From: [w--li--h] at [ix.netcom.com] (William House ) Newsgroups: alt.law-enforcement,alt.drugs,alt.drugs.culture,alt.drugs.hard,alt.drugs.pot,rec.drugs.cannabis,rec.drugs.misc,rec.drugs.psychedelic,talk.politics.drugs,talk.politics.libertarian,talk.politics.misc,soc.culture.african.american Subject: p2 The Nadelmann Study : Costs, Consequences, and Alternatives to Prohibition. Date: 26 Oct 1995 14:37:57 GMT Perhaps the most difficult costs to evaluate are those that relate to the widespread defiance of the drug prohibition laws; the effects of labeling as criminals the tens of millions of people who use drugs illicitly, subjecting them to the same risks of criminal sanction, and obliging many of those same people to enter into relationships with drug dealers (who may be criminals in many more senses of the word) in order to purchase their drugs; the cynicism that such laws generate toward other laws and the law in general; and the sense of hostility and suspicion that many otherwise law-abiding individuals feel toward law enforcement officials. It was costs such as these that strongly influenced many of Prohibition's more conservative opponents. Among the most dangerous consequences of the drug laws are the harms that stem from the unregulated nature of illicit drug production and sale (37). Many marijuana smokers are worse off for having smoked cannabis that was grown with dangerous fertilizers, sprayed with paraquat, or mixed with more dangerous substances. Consumers of heroin and the various synthetic substances sold on the street face even more severe consequences, including fatal overdoses and poisonings from unexpectedly potent or impure drug supplies. In short, nothing resembling an underground Food and Drug Administration has arisen to impose quality control on the illegal drug market and provide users with accurate information on the drugs they consume. More often than not, the quality of a drug addict's life depends greatly on his or her access to reliable supplies. Drug enforcement operation that succeed in temporarily disrupting supply networks are thus a double-edged sword: they encourage some addicts to seek admission into drug treatment programs, but they oblige others to seek out new and hence less reliable suppliers, with the result that more, not fewer, drug- related emergencies and deaths occur. Today, about 25% of all acquired immunodeficiency syndrome (AIDS) cases in the United States and Europe, as well as the large majority of human immunodeficiency virus (HIV)-infected heterosexuals, children, and infants, are believed to have contracted the dreaded disease directly or indirectly >from illegal intravenous (IV) drug use (38). In the New York metropolitan area, the prevalence of a seropositive test for HIV among illicit IV drug users is over 50% (39). Reports have emerged of drug dealers beginning to provide clean syringes together with their illegal drugs (40). In England, recent increases in the number of HIV-infected drug users have led to renewed support among drug treatment clinicians for providing IV heroin addicts with free supplies of injectable methadone and heroin; this reversal of the strong since the early 1970s for oral methadone maintenance has been spearheaded by Philip Connell, chairman of the Home Office Advisory Committee on the Misuse of Drugs (41). But even as governments in England, Scotland, Sweden, Switzerland, Australia, the Netherlands, and elsewhere actively attempt to limit the spread of AIDS by and among drug users by removing restrictions on the sale of syringes and instituting free syringe exchange programs (42), state and municipal governments in the United States have resisted following suit, arguing, despite mounting evidence to the contrary (43), that to do so would "encourage" or "condone" the use of illegal drugs (44). Only in late 1988 did needle exchange programs begin emerging in U.S. cities, typically at the initiative of nongovernmental organizations. By mid-1989, programs were under way or close to being implemented in New York City; Tacoma, Washington; Boulder, Colorado; and Portland, Oregon (45). At the same time, drug treatment programs remain notoriously underfunded, turning away tens of thousands of addicts seeking help even as increasing billions of dollars are spent to arrest, prosecute, and imprison illegal drug sellers and users. Other costs of current drug prohibition policies include the restrictions on using the illicit drugs for legitimate medical purposes (46). Marijuana has proven useful in alleviating pain in some victims of multiple sclerosis, is particularly effective in reducing the nausea that accompanies chemotherapy, and may well prove effective in the treatment of glaucoma (47-49); in September 1988, the administrative law judge of the Drug Enforcement Administration accordingly recommended that marijuana be made legally available for such purposes (49), although the agency head has