Michigan and the National Household Survey on Drug Abuse done by the
Research Triangle Institute, each ask people to volunteer information about
their own drug use. The results of the surveys are often the subject of
partisan commentary, and they have dominated the quantitative policy goals
set by the White House's Office of National Drug Control Policy.

But prevalence is only one measure, and probably not even a very important
one, of the size of the problem or the success of our control efforts.
Prevalence in the use of any drug is a poor proxy measure for aggregate
damage. Most users of most drugs (cigarettes and heroin are the prominent
exceptions) are occasional users, suffering little damage, doing little
damage to others, and contributing little-even in the aggregate-to the
revenues of the illicit markets. Moreover, no one would argue that an
occasional marijuana smoker (by far the most common variety of illicit drug
user) faces personal risks or creates problems for others that are
comparable to the personal risks and social problems created by frequent
high-dose crack use. But by taking the total user count as the measure of
success, we implicitly give the two cases equal weight.

Although public opinion is strongly on the drug warrior side of the debate,
public concern about drug abuse does not in fact track data about drug use
prevalence. In the late 1970s, when the total number of illicit drug users
reached its peak, drug abuse was barely on the national radar screen. A
decade later, when the total number of drug users was only half as high,
but the crack epidemic was devastating city after city, opinion surveys
rated drug abuse the most serious threat to the nation's well-being.

The goal of drug policy ought to be to minimize the aggregate damage
created by drug taking, drug trafficking, and the enforcement effort. That
is, we ought to judge drug control efforts as we judge other public
policies: by their results in producing benefits or avoiding harm to
individuals or institutions. The major barrier to more effective
drug-control policies is that effectiveness, measured in terms of damage
control, has not been at the center of policymaking in this arena.

Using this "third way" of evaluating drug policies and programs would have
two key consequences. First, applying a damage standard would expand our
focus to include licit drugs such as alcohol and tobacco, which, precisely
because they are more widely used, cause much more aggregate damage than
any illicit drug. Second, within the realm of the illicit drugs, a damage
standard would prompt us to concentrate our efforts on frequent high-dose
users, especially those whose addiction to expensive drugs leads them into
criminal activity, rather than occasional marijuana smokers and other
casual users. A damage standard would also require us to pay as much
attention to the side effects of drug trafficking, especially violence and
the enticement of juveniles into illicit activity, as to the damage done by
the actual consumption of illegal drugs, and to count the financial and
social costs of enforcement and imprisonment.

Protecting juveniles

Thinking about juvenile drug abuse while ignoring alcohol and nicotine is
like studying oceans while ignoring the Atlantic and the Pacific. If our
goal is to protect children from the damage they can do to themselves by
abusing psychoactive chemicals, we need to concentrate on the licit drugs,
which are by far the greatest threats.

Relatively few adolescents are heavy smokers; the habit takes time to
develop. But about a quarter of high-school seniors do smoke, and most of
them will go on to months, if not years, of heavy daily smoking. Heavy
smoking, in turn, roughly doubles the mortality rate at any given age.

As for alcohol, its prevalence among high-school seniors approaches
universality (87 percent). According to the most recent Monitoring the
Future study, more high school seniors had gone on a drinking binge
(defined as more than five drinks at a sitting) in the previous two weeks
(31 percent) than had used any illicit drug in the previous month (23
percent).

In this context, the political fixation on marijuana use among children
seems bizarre. Of course, marijuana can pose a significant threat to
children but not primarily because it leads to hard drugs, as the so-called
gateway hypothesis holds. (The vast majority of juveniles who use marijuana
do not go on to use other illicit drugs, as both national surveys
demonstrate, and the causal significance, if any, of the statistical
association between early marijuana use and subsequent use of cocaine and
heroin remains open to debate.) Instead, the major risk is that marijuana
use itself will turn into a hard-to-break habit.

