Dr. Voth is a specialist in Internal Medicine and Addiction Medicine working at Stormont-Vail HealthCare in Topeka, Kansas. He is the chairman of the Institute on Global Drug Policy, is recognized as an international authority on drug use, and lectures nationally on drug policy-related issues, pain management, and appropriate prescribing practices. Dr. Voth serves as an advisor on alcohol and drug abuse issues to the Kansas State Board of Healing Arts, consults to numerous international drug prevention organizations, and is a Clinical Associate Professor of Internal Medicine at the University of Kansas School of Medicine.
Dr. Voth has advised the Reagan, Bush, and Clinton administrations, and has advised or testified for numerous Congressional offices on drug related issues. He was the Chairman of the International Drug Strategy Institute from 1992-2000, and was former medical director of the St. Francis Chemical Dependence Services in Topeka Kansas. He has also served as a consultant to the Presidential Commission on AIDS.
Dr. Voth has appeared on or consulted to CBS, and CBS Evening News, NBC, ABC, CNN, CNBC, Fox Television, National Public Radio, numerous other radio media, and has been quoted by numerous print media including the Washington Post, Washington Times, New York Times, Los Angeles Times, USA Today, Chicago Tribune, and Wall Street Journal.
Contents (click on the respective article):
1.Harm Reduction Drug Policy
2.Drug Legalization, Harm Reduction, and Drug Policy
Robert L. DuPont, M.D. President Institute for Behavior and Health, Inc. Rockville, MD 20852 and Clinical Professor of Psychiatry Georgetown University School of Medicine Washington, D.C.
Eric A. Voth, M.D. FACP Chairman The International Drug Strategy Institute and Clinical Assistant Professor of Medicine University of Kansas School of Medicine Kansas City, Kansas
3. Contemporary Drug Policy
Northwestern University Journal of International Policy, 1/21/2000
Eric A. Voth, M.D., FACP Chairman, The International Drug Strategy Institute
Ambassador Melvyn Levitsky, Syracuse University, Maxwell School of Citizenship and Public Affairs
Harm Reduction Drug Policy
Congressman Sounder, distinguished members of the Congress. It is my position and that of the Institute on Global Drug Policy that the most effective drug policy is a restrictive policy based on primary prevention, abstinence-focused rehabilitation, and strong law enforcement. All three of these fill important functions if drug policy is to succeed.
At one time, the concept of “Harm Reduction” seemed to be a reasonable approach to decrease the effect that drug abuse would have on society. However, the phraseology and policies termed “Harm Reduction” have been hijacked by those who are seeking to tear down drug policy and ultimately gain decriminalization or legalization of drugs. These catch phrases are parroted by the leaders of the movement like Ethan Nadelman, or Arnold Trebach who contend that the harms from drug use are exceeded by the harms of trying to control it. Pat O’Hare, former director of the International Harm Reduction Society, has said, “If kids can’t have fun with drugs when they are young when can they?” In some venues, Harm Reduction has been a ruse to cover criminal behavior with a cloak of political advocacy and cynical care for addicts.
The Harm Reduction movement has gained much of its international push from groups that also support drug legalization such as the Drug Policy Alliance, the Marijuana Policy Project, Open Society Institute, and dozens of spin off organizations who seek to hide destructive and illegal behavior under the shroud of political advocacy.
Billionaire George Soros, along with a cadre of other wealthy individuals such as Peter Lewis, John Sperling, George Zimmer, has financed these organizations along with numerous Harm Reduction and legalization schemes. His nucleus of power brokers are attempting to destabilize drug policy as we know it. If you have heard the phrase “the drug war has failed,” chances are the message is being brought to you via such people. Saying, “The Drug War has failed,” flies in the face of substantial and steady reductions in drug use since the 1970’s. For instance, among high school students marijuana use has dropped by about half since the 1970’s. It is an attempt to demoralize the public and destroy the gains of restrictive drug policy. If any other medical malady had dropped by that amount, we would celebrate in the streets.