yet to approve the change. Heroin has proven highly effective in helping patients to deal with severe pain; some researcher have found it more effective than morphine and other opiates in treating pain in some patients (50). It is legally prescribed for such purposes in Britain (50) and Canada (51). The same may be true of cocaine, which continues to be used by some doctors in the United States to treat pain despite recently imposed bans (52). The psychedelic drugs, such as LDS (d-lysergic acid diethylamide), peyote, and MDMA (known as Ecstasy) have shown promise in aiding psychotherapy and in reducing tension, depression, pain, and fear of death in the terminally ill(53); they also have demonstrated some potential, as yet unconfirmed, to aid in the treatment of alcoholism (47, 53). Current drug laws and policies, however, greatly hamper the efforts of researchers to investigate these and other potential medical uses of illegal drugs; they make it virtually impossible for any of the illegal drugs, particularly those in Schedule I, to be legally provided to those who would benefit from them; and they contribute strongly to the widely acknowledged undertreatment of pain by the medical profession in the United States (54). Among the strongest arguments in favor of legalization are the moral ones. On the one hand, the standard refrain regarding the immorality of drug use crumbles in the face of most Americans' tolerance for alcohol and tobacco use. Only the Mormons and a few other like-minded sects, who regard as immoral any intake of substances to alter one's state of consciousness or otherwise cause pleasure, are consistent in this respect; they eschew not just the illicit drugs, but also alcohol, tobacco, caffeinated coffee and tea, and even chocolate. "Moral" condemnation by the majority of Americans of some substances and not others is little more than a transient prejudice in favor of some drugs and against others. On the other hand, drug enforcement involves its own immoralities. Because drug law violations do not create victims with an interest in notifying the police, drug enforcement agents must rely heavily on undercover operations, electronic surveillance, and information provided by informants. In 1986, almost half of the 754 court- authorized orders for wiretaps in the United States involved drug trafficking investigations (55). These techniques are certainly indispensable to effective law enforcement, but they are also among the least desirable of the tools available to police. The same is true of drug testing. It may be useful and even necessary for determining liability in accidents, but it also threatens and undermines the right of privacy to which many Americans believe they are morally and constitutionally entitled. There are good reasons for requiring that such measures be used sparingly. Equally disturbing are the increasingly vocal calls for people to inform not just on drug dealers but on neighbors, friends, and even family members who use illicit drugs. Intolerance of illicit drug use and users is heralded not merely as an indispensable ingredient in the war against drugs but as a mark of good citizenship. Certainly every society requires citizens to assist in the enforcement of criminal laws. But societies, particularly democratic and pluralistic ones, also rely strongly on an ethic of tolerance toward those who are different but do no harm to others. Overzealous enforcement of the drug laws risks undermining that ethic and propagating in its place a society of informants. Indeed, enforcement of drug laws makes a mockery of an essential principle of a free society, that those who do no harm to others should not be harmed by others, and particularly not by the state. Most of the nearly 40 million Americans who illegally consume drugs each year do no direct harm to anyone else; indeed, most do relatively little harm even to themselves. Directing criminal and other sanctions at them, and rationalizing the justice of such sanctions, may well represent the greatest societal cost of our current drug prohibition system. Alternatives to Drug Prohibition Policies Repealing the drug prohibition laws clearly promises tremendous advantages. Between reduced government expenditures on enforcing drug laws and new tax revenues from legal drug production and sales, public treasuries would enjoy a net benefit of at least $10 billion per year and possibly much more; thus billions in new revenues would be available, and ideally targeted, for funding much-needed drug treatment programs as well as the types of social and educational programs that often prove most effective in creating incentives not to abuse drugs. The quality of urban life would rise significantly. Homicide rates would decline. So would robbery and burglary rates. Organized criminal groups, particularly the up-and-coming ones that have yet to diversify into nondrug areas, would be dealt a devastating