Background

Modern drug prohibition began in the 19th century when the medicinal chemistry industry began to produce many potent and habituating drugs. One such drug was heroin, which was first sold in the United States in 1898. These drugs were sold as ordinary commercial items along with a popular new drink, cocaine-containing Coca-Cola. At that time, physicians freely prescribed addicting drugs to their patients, thereby producing a large group of medical addicts. Drugs such as cocaine were originally used for legitimate medical indications. Drug use by the public later rapidly grew to include compulsive use, illegal activity to support nonmedical use, and consumption despite clear negative medical and social consequences.

This era of indiscriminate sale and use of addictive drugs ended during the first two decades of the 20th century with a new social contract embodied in the Pure Food and Drug Act of 1906 [3], which addressed the labeling of drugs. In 1914, the Harrison Narcotics Act [4] prohibited the sale of narcotics. The Volstead Act, along with the 18th Amendment to the Constitution in 1919, prohibited the sale of alcohol. These laws were part of a broad reform movement in the United States that also promoted women's right to vote.

Under this new social contract, habituating drugs were not available except through a physician's prescription; even then the drugs were used sparingly in treating illnesses other than addiction. In 1933, alcohol was removed from the list of strictly controlled or prohibited substances. In 1937, marijuana was added to the list of prohibited substances because of a sudden increase in the use of the drug [5]. The patent drug epidemic had begun with morphine and heroin in the final decade of the 19th century and ended with an explosive increase in the use of cocaine during the first decade of the 20th century.

The social contract regulating drugs of abuse served the country well by nearly ending the first drug abuse epidemic. The U.S. drug control laws proved to be a model throughout the world during the first two thirds of the 20th century. The use of habituating drugs, which had been out of control at the end of the 19th century, was dramatically reduced in the United States between 1920 and 1965 [5].

The nation was lulled into complacency by the great and prolonged success of this drug abuse policy. Public and policy leaders in the United States entered a period of amnesia of the tragic consequences of widespread drug use. By the 1960s, most Americans had no personal memory of the earlier U.S. addiction epidemic. Strict prohibition of nonalcohol drugs was broadly respected until the ascendant youth culture integrated drugs as a central element of its new lifestyles.

Marijuana, the hallucinogens, and cocaine became widely defined as "marginally addictive" or "soft" drugs [6]. Their use became the focus of a call for legalization based on unsubstantiated claims that these drugs were no worse than alcohol and tobacco. Both the substantial health and addiction problems now known to result from the use of crack cocaine and marijuana and the extensive research on the harmful effects of many drugs are testimony to the manner in which society was misled in the 1960s [7]. These effects include addiction, vehicular trauma, disease, suicide, and specific negative physical effects of the drugs themselves [8-15].

Legalization of Illegal Drugs

In recent years, the drug legalization movement has gained modest public support by attempting to associate opponents of drug legalization with the negative public perceptions of alcohol prohibition and by calling the opponents of legalization prohibitionists. For this discussion, we define prohibition as a restrictive policy that maintains legal restrictions against the nonmedical use or sale of addicting drugs, as covered under the Controlled Substances Act [16].

Drug legalization is neither a simple nor singular public policy proposal. For example, drug legalization could at one extreme involve a return to open access to all drugs for all persons, as was seen at the end of the 19th century. Partial legalization could entail such policy changes as making currently illegal drugs available in their crude forms to certain types of ill patients. This limited legalization might include the maintenance of persons addicted to heroin or their drug of choice, distribution of needles to addicts without requiring that they stop using drugs, or marked softening of sentencing guidelines for drug-related offenses.

The evidence of the negative global experience with the legal substances tobacco and alcohol is overlooked by most supporters of drug legalization. The data on alcohol and tobacco support the view that legalization of drugs leads to large increases in the use of the legalized drugs and to higher total social costs. These added costs are primarily paid in lost productivity, illness, and death. In the United States, about 125 000 and 420 000 deaths are annually attributed to alcohol and tobacco, respectively. Fewer than 10 000 deaths each year result from the use of all illicit drugs combined. The social costs from alcohol use in the United States are estimated to be $86 billion, whereas the annual costs of prohibiting illegal drug use (including enforcement and incarceration) are $58 billion [17, 18]. The social costs of tobacco use are estimated to be $65 billion annually [17]. If one of the goals of a drug policy is to reduce the harm to society that results from drug use, then alcohol and tobacco must be a top priority within this strategy.

Considering the number of users of illegal and legal drugs in the United States and the trends in the rates of use from 1985 to 1991 Table 1, it becomes apparent that prohibitive drug policy has actually maintained low levels of use compared with the wide availability of habituating substances. Equally important are the rates of illicit drug use, which have decreased faster than the rates of legal drug use [19].

