DRUG TRIAL : INTRODUCTION

Is "medicalization" the first step in ending the drug war? Or just the next
step in continuing it? Jacob Sullum lays out the "public health" issues and
a panel of experts responds.

Washington state's Initiative 685, the "Drug Medicalization and Prevention
Act of 1997," failed by a big margin last November. But "medicalization" is
here to stay. In one form or another, it is the most frequently endorsed
alternative to the war on drugs - far more popular among reformers than the
free market favored by libertarians. That fact is a source of hope to some,
dismay to others.

In 1988, when Baltimore Mayor Kurt Schmoke helped generate a surge of
interest in drug policy reform by calling for "a national debate on the
merits of decriminalizing drugs," it was medicalization he had in mind.
"Making drugs illegal has not diminished the American appetite for these
substances," he later explained. That is because drug abuse is a disease.
And like any other disease, it responds to medical treatment, not criminal
sanctions.... Decriminalization is in effect 'medicalization,' a broad
public health strategy - led by the Surgeon General, not the Attorney
General - designed to reduce the harm caused by drugs by pulling addicts
into the public health system. Criminal penalties for drug use would be
removed and health professionals would be allowed to use currently illegal
drugs, or substitutes, as part of an overall treatment program for
addicts.... Drugs would not be dispensed to non-users, and it would be up
to a health professional to determine whether a person requesting
maintenance is an addict."

This general approach - with some important differences in detail - has
played a leading role in criticism of the war on drugs during the past
decade. One cannot attend the Drug Policy Foundation's annual conference
without hearing repeatedly about the merits of a "medical" or "public
health" model. The Lindesmith Center, a New York drug policy think tank
funded by billionaire philanthropist George Soros, emphasizes "harm
reduction," a public health strategy aimed at mitigating the costs of both
drug use and drug laws through measures such as needle exchange, heroin
maintenance, and the legalization of marijuana for medical use.

Physician Leadership on National Drug Policy, a new group that includes
former FDA Commissioner David Kessler and former Secretary of Health and
Human Services Louis Sullivan, declares that "addiction to illegal drugs is
a chronic illness." Without calling for decriminalization, the group argues
that law enforcement has been overemphasized, saying "enhanced medical and
public health approaches are the most effective method of reducing harmful
use of illegal drugs."

Washington's Initiative 685, which was modeled after Arizona's Proposition
200, echoed this theme. "In addition to actively enforcing our criminal
laws against drugs," it said, "we need to medicalize Washington's drug
control policy and recognize that drug abuse and addiction are public
health problems that should be treated as diseases." Accordingly, it
prescribed "treatment" rather than incarceration for "nonviolent persons
convicted of personal possession or use of drugs." Such offenders would
receive probation, and the sentencing judge could "require participation in
an appropriate drug treatment or education program." If already in prison,
people in this category would be "eligible for immediate parole and drug
treatment, education, and community service," provided they were not
covered by a "habitual criminal" statute or serving a concurrent sentence
for another crime.

Despite the line about "actively enforcing our criminal laws against
drugs," these provisions would have eliminated jail time for simple
possession - a dramatic change from current policy. But another aspect of
the initiative, authorizing doctors to "recommend" Schedule I drugs for the
treatment of "seriously ill" patients, got more attention, since it tied
into the national debate over medical marijuana. This section said a
physician who recommended a Schedule I substance, such as heroin, LSD, or
marijuana, would not be prosecuted or disciplined as long as he cited
relevant scientific research, obtained the patient's written consent, and
got a second opinion from another doctor.

Washington's voters did not go for it. Although its backers spent 10 times
as much as their opponents - with infusions of money from Soros, Phoenix
entrepreneur John Sperling, and Peter Lewis, CEO of Cleveland-based
Progressive Insurance - the measure lost by 20 percentage points. Some
voters may have felt that out-of-state organizers with out-of-state money
were trying to pull one over on them. The opposition's ads, funded in part
by Microsoft and by presidential hopeful Steve Forbes's Americans for Hope,
Growth and Opportunity, sought to reinforce that impression. The
conservatives who turned out to oppose the state's highly publicized gun
control initiative probably also helped defeat Initiative 685.

The loss in Washington was a mirror image of the victory in Arizona, where
65 percent of voters endorsed essentially the same initiative in November
1996. Since then the Arizona legislature has passed bills overriding key
elements of the proposition. In response, the initiative's supporters have
gathered signatures to submit those bills to the voters as referendums on
the 1998 ballot. They are also backing the Voter Protection Act, a
proposition that would amend the state constitution to require a
three-fourths majority in each house of the legislature to overturn a
voter-approved initiative.