This happens far more often than many people believe. James Anthony, Lynn
Warner, and Ronald Kessler, analyzing data from the National Comorbidity
Survey, found that 9.1 percent of those who had ever used marijuana
eventually became clinically dependent on it. That "capture rate" is lower
than the comparable figures for tobacco (31.9 percent), cocaine (16.7
percent) or alcohol (15.4 percent), but 1 chance in 11 represents a
substantial risk.

Even so, the total damage done to adolescents by marijuana doesn't approach
that done by alcohol and nicotine-nicotine because of its very high
addiction risk and the grave health consequences from years of heavy
smoking; alcohol because of its very widespread use, the risks associated
with drunken behavior (even if episodes are infrequent), and the
substantial probability and devastating consequences of chronic alcoholism.
Nearly 40 million Americans are addicted to tobacco and about 22 million
people suffer from either alcohol dependency or its less severe form,
alcohol abuse.

Drinking and drunken behavior exact a terrible toll. Surveys of offenders
under criminal justice supervision show that 40 percent of them had been
drinking at the time they committed the offense that led to their
convictions; and alcohol involvement in some categories of violent
offenses, including murder and, especially domestic violence and hate
crime, is even higher. (Alcohol is also a substantial risk factor for being
a victim of a violent crime.)

Alcohol also contributes to risky sexual behavior. In the furor over the
use of the drug flunitrazepam (Rohypnol) in date rapes, almost no one
mentioned the much larger role of alcohol in creating the conditions not
only for date rape but for unplanned and unprotected intercourse and the
unwanted pregnancy and sexually transmitted disease that results from it.
(Although there is no careful scientific backup for the assertion that
alcohol has been associated with more cases of HIV transmission than has
heroin, it is almost certainly true.)

The death toll from tobacco consumption is about 400,000 per year; from
alcohol consumption, about 100,000 per year. Whether alcohol or tobacco
should be considered the bigger threat depends on how one weighs chronic
health damage against accidents, crimes, suicides, and irresponsible sexual
behavior.

Fortunately, we know exactly how to reduce smoking and drinking among
juveniles: Make them more expensive. The $1.10 cigarette tax increase
rejected by Congress this year would have reduced the prevalence of
juvenile smoking by about a third; further disincentives aimed at the
tobacco industry might lead to even larger reductions. Among feasible
public actions to reduce adolescent substance abuse, only a similarly
massive increase in alcohol taxation could conceivably create comparable
benefits.

The path to reducing illicit drug use among schoolchildren is less clear.
We know a lot more than we used to about education to prevent drug abuse,
and most of it is discouraging. A few high-quality programs have been shown
to be significantly but not spectacularly effective, reducing the
prevalence of drug use among those exposed to them by about 10 percent as
compared to those who haven't been in a program. Most programs do much
worse than that, and so far there is only scanty evidence that the most
popular one of all, Drug Abuse Resistance Education (DARE), has had any
measurable effect whatsoever on drug use. (Its benefits in terms of
police-community relations are a separate issue.) Media-based prevention
campaigns, such as the one recently launched with great fanfare by the
federal government and the Partnership for a Drug-Free America, have proven
much more successful at hardening antidrug attitudes among those
uninterested in drugs in the first place than at changing the behavior of
those actually at risk. A case could be made for replacing much of the
explicit antidrug persuasion effort with a truly educational effort aimed
more broadly at achieving self-control and at recognizing and avoiding
health risk behaviors, if only we knew how.

Addressing illicit drugs

According to the National Household Survey, fewer than 6 million people in
the United States use illicit drugs other than marijuana. Because this
survey does not include the homeless and prisoners and because illicit drug
users are probably undercounted because of sample bias and response bias,
the actual number is probably substantially higher, though there is no
carefully developed published estimate. Moreover, even for the hardest
drugs-heroin, cocaine, and methamphetamine-long-term addiction is far from
universal among users. Estimates combining survey results with the drug
tests performed on a sampling of arrestees under the National Institute of
Justice Arrestee Drug Abuse Monitoring program put the total number of hard
drug addicts at any one time at fewer than 4 million.

