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.
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.
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.
Avram Goldstein, Addiction: From Biology to Drug Policy. New York: W.H Freeman & Co., 1993.
Mark Kleiman, Against Excess: Drug Policy for Results. New York: Basic Books, 1992.
Robert MacCoun and Peter Reuter, Beyond the Drug War: Learning From Other Places, Other Times, and Other Vices. Cambridge University Press, forthcoming.
Peter Reuter, "Why Can't We Make Prohibition Work Better?" Proceedings of the American Philosophical Society, Vol. 141, No. 3, September, 1997.
Peter Reuter, "After the Borders are Sealed: Can Domestic Sources Substitute for Imported Drugs?," Drug Policy in the Americas. Santa Monica, Calif: The RAND Corporation, 1992.
Peter C. Rydell and Susan S. Everingham, Controlling Cocaine: Supply Versus Demand Programs. Santa Monica, Calif.: The RAND Corporation, 1994.
Relevant Web sites
College on the Problems of Drug Dependence (CPDD) "Statement on National Drug Policy" (http://views.vcu.edu/cpdd/policy/drugpol.html).
Drug Policy Analysis Bulletin (http://www.fas.org/drugs/issue4.htm).
The Federation of American Scientists Drug Policy Project (http://www.fas.org/drugs).
Join Together (a national resource center for community antidrug efforts). (http://www.jointogether.org).
Physician Leadership on National Drug Policy (http://www.caas.brown.edu/plndp/).
"Principles for Practical Drug Policies" (http://www.fas.org/drugs/Principles.htm).
Mark A. R. Kleiman is a professor of policy studies at UCLA, a lecturer on public policy at Harvard Medical School, and editor of the Drug Policy Analysis Bulletin. From 1979 to 1983, he was deputy director for Drug Control Programs and then director of the Office of Policy and Management Analysis of the Justice Department's Criminal Division.