COMMONSENSE DRUG POLICY (1 of 2)

FIRST, REDUCE HARM

In 1988 Congress passed a resolution proclaiming its goal of "a drug-free
America by 1995." U.S. drug policy has failed persistently over the decades
because it has preferred such rhetoric to reality, and moralism to
pragmatism. Politicians confess their youthful indiscretions, then call for
tougher drug laws. Drug control officials make assertions with no basis in
fact or science. Police officers, generals, politicians, and guardians of
public morals qualify as drug czars-but not, to date, a single doctor or
public health figure. Independent commissions are appointed to evaluate
drug policies, only to see their recommendations ignored as politically
risky. And drug policies are designed, implemented, and enforced with
virtually no input from the millions of Americans they affect most: drug
users. Drug abuse is a serious problem, both for individual citizens and
society at large, but the "war on drugs" has made matters worse, not better.

Drug warriors often point to the 1980s as a time in which the drug war
really worked. Illicit drug use by teenagers peaked around 1980, then fell
more than 50 percent over the next 12 years. During the 1996 presidential
campaign, Republican challenger Bob Dole made much of the recent rise in
teenagers' use of illicit drugs, contrasting it with the sharp drop during
the Reagan and Bush administrations. President Clinton's response was
tepid, in part because he accepted the notion that teen drug use is the
principal measure of drug policy's success or failure; at best, he could
point out that the level was still barely half what it had been in 1980.

In 1980, however, no one had ever heard of the cheap, smokable form of
cocaine called crack, or drug-related HIV infection or aids. By the 1990s,
both had reached epidemic proportions in American cities, largely driven by
prohibitionist economics and morals indifferent to the human consequences
of the drug war. In 1980, the federal budget for drug control was about $1
billion, and state and local budgets were perhaps two or three times that.
By 1997, the federal drug control budget had ballooned to $16 billion,
two-thirds of it for law enforcement agencies, and state and local funding
to at least that. On any day in 1980, approximately 50,000 people were
behind bars for violating a drug law. By 1997, the number had increased
eightfold, to about 400,000. These are the results of a drug policy
over-reliant on criminal justice "solutions," ideologically wedded to
abstinence-only treatment, and insulated from cost-benefit analysis.

Imagine instead a policy that starts by acknowledging that drugs are here
to stay, and that we have no choice but to learn how to live with them so
that they cause the least possible harm. Imagine a policy that focuses on
reducing not illicit drug use per se but the crime and misery caused by
both drug abuse and prohibitionist policies. And imagine a drug policy
based not on the fear, prejudice, and ignorance that drive America's
current approach but rather on common sense, science, public health
concerns, and human rights. Such a policy is possible in the United States,
especially if Americans are willing to learn from the experiences of other
countries where such policies are emerging.

ATTITUDES ABROAD

Americans are not averse to looking abroad for solutions to the nation's
drug problems. Unfortunately, they have been looking in the wrong places:
Asia and Latin America, where much of the world's heroin and cocaine
originates. Decades of U.S. efforts to keep drugs from being produced
abroad and exported to American markets have failed. Illicit drug
production is bigger business than ever before. The opium poppy, source of
morphine and heroin, and cannabis sativa, from which marijuana and hashish
are prepared, grow readily around the world; the coca plant, from whose
leaves cocaine is extracted, can be cultivated far from its native
environment in the Andes. Crop substitution programs designed to persuade
Third World peasants to grow legal crops cannot compete with the profits
that drug prohibition makes inevitable. Crop eradication campaigns
occasionally reduce production in one country, but new suppliers pop up
elsewhere. International law enforcement efforts can disrupt drug
trafficking organizations and routes, but they rarely have much impact on
U.S. drug markets.

Even if foreign supplies could be cut off, the drug abuse problem in the
United States would scarcely abate. Most of America's drug-related problems
are associated with domestically produced alcohol and tobacco. Much if not
most of the marijuana, amphetamine, hallucinogens, and illicitly diverted
pharmaceutical drugs consumed in the country are made in the U.S.A. The
same is true of the glue, gasoline, and other solvents used by kids too
young or too poor to obtain other psychoactive substances. No doubt such
drugs, as well as new products, would quickly substitute for imported
heroin and cocaine if the flow from abroad dried up.

While looking to Latin America and Asia for supply-reduction solutions to
America's drug problems is futile, the harm-reduction approaches spreading
throughout Europe and Australia and even into corners of North America show
promise. These approaches start by acknowledging that supply-reduction
initiatives are inherently limited, that criminal justice responses can be
costly and counterproductive, and that single-minded pursuit of a
"drug-free society" is dangerously quixotic. Demand-reduction efforts to
prevent drug abuse among children and adults are important, but so are
harm-reduction efforts to lessen the damage to those unable or unwilling to
stop using drugs immediately, and to those around them.