Substantial progress was made in reducing adolescent drug use from 1978 to 1992 (Table 2). That success was due to a relatively clear national message and broad-based antidrug efforts in both the public and private sectors. Since 1992, adolescent drug use has increased, and attitudes toward drug use have become more accepting [20]. Although these changes have many causes, the reduction of government and media antidrug efforts and increases in media campaigns promoting drugs have played a role.

Harm Reduction

Although reducing the harm caused by drug use is a universal goal of all drug policies, policy proposals called "harm reduction" proposals include a creative renaming of the dismantling of legal restrictions against the use and sale of drugs. The essential components of legalization policies are couched within this concept. Much of the driving force behind the harm reduction movement also centers on personal choice and "safe" habits for drug use [21].

Paradoxically, some public policy attempts at reducing the harms associated with the use of alcohol and tobacco involve tightening restrictions on intoxicated driver legislation and smoking restrictions [22], whereas current harm reduction proposals generally involve softening the restrictions on the use of illegal drugs.

The current harm reduction proposals for drugs other than tobacco or alcohol focus heavily on reducing or eliminating criminal penalties for drug offenses, softening sentencing guidelines, providing addict maintenance programs and needle exchange programs for intravenous drug users, and removing work-place drug testing programs [23]. The efficacy of these proposals has not been established.

As it is represented in the current policy debate, harm reduction policy also attempts to mitigate the negative effects of nonmedical drug use without reducing the use of illegal drugs. The policy is based on the assumption that most of the harm caused by nonmedical drug use is the result of the societal efforts to stop drug use rather than the result of drug use itself. Those harms are generally considered to be associated with arrests from and legal consequences of illegal behavior and with incarceration [24]. Advocates of harm reduction contend that essentially innocent drug users are targeted by prohibition; however, only 2% of federal inmates are incarcerated for possession-related crime compared with 48% incarcerated for drug trafficking. Despite the clear deterring effect of legal penalties, some positive outcomes can be attributed to the criminal justice system. For example, 35% of persons imprisoned for drug-related offenses are treated for drug addiction while incarcerated [25].

In the Netherlands, an international model for decriminalization and harm reduction, decriminalization has been associated with an increase in crime and drug use. From 1984 to 1992, cannabis use among students in the Netherlands increased 250%. Between 1988 and 1993, the number of registered addicts increased 22%. Also reflecting the decriminalization of marijuana, the number of marijuana addicts increased 30% from 1991 to 1993 alone. As we see in the United States, the harms of increased drug use go beyond those to the user alone. Since the tolerant drug policy was instituted in the Netherlands, shootings have increased 40%, hold-ups have increased 69%, and car thefts have increased 62% (Gunning KF. Personal communication).

In the United States, we experimented briefly with the decriminalization of marijuana. That temporary softening of drug policy resulted in a statistically significant increase in the reported number of marijuana-related visits to emergency departments compared with metropolitan areas in which marijuana use was not decriminalized [26].

The current and still dominant drug policy seeks to curb drug use and the associated harms by using the legal system and other methods such as work-place drug testing and treatment to reduce nonmedical drug use. In contrast to the advocates of harm reduction or legalization, supporters of the current restrictive drug policy emphasize that most drug-related harm is caused by drug use and not just by drug prohibition [27].

The two groups find some common ground in the support of drug education and treatment. Supporters of restrictive drug policy teach complete avoidance of nonmedical drug use, and harm reductionists support teaching "responsible use" of currently illegal drugs. Many proponents of harm reduction admit that they seek the ultimate legalization of illegal drugs, especially marijuana. Some harm reduction supporters advocate this policy because decriminalization would relieve the legal pressure on their own drug use. These persons seek to manipulate drug policy to justify their own drug-using behaviors.

Clearly, all forms of legalization, including harm reduction, are strategies ultimately aimed at softening public and government attitudes against nonmedical drug use and the availability of currently illegal drugs.

Costs of Drug Policy

Advocates of legalization correctly point out that prohibiting the use of our currently illegal drugs is expensive. The sources of overall costs produced by the use of legal drugs compared with costs of illegal drug use are listed in Table 3. These data also show that restrictive drug policy shifts the costs of drug use related to health and productivity to the criminal justice system.

Augmenting a restrictive drug policy by broadening the drug treatment available to addicts may be beneficial and cost-effective. A recent study by RAND [28] estimates that the current societal costs and actual costs of controlling cocaine use alone total $42 billion annually ($13 billion for control costs and $29 for societal costs). This study also estimated that the net control and societal costs related to cocaine could be reduced to $33.9 billion by maintaining our current enforcement policies and adding to it the treatment of all addicts. The RAND study concluded that the treatment is effective in reducing the costs to society not only by reducing the demand for drugs but also by removing the addict from drugs for sustained periods of time.