Harm Reduction policy has become a cynical process for marginalizing and giving up on the addict while contending that drug use is inevitable. It also completely ignores the huge group of non-addicted users which serves to recruit non-users into drug using behavior, and which serves as a large reservoir to provide future addicts.
Examples of its misguided components include:
Drug prevention focused on teaching “responsible” and inevitable drug use
Needle handouts (needle exchange programs, NEP’s)
Non-abstinence based treatment such as heroin hand-out programs
Responsible crack cocaine use kits
"Safe" shooting rooms for IV drug addicts
Drug decriminalization or legalization.
Medical excuse marijuana.
Time does not allow me to discuss each of these issues in depth, but I have provided publications which discuss these topics. I will cover some highlights.
Needle handouts to IV drug abusers are a great farce. There should be at least three measures of success for needle handouts: 1) Is there a consistent reduction in Hepatitis B, C and HIV in terms of net incidence and conversion rate among the participants not just on the needles tested? 2) Is there a significant reduction in actual use of IV drugs and a consistent increase in the numbers of patients who originate in NEPs who end up seeking and participating in treatment? 3) Is there an elimination of dirty needles on the street? You will find that most, if not all, needle handouts fail in every one of these measures.
Detailed evaluations in Montreal and Seattle as well as several others clearly demonstrate that HIV and Hepatitis B and C among the participants in needle handouts increases over non-participants. In Montreal, a study of HIV seroconversion rate found a rate of 7.9 per 100 person-years among NEP participants, and a rate of 3.1 per 100 person-years among non-participants. A cumulative probability of 33% HIV seroconversion existed among NEP participants as compared to 13% for non-users.
An analysis of behaviors in needle handouts in Puerto Rico demonstrated no significant change in injection habits; only 9.4% entered treatment, but results improved in the last month of the study by aggressive outreach. At the low, only 12.4% and at the high only 40.3% of needles were returned, and 26.6% of the needles turned in were sero positive for HIV.
In Seattle, in 1996 prevalence of HIV, Hepatitis B, and Hepatitis C were respectively 1%, 8%, and 17%. In February 2002, prevalence was 2%, 18%, and 66%. The conclusion was that the needle exchange program alone was not able to control the spread of Hepatitis C.
I refer to NEPs as needle handouts because even among the best programs in North America, 38 % of the needles are not returned. In 1998 that amounted to over 7 million needles floating around on our streets. On average , a singe heroin user will require around 2,900 needle per year, and a cocaine user as many as 7,300. The cost and health exposure of giving needles to the approximately 3 million addicts would be staggering. Of course, once a needle is used, it becomes contaminated and must be disposed of safely. For example, the NEP in Sidney Australia handed out 262,000 needles in 2003, and in the area of the NEP program, so many children were stuck with dirty needles that parents have quit reporting it.
A comparison between the prevention strategies of Norway, Sweden, and Denmark demonstrated that HIV counseling and testing may be more effective than needle handouts alone. Sweden and Norway had significantly lower rates of HIV in IV users as compared to Denmark where needles were the primary approach but with lower levels of counseling and required participation than Sweden. HIV rates in Denmark (with needle handouts) have been found since 1991 to be 1.49/1000, in Norway they were 0.92/1000 in 1991—0.58 in1996, in Sweden 0.77/1000 in1991 and 0.58/1000 in 1996
It is essential to remember that NEPs do nothing for the underlying drug addiction, and they waste precious resources that could be devoted to outreach, intervention, and treatment. No one has demonstrated that the outcomes for HIV control are superior to aggressive intervention and treatment.