setback. The police, prosecutors, and courts would focus their resources on combating the types of crimes that people cannot walk away from. More ghetto residents would turn their backs on criminal careers and seek out legitimate opportunities instead. And the health and quality of life of many drug users and even drug abusers would improve significantly. Internationally, U.S. foreign policymakers would get on with more important and realistic objectives, and foreign governments would reclaim the authority they have lost to the drug traffickers. All the benefits of legalization would be for naught, however, if millions more people were to become drug abusers. Our experience with alcohol and tobacco provides ample warnings. Today, alcohol is consumed by 140 million Americans and tobacco by 50 million. All of the health costs associated with abuse of the illicit drugs pale in comparison with those resulting from tobacco and alcohol abuse. In 1986, for instance, alcohol was identified as a contributing factor in 10% of the work-related injuries, 40% of suicide attempts, and about 40% of the approximately 46,000 annual traffic deaths in 1983. An estimated 18 million Americans are reported to be either alcoholics or alcohol abusers. The total cost of alcohol abuse to American society is estimated at over $100 billion annually (56). Estimates of the number of deaths linked directly and indirectly to alcohol use vary from a low of 50,000 to a high of 200,000 per year (57). The health costs of tobacco use are different but of similar magnitude. In the United States alone, an estimated 320,000 people die prematurely each year as a consequence of their consumption of tobacco. By comparison, the Nation Council on Alcoholism reported that only 3,562 people were known to have died in 1985 from the use of all illegal drugs combined (58). Even if we assume that thousands more deaths were related in one way or another to illicit drug use but not reported as such, we still are left with the conclusion that all of the health costs of marijuana, cocaine, and heroin combined amount to only a small fraction of those caused by either of the two licit substances. At the very least, this contrast emphasized the need for a comprehensive approach to psychoactive substances involving much greater efforts to discourage tobacco and alcohol abuse. The impact of legalization of the nature and level of consumption of those drugs that are currently illegal is impossible to predict with any accuracy. On the one hand, legalization implies greater availability, lower prices, and the elimination (particularly for adults) of the deterrent power of the criminal sanction - all of which would suggest higher levels of use. Indeed, some fear that the extent of drug abuse and its attendant costs would rise to those currently associated with alcohol and tobacco (59). On the other hand, there are many reasons to doubt that a well-designed and implemented policy of controlled drug legalization would yield such costly consequences. The logic of legalization depends in part upon two assumptions: that most illegal drugs are not as dangerous as is commonly believed; and that those types of drugs and methods of consumption that are most risky are unlikely to prove appealing precisely because they are so obviously dangerous. Consider marijuana. Among the roughly 60 million Americans who have smoked marijuana, not one has died from a marijuana overdose (49), a striking contrast with alcohol, which is involved in approximately 10,000 overdose deaths annually, half in combination with other drugs (57). Although there are good health reasons for people not to smoke marijuana daily, and for children, pregnant women, and some others not to smoke at all, there still appears to be little evidence that occasional marijuana consumption does much harm at all. Certainly, it is not healthy to inhale marijuana smoke into one's lungs; indeed, the National Institute on Drug Abuse (NIDA) has declared that "marijuana smoke contains more cancer-causing agents than is found in tobacco smoke." (60). On the other hand, the number of "joints" smoked by all but a very small percentage of marijuana smokers is a tiny fraction of the 20 cigarettes a day smoked by the average cigarette smoker; indeed the average may be closer to one or two joints per week than one or two per day. Note that the NIDA defines a "heavy" marijuana smoker as one who consumes at least two joints "daily." A heavy tobacco smoker, by contrast, smokes about 40 cigarettes per day. Nor is marijuana strongly identified as a dependence-causing substance. A 1982 survey of marijuana use by young adults (18 to 25 years) found that 64% had tried marijuana at least once, that 42% had used it at least ten times, and that 27% had smoked in the last month. It also found that 21% had passed through a period during which they smoked "daily" (defined as 20 or more days per month) but