Supporters of restrictive drug policy must acknowledge that prohibition alone does not eliminate either the use of prohibited drugs or the high cost to society that results from the use of these drugs. Furthermore, drug prohibition achieves its goals at a substantial cost in the form of maintaining the criminal justice system and restricting personal choice. Prohibiting the use of some drugs is undeniably costly; however, because the overall level and total societal costs of drug use are reduced, this prohibition is well worth the cost.

Drug Policy Options

Given the range of options available within legalization and drug prohibition policies, it is important to look at the overall picture of drug policy. We must ask whether prohibiting the consumption of some drugs is effective in reducing social costs, or "harm," and whether restrictive policy is cost-effective. Two models for drug policy help answer these questions.

The first model examines life in the United States 100 years ago, a time when habituating drugs were sold like toothpaste or candy. At the end of the 19th century, Americans considered the problems with freely available habituating drugs unacceptable. In the context of today's debate on drug policy, it should be recalled that prohibition policies resulted from a nonpartisan outcry over the serious negative effects of uncontrolled drug use. In other words, the prohibition of marijuana, heroin, and cocaine did not cause widespread drug use in the United States. Rather, widespread use of those drugs use caused their prohibition. Furthermore, prohibition of nonalcohol drugs was successful in reducing drug use and was almost universally supported by all political parties in the United States and throughout the world for half a century.

While it lasted, alcohol prohibition was also largely successful from a health perspective. For example, the number of deaths from cirrhosis of the liver decreased from 29.5/100 000 persons in 1911 to 10.7/100 000 persons in 1929. Admissions to state mental hospitals for alcohol psychosis decreased from 10/100 000 persons in 1919 to 4.7/100 000 persons in 1928 [29]. The main failure of alcohol prohibition was its attempt to remove the availability of alcohol from the public after it had been legal, accepted, and deeply integrated into society for many years. Currently illegal drugs do not share that same level of acceptance and integration.

The second model for drug policy compares the costs generated by the drugs that are now legal for adults with the costs of those that are not. This entails comparing the social costs resulting from the use of alcohol and tobacco (legal drugs) with costs of using marijuana, cocaine, heroin, and other illegal drugs. Alcohol and tobacco produce more harm than all of the illegal drugs combined because they are so widely used, and they are more widely used because they are legal. As legal substances, they enjoy greater social acceptance, widespread advertising, and glorification. The national experience with alcohol and tobacco does not represent an attractive alternative to the prohibition of drug use as it is currently practiced in the United States and other countries.

Because alcohol and tobacco are deeply integrated into society, prohibiting their use is politically unrealistic. However, major constraints on the use alcohol and tobacco, such as total elimination of advertising, high taxation, restriction on smoking locations, designated driver programs, and product liability by the manufacturers and distributors of these products, show some promise in reducing the harm produced by these legal drugs [23].

Recommendations

Top Recommendations Author & Article Info References

The relevant policy question is whether legalization or reducing the restrictions on the availability of drugs would increase the number of drug users and total social harm produced by the use of currently illegal drugs. The available data show that legalization would increase the use of currently prohibited drugs [3, 20, 27].

Legalization or decriminalization creates a particular risk among young persons, whose social adaptation and maturation are not yet complete. This fact can be shown by comparing the levels of the use of currently legal drugs by young persons (alcohol and tobacco) with the levels of illegal drug use. The use of all of these drugs is illegal for young persons, but the drugs that are legal for adults are more widely used by youths than the drugs that are illegal for both adults and young persons (Table 4).

What is needed today is not the dismantling of restrictive drug policies. Rather, a strong national policy should seek to reduce the harm of drug use through harm prevention (for example, by creating drug-prevention programs) and harm elimination (by implementing broader interdiction and rehabilitation efforts) [30-32]. This new policy should strengthen efforts to reduce the use of alcohol and tobacco as well as currently illegal drugs. In so doing, this policy should take aim at especially vulnerable persons in the community, with a special emphasis on the young.

If persons who seek to reform drug policy and harm reduction are sincere in their intent, they would focus their efforts on alcohol and tobacco, substances for which "harm reduction" is greatly needed, and leave the currently illegal drugs illegal. Unless those who subscribe to the notion of harm reduction move ahead to prevention and elimination of harm, the global costs associated with any form of drug use will continue to increase. Relaxation of the restrictive policies on the use of currently illegal drugs should only be considered in the context of programs that can first prove drastic and lasting reductions in alcohol and tobacco use. Real harm reduction involves prohibiting illegal drugs while concurrently working to prevent and treat their use. We do not need new experiments to tell us what we have already learned from legal alcohol and tobacco. Those experiments have already been done at the cost of great human suffering.

Dr. Voth: The International Drug Strategy Institute, 901 Garfield, Topeka, KS 66606.