This small group of hard-core hard-drug users, which accounts for about 80
percent of total consumption, creates a set of problems out of any
proportion to their numbers. They suffer enormously and cause suffering
around themselves. Their health problems are extensive, their behavior
frequently obnoxious. Few of them can hold down steady jobs, though many
work off and on. Most of their money goes to pay for drugs; a heavy heroin
or cocaine habit costs $10,000 to $15,000 per year. In addition to legal
work, which is rarely the major source, this money comes from drug dealing,
from theft, from prostitution, from relatives or lovers, and from
income-support payments of various kinds. (Compared to addicts in Europe,
where income-support payments are much more generous, U.S. addicts are much
more likely both to work and to steal.)

Of the conventional tools of drug policy-prevention, enforcement, and
treatment-only treatment has much relevance to controlling the problems of
this group. Prevention is obviously too late for those who are already
addicted. Enforcement also appears to have little to offer. Policymakers
have long believed that the demand for hard drugs is inelastic; that is, it
is not sensitive to changes in price. Recent research (as well as common
sense) contradicts this notion, suggesting that enforcement could curtail
drug use if it succeeded in driving up prices. This encouraging finding,
however, is offset by the discouraging fact that hard drug prices have
proven remarkably insensitive to the massive increase in enforcement and
punishment directed at drug dealing over the past two decades. Cocaine
prices are at about one-quarter of their late-1970s values, and heroin
prices have fallen even further, to levels not recorded since the mid-1960s.

But treatment matters. The benefits of treating a hard-core addict, even if
with only partial success, are enormous. The National Research Council
report Treating Drug Problems summarized a mountain of data showing the
correlation between treatment participation and large decreases in drug use
and criminal activity. Although long-term cessation is a highly desirable
goal and for most former drug abusers probably represents the only stable,
healthy state, even imperfectly successful attempts to quit have benefits
in the form of greatly reduced drug consumption and drug-related harm
during the attempt, and lesser but still worthwhile reductions for some
time after it. When Barry McCaffrey, director of the Office of National
Drug Control Policy, says, as he often does, "If you hate crime, you love
drug treatment," he is reciting an obvious truth.

Evaluated as a crime-control measure alone, providing drug treatment for
criminally active addicts is strikingly cost-effective, reducing criminal
activity by about two-thirds at about 10 percent of the cost of a prison
cell, according to a study conducted by the California Department of
Alcohol and Drug Programs and the National Opinion Research Center. Yet
here again the focus on prevalence as the single measure of drug-control
success distorts our efforts. Consistent with the misleading notion that
the best measure of the drug problem is the number of people using any
quantity of any illicit drug, the goal of treatment is widely understood as
producing immediate, total, and lasting abstinence. Any other outcome is
scored as a failure in computing a program's success rate, and the very
high rate of eventual relapse is taken as evidence that treatment is
ineffective. Because addicts represent a minority of drug users and because
most treatment episodes reduce drug use rather than eliminating it
entirely, treatment has little impact on the total number of drug users
even when it dramatically reduces the total damage.

Partly because of these factors, publicly funded drug treatment remains
scarce and is frequently of poor quality. Part of the reason is that
treatment has become more politically unpalatable as public hostility
toward drug users has intensified. The benefits to crime victims, usually a
sure winner politically, have been largely ignored, in part because
victims' advocacy groups, with their strong ties to law enforcement and
hostility to anything that might benefit offenders, have been largely
silent on the matter.

Even if money were no obstacle, getting hard-core hard drug users into
treatment and keeping them there would remain a major problem.
Unfortunately, this is the group that is least likely to enter treatment
voluntarily, most expensive to treat, and least likely to succeed by the
standard of total abstinence. The hard truth is that most of them would
rather have drugs than treatment, as long as they can get the drugs. This
gives treatment providers a strong incentive to serve other kinds of
clients for whom the apparent success rate will be higher, even though the
damage prevented per person treated is much lower.