that only one-third of those currently smoked daily and only one-fifth (or about 4% of all young adults) could be described as heavy daily users (averaging two or more joints per day) (61). This suggests in part that daily marijuana use is typically a phase through which people pass, after which their use becomes more moderate. By contrast, almost 20% of high school seniors smoke cigarettes daily. The dangers associated with cocaine heroin, the hallucinogens, and other illicit substances are greater than those posed by marijuana but not nearly so great as many people seem to think. Consider the case of cocaine. In 1986, NIDA reported that over 20 million Americans had tried cocaine, that 12.2 million had consumed it at least once during 1985, and that nearly 5.8 million had used it within the past month. Among 18- to 25-year-olds, 8.2 million had tried cocaine; 5.3 million had used it within the past year; 2.5 million had used it within the past month; and 250,000 had used it on the average weekly (20). One could extrapolate from these figures that a quarter of a million young Americans are potential problem uses. But one could also conclude that only 3% of those 18- to 25-year-olds who had ever tried the drug fell into that category, and that only 10% of those who had used cocaine monthly were at risk. (The NIDA survey did not, it should be noted, include persons residing in military or student dormitories, prison inmates, or the homeless.) All of this is not to say that cocaine is not a potentially dangerous drug, especially when it is injected, smoked in the form of "crack," or consumed in tandem with other powerful substances. Clearly, many tens of thousands of Americans have suffered severely from their abuse of cocaine and a tiny fraction have died. But there is also overwhelming evidence that most users of cocaine do not get into trouble with the drug. So much of the media attention has focused on the relatively small percentage of cocaine users who have become addicted that the popular perception of how most people use cocaine has become badly distorted, In one survey of high school seniors' drug use, the researchers questioned those who had used cocaine recently whether they had ever tried to stop using cocaine and found that they could not stop. Only 3.8% responded affirmatively, in contrast to the almost 7% of marijuana smokers who said they had tried to stop and found they could not, and the 18% of cigarette smokers who answered similarly (62). Although a survey of crack users and cocaine injectors surely would reveal a higher proportion of addicts, evidence such as this suggests that only a small percentage of people who snort cocaine end up having a problem with it. In this respect, most people differ from captive monkeys, who have demonstrated in tests that they will starve themselves to death if provided with unlimited cocaine (63). With respect to the hallucinogens such as LSD and psilocybic mushrooms, their potential for addiction is virtually nil. The dangers arise primarily >from using them irresponsibly on individual occasions (53). Although many of those who have used hallucinogens have experienced "bad trips," far more have reported positive experiences and very few have suffered any long-term harm (53). As for the great assortment of stimulants, depressants, and tranquilizers produced illegally or diverted from licit channels, each evidences varying capacities to create addiction, harm the user, or be used safely. Until recently, no drugs were regarded with as much horror as the opiates, and in particular heroin. As with most drugs, it can be eaten, snorted, smoked, or injected. The custom among most Americans, unfortunately, is the last of these options, although the growing fear of AIDS appears to be causing a shift among younger addicts toward intranasal ingestion (64). There is no question that heroin is potentially highly addictive, perhaps as addictive as nicotine. But despite the popular association of heroin use with the most down-and- out inhabitants of urban ghettos, heroin causes relatively little physical harm to the human body. Consumed on an occasional or regular basis under sanitary conditions, its worst side effect, apart from the fact of being addicted, is constipation (65). That is one reason why many doctors in early 20th-century America saw opiate addiction as preferable to alcoholism and prescribed the former as treatment for the latter where abstinence did not seem a realistic option (66, 67). It is both insightful and important to think about the illicit drugs as we do about alcohol and tobacco. Like tobacco, some illicit substances are highly addictive but can be consumed on a regular basis for decades without demonstrable harm. Like alcohol, many of the substances can be, an are, used by most most consumers in moderation, with little in the way of harmful effects; but like alcohol they also lend themselves to abuse by a