Most proponents of harm reduction do not favor legalization. They recognize
that prohibition has failed to curtail drug abuse, that it is responsible
for much of the crime, corruption, disease, and death associated with
drugs, and that its costs mount every year. But they also see legalization
as politically unwise and as risking increased drug use. The challenge is
thus making drug prohibition work better, but with a focus on reducing the
negative consequences of both drug use and prohibitionist policies.

Countries that have turned to harm-reduction strategies for help in
alleviating their drug woes are not so different from the United States.
Drugs, crime, and race problems, and other socioeconomic problems are
inextricably linked. As in America, criminal justice authorities still
prosecute and imprison major drug traffickers as well as petty dealers who
create public nuisances. Parents worry that their children might get
involved with drugs. Politicians remain fond of drug war rhetoric. But by
contrast with U.S. drug policy, public health goals have priority, and
public health authorities have substantial influence. Doctors have far more
latitude in treating addiction and associated problems. Police view the
sale and use of illicit drugs as similar to prostitution-vice activities
that cannot be stamped out but can be effectively regulated. Moralists
focus less on any inherent evils of drugs than on the need to deal with
drug use and addiction pragmatically and humanely. And more politicians
dare to speak out in favor of alternatives to punitive prohibitionist
policies.

Harm-reduction innovations include efforts to stem the spread of HIV by
making sterile syringes readily available and collecting used syringes;
allowing doctors to prescribe oral methadone for heroin addiction
treatment, as well as heroin and other drugs for addicts who would
otherwise buy them on the black market; establishing "safe injection rooms"
so addicts do not congregate in public places or dangerous "shooting
galleries"; employing drug analysis units at the large dance parties called
raves to test the quality and potency of MDMA, known as Ecstasy, and other
drugs that patrons buy and consume there; decriminalizing (but not
legalizing) possession and retail sale of cannabis and, in some cases,
possession of small amounts of "hard" drugs; and integrating harm-reduction
policies and principles into community policing strategies. Some of these
measures are under way or under consideration in parts of the United
States, but rarely to the extent found in growing numbers of foreign
countries.

STOPPING HIV WITH STERILE SYRINGES

The spread of HIV, the virus that causes aids, among people who inject
drugs illegally was what prompted governments in Europe and Australia to
experiment with harm-reduction policies. During the early 1980s public
health officials realized that infected users were spreading HIV by sharing
needles. Having already experienced a hepatitis epidemic attributed to the
same mode of transmission, the Dutch were the first to tell drug users
about the risks of needle sharing and to make sterile syringes available
and collect dirty needles through pharmacies, needle exchange and methadone
programs, and public health services. Governments elsewhere in Europe and
in Australia soon followed suit. The few countries in which a prescription
was necessary to obtain a syringe dropped the requirement. Local
authorities in Germany, Switzerland, and other European countries
authorized needle exchange machines to ensure 24-hour access. In some
European cities, addicts can exchange used syringes for clean ones at local
police stations without fear of prosecution or harassment. Prisons are
instituting similar policies to help discourage the spread of HIV among
inmates, recognizing that illegal drug injecting cannot be eliminated even
behind bars.

These initiatives were not adopted without controversy. Conservative
politicians argued that needle exchange programs condoned illicit and
immoral behavior and that government policies should focus on punishing
drug users or making them drug-free. But by the late 1980s, the consensus
in most of Western Europe, Oceania, and Canada was that while drug abuse
was a serious problem, aids was worse. Slowing the spread of a fatal
disease for which no cure exists was the greater moral imperative. There
was also a fiscal imperative. Needle exchange programs' costs are minuscule
compared with those of treating people who would otherwise become infected
with HIV.

Only in the United States has this logic not prevailed, even though aids
was the leading killer of Americans ages 25 to 44 for most of the 1990s and
is now No. 2. The Centers for Disease Control (CDC) estimates that half of
new HIV infections in the country stem from injection drug use. Yet both
the White House and Congress block allocation of aids or drug-abuse
prevention funds for needle exchange, and virtually all state governments
retain drug paraphernalia laws, pharmacy regulations, and other
restrictions on access to sterile syringes. During the 1980s, aids
activists engaging in civil disobedience set up more syringe exchange
programs than state and local governments. There are now more than 100 such
programs in 28 states, Washington, D.C., and Puerto Rico, but they reach
only an estimated 10 percent of injection drug users.