Rethinking drug treatment

The choice, however, does need not be left entirely up to the addicts.
Sooner or later, most hard drug addicts wind up under the jurisdiction of
the criminal justice system. (Although there is a small population of
legitimately prosperous addicts, most find it hard to finance a heavy habit
without doing something they eventually get arrested for.) About
three-quarters of all heavy cocaine users, for example, are arrested in the
course of a year. The criminal justice system can become a powerful tool
for imposing treatment on those who are unwilling or unable to quit.

That is the idea underlying drug diversion, drug courts, and coerced
abstinence programs. Together, these three programs offer the best
prospects for actually shrinking the hard-drug markets, reducing the
criminal activity of hard-core users, and improving addicts' lives by
keeping them out of prison and reducing, if not ending, their drug abuse.

Drug diversion offers treatment as an alternative to prison to offenders
facing criminal charges who also have substance-abuse problems. Those who
fail to appear for treatment or to comply with treatment programs may be
referred back to court for sentencing on the original charge.

Drug courts are a variation on the diversion theme. Instead of leaving the
supervision of the addict/offender entirely up to the treatment program,
drug courts use their own staff to monitor compliance. Drug court
participants meet frequently with the judge, who hands out praise, censure,
and, if necessary, sanctions, sometimes including time in jail. There is
good evidence that diversion programs and drug courts save substantial
amounts of money compared to incarceration and that they are successful in
recruiting offenders into treatment and keeping them there. But both kinds
of programs face serious limitations on their ability to expand to include
a large proportion of the truly hard-core population.

First, because the programs involve diversion from incarceration, the
offenders involved must be ones whom judges and prosecutors are prepared to
spare from prison as long as they agree to drug treatment. This tends to
exclude those with long criminal histories or records of committing
violence. The ironic result is that the worse an addict/offender's behavior
(and the greater the damage he or she causes), the less likely the addict
is to be pressured into change.

Second, since drug courts and diversion programs rely on voluntary
participation, some offenders simply opt out of them and take their chances
with the court system. Third, diversion programs and drug courts require
treatment capacity. In most places, there are already people waiting for
treatment who can't get in. As a result, diversion programs and drug courts
may in effect transfer treatment capacity from those who want it to those
who do not. Whether this is a good idea or not depends on how good the
courts are at singling out for mandatory treatment those who would do the
greatest amount of social damage if untreated.

All of this raises a question: When offenders are subject to coercion, why
coerce them into treatment rather than focus directly on the desired
outcome-that they simply stop using drugs? That's the idea behind "coerced
abstinence," a concept endorsed by the Clinton administration and recently
adopted in Maryland and Connecticut. Probationers and parolees identified
as having hard drug habits (about half of all probationers and parolees)
are to be subjected to twice-weekly drug testing, with immediate and
automatic sanctions such as community service, day reporting, or a few days
behind bars or in a halfway house for each missed or "dirty" test. Those
who cannot or will not abstain under this sort of pressure can then be
referred to treatment programs. Various pilot programs and one true
clinical trial, which is being conducted at the District of Columbia Drug
Court and evaluated by Adele Herrell of the Urban Institute, strongly
suggest that this approach will work for a large fraction of user/offenders.

One objection to the idea of coerced abstinence comes from the widely held
but mistaken belief that addicts have no capacity to control their drug
consumption without participating in treatment. Complete lack of control is
often taken to be the defining characteristic of addiction. But although
addiction implies diminished control over drug-taking, it does not imply
that drug-taking has become entirely involuntary, the way a reflex action
or the tremor of Parkinson's disease is involuntary. As Herbert Kleber of
the National Center on Addiction and Substance Abuse at Columbia University
is fond of saying, "Alcoholism is not a disease of the elbow." Addictive
behavior is subject to manipulation by consequences, but the consequences
have to be immediate and certain, not deferred and random.

The management problems of running coerced-abstinence programs are
daunting, but the potential rewards are enormous. By my calculations, a
national program could reduce the quantity of cocaine bought and sold in
this country by about 40 percent. The cost, roughly $7 billion per year,
would be more than covered by reduced incarceration, both for the offenders
under coerced-abstinence supervision and for the drug dealers they would no
longer be keeping in business.

