Editor’s note: This is an article from the December 1998 issue of UCLA Magazine.
“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 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 kind of 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 blame “drugs” for all our social ills and advocate stricter controls and harsher punishments, and the “legalizers,” who blame drug prohibition instead and 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’s drug problem could be much smaller five years from now than it is today. Repairing our broken policies will require a clearer vision of what the drug problem is and more moderate expectations about what drug-control policies can actually accomplish.
Current policies, which largely reflect the drug-warrior approach, aim above all at reducing drug use. The favored tools are stricter controls, increased enforcement, harsher punishments and school-based and mass-media efforts to stigmatize the use of illicit drugs. Treatment is very much an afterthought.
At least three-quarters of the roughly $40 billion now spent by governments at all levels on the control of illicit drug abuse now goes into enforcement; the size of that effort and the number of persons incarcerated for drug-law violations have grown approximately tenfold during the past 20 years. Yet hard-drug prices, the clearest measure of enforcement effectiveness, 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 non-users. The most widely debated, though not even nearly the most important, example is needle exchange, which aims to reduce the transmission of HIV and other pathogens from needle-sharing among drug injectors. Some advocates of harm reduction also assert that the legalization of drug use and distribution would decrease addicts’ need to steal to finance their habits and the violence associated with the drug trade.
What all this ignores is that the total damage associated with drug use depends not only on its harmfulness but also on its extent. Legal drugs would indeed do less harm to each user, but there would be many more users. Harm-reduction measures short of legalization also need to be scrutinized for their risks of increasing the extent of drug use, much greater in some cases than in others. (Needle exchange, for example, is low-risk, but also in most circumstances low-gain.)
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 harms to individuals or institutions.
Using this approach to 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 damage than any illicit drug. Second, thinking about damage would prompt us to concentrate our efforts on frequent, high-dose users, especially those whose addiction to expensive illicit drugs leads them into criminal activity. A damage standard would also direct our attention to reducing the side effects of drug trafficking, especially violence and the enticement of juveniles into illicit activity, and to start to count the financial and social costs of enforcement and imprisonment.
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, by far the greatest threats. About a quarter of high school seniors smoke, and most go on to heavy daily smoking. Heavy smoking, in turn, roughly doubles the mortality rate at any given age. As for alcohol, binge drinking is more common among adolescents than is the use of any illicit drug. The total damage done to adolescents by marijuana does not approach that done by alcohol and nicotine.
Societywide, drinking and drunken behavior exact a terrible toll. Surveys of offenders under criminal-justice supervision show that 40 percent had been drinking at the time they committed the offense that led to their convictions, and alcohol involvement in some categories of violent offenses is even higher.
Fortunately, we know exactly how to reduce smoking and drinking: Make tobacco and alcoholic beverages more expensive. The $1.10 cigarette tax increase rejected by Congress this year, for example, would have reduced the prevalence of juvenile smoking by about a third. The ideal tax on alcohol would be several times its current level of about a dime a drink.
The key to controlling the illicit drugs is to focus on the fewer than 4 million hard-drug addicts. This relatively small group accounts for about 80 percent of the total consumption of cocaine, heroin and methamphetamine. They create problems out of any proportion to their numbers. They suffer enormously and cause suffering around themselves.
Of the conventional tools of drug policy, only treatment has much relevance to controlling the problems of this group. A mountain of data shows that treating a hardcore addict, even if with only partial success, creates very large benefits. Although long-term cessation is a highly desirable goal, even imperfectly successful treatment episodes greatly reduce drug consumption and drug-related harm both while treatment lasts and for some time thereafter: gains more than adequate to cover the cost of treatment.
Getting hardcore hard-drug users into treatment and keeping them there remains a major problem. This is the group least likely to enter treatment voluntarily, most expensive to treat and least likely to succeed by the standard of total abstinence. Many prefer drugs to treatment, as long as they can get the drugs.
The choice, however, need not be left entirely up to the addicts. Sooner or later, most wind up under the jurisdiction of the criminal-justice system. 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 changing drug-taking behavior.
That is the idea underlying drug diversion, drug courts and coerced-abstinence programs. The central idea of all three is to make staying out of jail conditional on staying off hard drugs. The key to success is frequent testing and automatic, but not severe, sanctions for each detected instance of drug use, combined with treatment as necessary.
Together, these three programs offer the best prospects for actually shrinking the hard-drug markets, reducing the criminal activity of hardcore users and improving addicts’ lives by keeping them out of prison and reducing, if not ending, their drug abuse. Since drug courts and diversion programs rely on the limited capacity of the treatment system, the only version of this idea that could rapidly be brought to full scale is coerced abstinence: testing and sanctions alone, with treatment as a backup for those who repeatedly fail.
By my calculations, a national program of coerced abstinence 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.
But the polarization of the current drug debate between stereotyped “drug warrior” and “legalizer” positions creates the false impression that “ending prohibition” is the only alternative to an unrestricted “war on drugs,” effectively barring “third way” options such as coerced abstinence from serious consideration. In this climate, every idea, research finding or proposal put forth is scrutinized to determine which agenda it advances. As a result, questions that ought to be addressed on technical and practical grounds — such as methadone treatment — are instead debated as matters of ideological conviction.
Both drugs and drug policies cause harm. Any policy, including inaction, does harm as well as good. Once that is acknowledged, we can begin the hard work of shaping policies that do more good than harm. That work will demand reasoned analysis, scientific respect for evidence, and a willingness to learn from mistakes, rather than denying them. Whether we can summon the political will for that task remains an open question.