Governments at all levels in the United States refuse to fund needle
exchange for political reasons, even though dozens of scientific studies,
domestic and foreign, have found that needle exchange and other
distribution programs reduce needle sharing, bring hard-to-reach drug users
into contact with health care systems, and inform addicts about treatment
programs, yet do not increase illegal drug use. In 1991 the National aids
Commission appointed by President Bush called the lack of federal support
for such programs "bewildering and tragic." In 1993 a CDC-sponsored review
of research on needle exchange recommended federal funding, but top
officials in the Clinton administration suppressed a favorable evaluation
of the report within the Department of Health and Human Services. In July
1996 President Clinton's Advisory Council on HIV/aids criticized the
administration for its failure to heed the National Academy of Sciences'
recommendation that it authorize the use of federal money to support needle
exchange programs. An independent panel convened by the National Institute
of Health reached the same conclusion in February 1997. Last summer, the
American Medical Association, the American Bar Association, and even the
politicized U.S. Conference of Mayors endorsed the concept of needle
exchange. In the fall, an endorsement followed from the World Bank.

To date, America's failure in this regard is conservatively estimated to
have resulted in the infection of up to 10,000 people with HIV. Mounting
scientific evidence and the stark reality of the continuing aids crisis
have convinced the public, if not politicians, that needle exchange saves
lives; polls consistently find that a majority of Americans support needle
exchange, with approval highest among those most familiar with the notion.
Prejudice and political cowardice are poor excuses for allowing more
citizens to suffer from and die of aids, especially when effective
interventions are cheap, safe, and easy.

METHADONE AND OTHER ALTERNATIVES

The United States pioneered the use of the synthetic opiate methadone to
treat heroin addiction in the 1960s and 1970s, but now lags behind much of
Europe and Australia in making methadone accessible and effective.
Methadone is the best available treatment in terms of reducing illicit
heroin use and associated crime, disease, and death. In the early 1990s the
National Academy of Sciences' Institute of Medicine stated that of all
forms of drug treatment, "methadone maintenance has been the most
rigorously studied modality and has yielded the most incontrovertibly
positive results . . . Consumption of all illicit drugs, especially heroin,
declines. Crime is reduced, fewer individuals become HIV positive, and
individual functioning is improved." However, the institute went on to
declare, "Current policy . . . puts too much emphasis on protecting society
from methadone, and not enough on protecting society from the epidemics of
addiction, violence, and infectious diseases that methadone can help reduce."

Methadone is to street heroin what nicotine skin patches and chewing gum
are to cigarettes-with the added benefit of legality. Taken orally,
methadone has little of injected heroin's effect on mood or cognition. It
can be consumed for decades with few if any negative health consequences,
and its purity and concentration, unlike street heroin's, are assured. Like
other opiates, it can create physical dependence if taken regularly, but
the "addiction" is more like a diabetic's "addiction" to insulin than a
heroin addict's to product bought on the street. Methadone patients can and
do drive safely, hold good jobs, and care for their children. When
prescribed adequate doses, they can be indistinguishable from people who
have never used heroin or methadone.

Popular misconceptions and prejudice, however, have all but prevented any
expansion of methadone treatment in the United States. The 115,000
Americans receiving methadone today represent only a small increase over
the number 20 years ago. For every ten heroin addicts, there are only one
or two methadone treatment slots. Methadone is the most tightly controlled
drug in the pharmacopoeia, subject to unique federal and state
restrictions. Doctors cannot prescribe it for addiction treatment outside
designated programs. Regulations dictate not only security, documentation,
and staffing requirements but maximum doses, admission criteria, time spent
in the program, and a host of other specifics, none of which has much to do
with quality of treatment. Moreover, the regulations do not prevent poor
treatment; many clinics provide insufficient doses, prematurely detoxify
clients, expel clients for offensive behavior, and engage in other
practices that would be regarded as unethical in any other field of
medicine. Attempts to open new clinics tend to be blocked by residents who
don't want addicts in their neighborhood.

In much of Europe and Australia, methadone treatment was at first even more
controversial than in the United States; some countries, including Germany,
France, and Greece, prohibited it well into the 1980s and 1990s. But where
methadone has been accepted, doctors have substantial latitude in deciding
how and when to prescribe it so as to maximize its efficacy. There are
methadone treatment programs for addicts looking for rehabilitation and
programs for those simply trying to reduce their heroin consumption.
Doctors in regular medical practice can prescribe the drug, and patients
fill their prescriptions at local pharmacies. Thousands of general
practitioners throughout Europe, Australia, New Zealand, and Canada
(notably in Ontario and British Columbia) are now involved in methadone
maintenance. In Belgium, Germany, and Australia this is the principal means
of distribution. Integrating methadone with mainstream medicine makes
treatment more accessible, improves its quality, and allocates ancillary
services more efficiently. It also helps reduce the stigma of methadone
programs and community resistance to them.

