Thinking About the Unthinkable in Ukraine
What Happens If Putin Goes Nuclear?
Few issues generate more heat than substance abuse. Most Americans yearn for simple solutions that will make the problem go away. Ethan A. Nadelmann thinks he has found some in the experiences of some foreign countries. These, he argues, are sensible alternatives to America's failed policies ("Commonsense Drug Policy," January/February 1998). But his analysis merely further disseminates myths about overseas "successes" that do much to hinder the evolution of reasonable, popular, and effective U.S. drug policies.
Nadelmann maintains that "drugs are here to stay" and focuses on reducing the harm they cause. True, the United States will never be totally drug-free, any more than it will ever be totally crime-free or disease-free. But that is no cause for despair. Were the United States committed to an unambiguous and full-scale confrontation with illicit drugs, drug use could be brought down to a bare minimum and its extraordinary social and economic costs substantially reduced. There is no convincing evidence that liberalizing drug policies and accommodating drug use will reduce these harmful effects. Nor is there evidence of a need to ease up now. There is, however, ample proof that the consistent exercise of restrictive policies can minimize the damage. Such policies brought drug abuse under control in societies as diverse as Japan and Sweden. Widespread drug use need not be a fixture of modern life.
Those who advocate abandoning U.S. efforts to contain drug abuse often urge Americans to learn from the experiences of other countries. One of their favorite "successes" is Switzerland, which Nadelmann lauds for supposedly showing that keeping addicts on heroin prevents them from committing crimes and using other drugs. Organizers of a 1994 Swiss demonstration reported several benefits from supplying addicts with heroin, including less drug use and crime as well as better health, psychological well-being, and social skills. But these results are based primarily on unverified reports made by the participants themselves. No systematic verification of their claims was made by, say, regular urine screening, HIV testing, or examination of police records. Nevertheless, 18 months into the program, by the unverified accounts of the participants, fully 52 percent of them were using cocaine and a similar number were still using illicit heroin.
The Swiss demonstration, which boasted a retention rate of 69 percent after 18 months, counted as "retained" any participant who periodically returned to the program, no matter how infrequently. Those who dropped out were mostly long-time heroin addicts, heavy cocaine users, or HIV positive. Thus, the demonstration tended to lose those clients with the most severe addiction-related problems -- the very persons for whom the experiment was designed. Moreover, although the demonstration was supposed to target hard-core heroin addicts, nearly 20 percent of participants were not heroin users when they entered the program. For a number of reasons, including the unverified self-reports and the lack of appropriate control groups, the demonstration falls far short of scientific standards.
For a more balanced look at heroin maintenance, it would seem sensible to consider Britain's prolonged experience rather than Switzerland's brief experiment. In Britain, heroin maintenance has been available for decades, and many physicians are permitted to prescribe it. Yet today, among the nation's estimated 150,000 heroin addicts, 17,000 are receiving oral methadone and fewer than 400 are kept on heroin. The vast majority of British physicians found no compelling evidence that heroin maintenance is useful.
As Mark Kleiman of UCLA has pointed out, "The risk of heroin maintenance is the incentives it provides to 'fail' in other forms of treatment in order to become a publicly supported addict." Addicts characteristically resist treatment and, given the option, choose the least demanding intervention. The most dysfunctional substance abusers are generally deep in denial and rarely enter treatment unless compelled. Thus treatment's first task is overcoming denial and generating the motivation necessary for recovery. Fortunately, today's intensive, supportive, and appropriately demanding methods of rehabilitation are up to this task. Coerced treatment works. Research has demonstrated repeatedly that drug abusers who enter treatment under duress are no less successful than those who enter voluntarily.
Another favorite foreign myth of liberalization advocates comes from the Netherlands, where the quasi-legal status of cannabis products was thought to have narrowed the gateway to adult use of more potent drugs without significantly increasing adolescent use of marijuana. But quasi-legalization of pot in the Netherlands has proven unpopular with the Dutch, who recently demanded a crackdown on the tolerated (though still technically illegal) trade. Although the government still lets coffee shops sell cannabis products, it has slashed the amount permitted for sale or possession from 30 grams to 5 grams and is shutting down shops where heroin or cocaine can be bought.
Research has failed to show that quasi-legalization has broken the link between marijuana or hashish use and the use of cocaine. It has, however, revealed an extraordinary increase in marijuana use among Dutch youth between 1984 and 1996 as cannabis policy became increasingly permissive. In 1984, only 4.4 percent of Dutch adolescents had ever used pot. By 1996, 10.6 percent had. In the 18-to-20 age group, lifetime use rose from 15 percent to 44 percent. In this same age group, only 8.5 percent reported using marijuana in the past month in 1984; by 1996, that had jumped to 18.5 percent. Since 1984, cannabis use in the Netherlands has reached rates comparable to those in the United States.
What makes a rising level of marijuana use, particularly by adolescents, so troubling is not just the gateway pot creates to more potent substances. Marijuana itself is far from benign. It can impair short-term memory, deplete energy levels, and impede normal socialization and maturation -- all serious matters during adolescence. Moreover, epidemiological studies reveal a significant level of marijuana addiction. Among all users, including casual ones, 9 percent become dependent, as do 20 percent of those whose marijuana use continues beyond experimentation. Most teenagers who receive residential treatment at Phoenix House have used no drug more potent than pot.
Critics of U.S. drug policy argue that simple human compassion requires more lenient drug policies and decriminalizing the possession of drugs. But true compassion demands something quite different. Nadelmann's arguments for reducing the harm to drug users would shield abusers from penalties of their abuse while exacerbating the harm they do their families, their communities, and society itself. A policy that promotes child abuse, domestic violence, the destruction of families, and the devastation of neighborhoods is hardly compassionate.
User-friendly marijuana laws already exist in many states, and there is good reason to press for greater judicial discretion in the sentencing of drug offenders. But no compassionate case can be made for eliminating or significantly diminishing the legal sanctions that now -- no matter how imperfectly -- limit the spread of drug abuse. Nor can compassion argue for tolerating drug use. When one considers the populations and communities most affected by family dysfunction, social disorder, and violence deriving largely from hard-core substance abuse, the arguments for more lenient drug laws look naive, elitist, or worse.
Dispelling the myths of foreign "successes" would focus the debate on the shortcomings of present U.S. drug policy. With the air cleared of cant, Americans could ask why, with all the talk of a "war on drugs," the United States has never mounted an all-out, all-front assault on illegal drug use.
For a start, such an assault would have to be even-handed. Open-air drug markets could be tolerated no more readily in Harlem, southeast Washington, D.C., or South Central Los Angeles than on Manhattan's Upper East Side or in Georgetown or Brentwood. A serious antidrug policy would call for an equally serious federal investment in drug treatment, which research has consistently found to be cost-effective, with a focus on hard-core users. It would require appropriate treatment for criminals, expand court-mandated treatment, and revise restrictive sentencing laws to make possible more treatment in prison, after prison, and instead of prison. The federal government's prevention campaigns would be sustained, with a more aggressive effort to reach children at risk and increased support for broad community antidrug efforts. Finally, funding for research on abuse and addiction would be raised to a level that reflects drugs' true impact on society and cost to the nation. America has not yet begun to fight a real war on drugs, but that is hardly a reason to surrender.
Herbert D. Kleber, a former Deputy Director of the Office of National Drug Control Policy, is Executive Vice President of the National Center on Addiction and Substance Abuse and Director of the Division on Substance Abuse Research at Columbia University's College of Physicians and Surgeons. Mitchell S. Rosenthal is President of Phoenix House, a national network of drug treatment and prevention facilities.