Unlike the Arizona and Washington measures, initiatives that deal
exclusively with medical marijuana do not explicitly advocate a 'public
health" approach to drug policy generally, but they do represent one aspect
of the "harm reduction" agenda. After California's Proposition 215 passed
by a comfortable margin in 1996, Americans for Medical Rights began pushing
similar measures in other states. Activists hope to have medical marijuana
initiatives on the 1998 ballots in Alaska, Colorado, the District of
Columbia, Maine, Nevada, and Oregon.

However medicalization fares on state ballots, it will continue to shape
opposition to the war on drugs for years to come. That is partly because it
offers a sharp contrast to the prohibitionist approach that has long
dominated U.S. drug policy. The stated aim of the prohibitionists is to
eliminate drug use - by which they generally mean the use of certain drugs,
set apart from accepted intoxicants by custom, superstition, and historical
accident. The stated aim of the public health specialists, by contrast, is
to minimize morbidity and mortality - including the harm associated with
the use of all drugs, whatever their current legal status.

Thus, the public health specialists are in some ways more realistic than
the drug warriors: They acknowledge that any drug, licit or illicit, can be
harmful under certain circumstances. And they stress harm rather than drug
use per se. This implies that the consumption of psychoactive substances is
not necessarily problematic. It also suggests a willingness to consider the
undesirable effects of attempts to discourage drug use. This openness to
evidence is probably the most important way in which public health
specialists differ from prohibitionists.

In terms of policy, both prohibitionists and public health specialists talk
a lot about "education." Prohibitionists seem more willing to bend the
truth if they think it will help scare people away from drugs, while public
health specialists are more likely to insist that drug "education" have a
sound scientific basis. They note that scare tactics tend to backfire in
the long run, as people recognize that they've been misled and learn to
distrust the source. Still, public health messages about drugs, like public
health messages in general, are aimed at changing behavior, not simply
disseminating facts.

Aside from education, the policy prescriptions offered by public health
specialists sound quite different from those offered by drug warriors.
Prohibitionists emphasize interdiction, crop eradication, and other
attempts to reduce the supply of drugs, along with arrests, fines, property
forfeiture, and imprisonment for producers, sellers, and buyers. Public
health specialists emphasize treatment, taxes, and regulations.

The prohibitionist orientation is basically punitive: Using certain drugs
is a crime; people who do it deserve to be arrested, humiliated,
imprisoned, and divested of their property. The public health orientation,
by contrast, is therapeutic: Drug abuse is a disease; people afflicted by
it need to be treated. From this perspective, current policy is irrational
and inhumane. After all, you don't lock people up for cancer or diabetes.

But as Thomas Szasz and other critics of contemporary psychiatry have long
argued, the ostensibly liberal policy of treating behavior like a disease
can have profoundly illiberal consequences. A disease is something
inherently undesirable that happens to people against their will. No one in
his right mind wants to be sick. Furthermore, drug addiction is said to be
a disease that impairs the patient's judgment. Where's the harm, then, in
forcing him to be well? Under the circumstances, it would seem to be the
compassionate thing to do. Presumably, that is the rationale behind
Initiative 685's "court-supervised drug treatment." When the disease model
is combined with the public health imperative to minimize morbidity and
mortality, and to enlist the state's assistance in that endeavor, the
logical result is never-ending intervention in personal decisions. (See
"What the Doctor Orders," January 1996.)

Some reformers who are privately skeptical of the disease model push it
because they think that's what the public is prepared to accept. From their
polling and their focus groups, the supporters of the Arizona and
Washington initiatives knew that voters were not ready for outright
decriminalization. They needed to be assured that somebody would be in
charge - if not cops, then doctors. Given the fate of Washington's
initiative, the wisdom of this strategy is open to question. But even if
the measure had passed, it might have made further reform more difficult by
reinforcing the disease model. If voters believe that people cannot
reasonably be expected to control their drug use, how likely are they to
support the repeal of prohibition?

On the other hand, the war on drugs is not going to end overnight. Certain
piecemeal reforms can mitigate injustice now and help prepare the public
for more radical change later. Reducing the penalties for marijuana
possession in the 1970s was, I think, such a reform. Making marijuana
legally available as a medicine may be another. By the same token, surely
drug users would be better off if they were never sent to prison, even if
they sometimes had to endure court-ordered "treatment."

Judging from my conversations with reformers, I'm not the only one who is
ambivalent about these issues. To help bring the debate into focus, REASON
invited several prominent critics of the war on drugs to discuss the pros
and cons of medicalization.

Senior Editor Jacob Sullum (jsullum@reason.com) is the author of For Your
Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health,
forthcoming this spring from The Free Press.

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