Many factors prevent American doctors from experimenting with the more
flexible treatment programs of their European counterparts. The Drug
Enforcement Administration contends that looser regulations would fuel the
illicit market in diverted methadone. But the black market, in which
virtually all buyers are heroin addicts who cannot or will not enroll in
methadone programs, is primarily a product of the inadequate legal
availability of methadone. Some conventional providers do not want to cede
their near-monopoly over methadone treatment and are reluctant to take on
addicts who can't or won't commit to quitting heroin. And all efforts to
make methadone more available in the United States run up against the many
Americans who dismiss methadone treatment as substituting one addictive
drug for another and are wary of any treatment that does not leave the
patient "drug free."

Oral methadone works best for hundreds of thousands of heroin addicts, but
some fare better with other opiate substitutes. In England, doctors
prescribe injectable methadone for about 10 percent of recovering patients,
who may like the modest "rush" upon injection or the ritual of injecting.
Doctors in Austria, Switzerland, and Australia are experimenting with
prescribing oral morphine to determine whether it works better than oral
methadone for some users. Several treatment programs in the Netherlands
have conducted trials with oral morphine and palfium. In Germany, where
methadone treatment was initially shunned, thousands of addicts have been
maintained on codeine, which many doctors and patients still prefer to
methadone. The same is true of buprenorphine in France.

In England, doctors have broad discretion to prescribe whatever drugs help
addicted patients manage their lives and stay away from illegal drugs and
their dealers. Beginning in the 1920s, thousands of English addicts were
maintained on legal prescriptions of heroin, morphine, amphetamine,
cocaine, and other pharmaceutical drugs. This tradition flourished until
the 1960s, and has reemerged in response to aids and to growing
disappointment with the Americanization of British prescribing practices
during the 1970s and 1980s, when illicit heroin use in Britain increased
almost tenfold. Doctors in other European countries and Australia are also
trying heroin prescription.

The Swiss government began a nationwide trial in 1994 to determine whether
prescribing heroin, morphine, or injectable methadone could reduce crime,
disease, and other drug-related ills. Some 1,000 volunteers-only heroin
addicts with at least two unsuccessful experiences in methadone or other
conventional treatment programs were considered-took part in the
experiment. The trial quickly determined that virtually all participants
preferred heroin, and doctors subsequently prescribed it for them. Last
July the government reported the results so far: criminal offenses and the
number of criminal offenders dropped 60 percent, the percentage of income
from illegal and semi-legal activities fell from 69 to 10 percent, illegal
heroin and cocaine use declined dramatically (although use of alcohol,
cannabis, and tranquilizers like Valium remained fairly constant), stable
employment increased from 14 to 32 percent, physical health improved
enormously, and most participants greatly reduced their contact with the
drug scene. There were no deaths from overdoses, and no prescribed drugs
were diverted to the black market. More than half those who dropped out of
the study switched to another form of drug treatment, including 83 who
began abstinence therapy. A cost-benefit analysis of the program found a
net economic benefit of $30 per patient per day, mostly because of reduced
criminal justice and health care costs.

The Swiss study has undermined several myths about heroin and its habitual
users. The results to date demonstrate that, given relatively unlimited
availability, heroin users will voluntarily stabilize or reduce their
dosage and some will even choose abstinence; that long-addicted users can
lead relatively normal, stable lives if provided legal access to their drug
of choice; and that ordinary citizens will support such initiatives. In
recent referendums in Zurich, Basel, and Zug, substantial majorities voted
to continue funding local arms of the experiment. And last September, a
nationwide referendum to end the government's heroin maintenance and other
harm-reduction initiatives was rejected by 71 percent of Swiss voters,
including majorities in all 26 cantons.

The Netherlands plans its own heroin prescription study in 1998, and
similar trials are under consideration elsewhere in Europe, including
Luxembourg and Spain, as well as Canada. In Germany, the federal government
has opposed heroin prescription trials and other harm-reduction
innovations, but the League of Cities has petitioned it for permission to
undertake them; a survey early last year found that police chiefs in 10 of
the country's 12 largest cities favored letting states implement controlled
heroin distribution programs. In Australia last summer, a majority of state
health ministers approved a heroin prescription trial, but Prime Minister
John Howard blocked it. And in Denmark, a September 1996 poll found that 66
percent of voters supported an experiment that would provide registered
addicts with free heroin to be consumed in centers set up for the purpose.

Switzerland, attempting to reduce overdoses, dangerous injecting practices,
and shooting up in public places, has also taken the lead in establishing
"safe injection rooms" where users can inject their drugs under secure,
sanitary conditions. There are now about a dozen such rooms in the country,
and initial evaluations are positive. In Germany, Frankfurt has set up
three, and there are also officially sanctioned facilities in Hamburg and
Saarbrucken. Cities elsewhere in Europe and in Australia are expected to
open safe injection rooms soon.

[continues]

Copyright 1998, Foreign Affairs. Reprinted by permission. All rights reserved.