minority of users who become addicted or otherwise harm themselves or others as a consequence. And like both the legal substances, the psychoactive effects of each of the illegal drugs vary greatly from one person to another. To be sure, the pharmacology of the substance is important, as is its purity and the manner in which it is consumed. But much also depends upon not just the physiology and psychology of the consumer but his expectations regarding the drug, his social milieu, and the broader cultural environment, what Harvard University psychiatrist Norman Zinberg called the "set and setting" of the drug (68). It is factors such as these that might change dramatically, albeit in indeterminate ways, were the illicit drugs made legally available. It is thus impossible to predict whether or not legalization would lead to much greater levels of drug abuse. The lessons that can be drawn from other societies are mixed. China's experience with the British opium pushers of the 19th century, when millions reportedly became addicted to the drug, offers one worst-case scenario. The devastation of many native American tribes by alcohol presents another. On the other hand, the decriminalization of marijuana by 11 states in the Unites States during the mid-1970's does not appear to have led to increases in marijuana consumption (69). In the Netherlands, which went even further in decriminalizing cannabis during the 1970s, consumption has actually declined significantly; in 1976, 3% of 15- and 16-year-olds and 10% of 17- and 18-year-olds used cannabis occasionally; by 1985 the percentage had declined to 2 and 6% respectively (70). The policy has succeeded, as the government intended, "in making drug use boring." Finally, late 19th-century America is an example of a society in which there were almost no drug laws of even drug regulation but levels of drug use were about what they are today (71). Drug abuse was regarded as a relatively serious problem, but the criminal justice system was not regarded as part of the solution (72). There are however, strong reasons to believe that none of the currently illicit substances would become as popular as alcohol or tobacco even if they were legalized. Alcohol has long been the principal intoxicant in most societies, including many in which other substances have legally available. Presumably, its diverse properties account for its popularity: it quenches thirst, goes well with food, often pleases the palate, promotes appetite as well as sociability, and so on. The widespread use of tobacco probably stems not just from its powerful addictive qualities but from the fact that its psychoactive effects are sufficiently subtle that cigarettes can be integrated with most other human activities. None of the illicit substances now popular in the United States share either of these qualities to the same extent, nor is it likely that they would acquire them if they were legalized. Moreover, none of the illicit substances can compete with alcohol's special place in American culture and history, one that it retained even during Prohibition. Much of the damage caused by illegal drugs today stems from their consumption in particularly potent and dangerous ways. There is good reason to doubt that many Americans would inject cocaine or heroin into their veins even if given the chance to do so legally. And just as the dramatic growth in the heroin-consuming population during the 1960s leveled off for reasons apparently having little to do with law enforcement, so we can expect, if it has not already occurred, a leveling off in the number of people who smoke crack. Perhaps the most reassuring reason for believing that repeal of the drug prohibition laws will not lead to tremendous increases in drug abuse levels is the fact that we have learned something from our past experiences with alcohol and tobacco abuse. We now know, for instance, that consumption taxes are an effective method for limiting consumption rates and related costs (73). Substantial evidence also suggests that restriction and bans on advertising, as well as promotion of negative advertising, can make a difference (74). The same seems to be true of other government measures, including restrictions on time and place of sale (75), bans on vending machines, prohibition of consumption in public places, packaging requirements, mandated adjustments in insurance policies, crackdowns on driving while under the influence (76), and laws holding bartenders and hosts responsible for the drinking of customers and guests. There is even some evidence that some education programs about the dangers of cigarette smoking have deterred many children from beginning to smoke (77). At the same time, we also have come to recognize the great harms that can result when drug control policies are undermined by powerful lobbies such as those that now block efforts to lessen the harms caused by abuse of alcohol and tobacco.