Reframing the debate

Anyone expressing real optimism about the prospects for significant drug
policy improvements in the short run might reasonably be asked what he or
she has been smoking (or drinking). The most vocal critics of current
policies, the legalizers, have played into the hands of their drug warrior
opponents by asserting that the fundamental problem is drug prohibition and
that the only real drug policy debate is between those who support
prohibition and those who oppose it. This assertion, and their subsequent
backtracking into a variety of harm reduction measures and such side issues
as the medical use of marijuana, have created a political climate in which
anyone who challenges any aspect of current policies can be charged with
aiding and abetting the cause of drug legalization, which is supported by
no more than a quarter of the voters.

Nonetheless, there is an emerging consensus for change within the research
community that studies drugs and drug policy. In the fall of 1997, a group
of leading drug policy thinkers and law enforcement and treatment
practitioners released a statement entitled "Principles for Practical Drug
Policies," emphasizing the need to adopt a damage standard, address licit
as well as illicit drugs, and shift the focus of illicit drug policy away
from enforcement measures and school-based and media-based drug prevention
efforts and toward a new emphasis on treatment for heavy hard drug users
and hard-core addicts. The College on the Problems of Drug Dependency, the
largest professional organization of drug abuse researchers, and a new
group of medical school deans and other high-profile medical doctors called
Physician Leadership on National Drug Policy, have issued similar calls for
a rethinking of current policies, again with an eye to making prohibition
work better rather than repealing it.

Some of the organizers of the "Principles for Practical Drug Policies"
effort have created a project called Analysis and Dialogue on Anti-Drug
Policies and Tactics (ADAPT) under the auspices of the Federation of
American Scientists. They are now assembling working groups to address
specific drug policy topics, such as sentencing, retail-level law
enforcement, treatment, and alcohol regulation. Some key policy reforms
could include:

· Using a mix of coercion and treatment to reduce drug-taking among
hard-core hard-drug addicts under criminal justice supervision.

· Greatly increasing alcohol and tobacco taxes and creating a media-based
antidrunkenness campaign on the model of the current antismoking effort.

· Changing sentencing practices and enforcement tactics to concentrate on
the dealers who employ juveniles, use violence, and greatly disrupt
neighborhood life, and designing retail enforcement to break up flagrant
drug markets rather than simply arresting dealers. The result would be
safer communities and a substantial reduction in the current level of drug
law imprisonment. (Of the 1.7 million persons now in U.S. prisons, about
half a million are confined for drug law violations.)

· Increasing funding for publicly paid drug treatment and improving the
performance of health care providers in recognizing substance abuse and
undertaking interventions to deal with it. That improvement would require
changes in medical education and in health care finance. Special efforts
should be made to resolve the problems that currently limit opiate
maintenance therapy to a small fraction of heroin addicts. These include
the laws restricting methadone to specialized clinics; regulations
encouraging the use of inadequate methadone dosages; and the whole web of
regulations and customs that have slowed the use of two other promising
agents, LAAM (a longer-acting form of methadone) and buprenorphine.

· Developing school- and media-based programs to make children more capable
of self-control and more aware of the need to avoid health-risk behaviors.
This would require a substantial R&D effort.

· Learning how to use persuasion to prevent drug dealing by youngsters.
Changes in enforcement and sentencing can do part of the job, but someone
ought to be talking to the kids. No one has designed such a program yet,
but inaction can hardly be the right policy.

With the political forces that support the current unsatisfactory set of
policies and outcomes likely to remain in place for the foreseeable future,
the prospects for better policies seem dim. But because no quick fix is
available, we can hope that some elected officials, given adequate cover
against the dreaded charge of being "soft on drugs," might be willing to
accept a slow fix in the form of a more realistic set of policies aimed at
reducing the total social damage associated with drug use, drug
trafficking, and drug control efforts. Even when optimism is unjustified,
hope remains a virtue.

(continued in part 2)


Checked-by: Richard Lake