The notion of “responsible” drug use among children is one of the most sinister components of harm reduction. It upholds the misguided notion that kids can be taught to use drugs responsibly. A key leader in this movement, Marsha Rosenbaum, promotes a concept called “Safety First.” Recently, they have endorsed a book called, “It’s Just a Plant.” This is a pre-teen book teaching small children to accept marijuana. Credits in the book thank none other than George Soros. I include passages from the book that glorify marijuana and seek to create a positive picture on the part of children. At one place in the book, the little girl is gleefully telling her mother that she wants to grow her own marijuana plants. Once children are seduced into the marijuana culture, they may not escape it.
Those who embrace “responsible” drug use appear willing to ignore the fact that judgment is one of the first areas of impairment with drug use. While that creates its own set of problems in adults, it is even worse in young people who have not yet developed social and wise decision-making skills. The idea of teaching kids responsible marijuana use, much less heroin, cocaine, or methamphetamine use, is ludicrous.
So-called safe shooting galleries give addicts supposedly protected locations to take their drugs, and again, do nothing for the underlying destructive disease of addiction. Some cities have tried things like safe-crack kits teaching addicts to smoke crack instead of injecting and to not share pipes without cleaning them completely ignoring the destructive consequences of the continued drug use.
The medical excuse marijuana movement is a dramatic example of how millions of dollars can purchase drug policy and public opinion. In the papers I have included on marijuana, I document examples of the millions of dollars spent to manipulate various state marijuana initiatives. Soros and associates are jeopardizing consumer protection and have created an environment of medicine by popular vote rather than by science. None of the multiple international scientific evaluations have considered smoking crude pot to be an adequate medical treatment. I would be happy to discuss this in detail if requested.
Drastic examples of failed Harm Reduction policy include Vancouver, Baltimore, Holland, and Switzerland.
In Vancouver, despite a needle handout which gave out over 3 million needles in 2000, prevalence rates of HIV were 35% for men and 25.8% for women and was largely linked to cocaine use. Studies have demonstrated that 27.6% of participants in the Vancouver needle handout reported sharing needles in prior 6 months and needle sharing remains an alarmingly common practice. In the NEP, 50% of recipients who were also on methadone treatment still share needles. Vancouver also spends $3 million per year on “safe” injections sites whose staff claim to have treated “only” 107 overdoses so far.
As if their situation is not bad enough, health officials in Vancouver, Montreal, and Toronto have recently announced that the cities will experiment with giving addicts daily doses of heroin. From 1994 to 2004 use of marijuana has doubled. Thirty percent of young people in Canada age 15 to 17 have used marijuana in the last year. Such an approach to drug use is having other dire consequences. Concurrent with the extremely lax attitude toward drug use, British Columbia has the highest number of drug overdose deaths per capita ( 4.7 per 100,000) which is the leading cause of death in adults age 30-49.
The Harm Reduction philosophy in Baltimore was initiated under Mayor Kurt Schmoke. Since the inception of Harm Reduction, the heroin use in Balitmore has become a staggering problem and is reputed as one of the worse in the USA. Its violent crime rate per 100,000 population equals or exceeds that of Detroit, New York City, San Diego, Dallas, San Francisco, Denver, Los Angeles, Miami, or Atlanta. The purity of the heroin used there is extremely high, and there is an influx of young people coming into the city to obtain heroin because of the relatively lax enforcement attitude and sense of protection of users.
The 2002 DAWN (Drug Abuse Warning Network) Data demonstrates that the drug related fatality rate reported in the Baltimore was 23 per 100,000 population. Heroin was the cause of 69% of these deaths. This drug-related mortality rate is about twice as high as Chicago, Dallas, Denver, New York, and about 35% higher than Philadelphia. Harm reduction has clearly failed in Baltimore.
Those controlling Swiss drug policy have been at odds with many traditional Swiss physicians who favor abstinence and rehabilitation for addicts. The Swiss heroin hand out program that was initiated several years ago was condemned by the World Health Organization as being so poorly designed and monitored that no conclusions could be derived. There was no mandatory examination of HIV rates, patients self reported use rather than being verified by drug testing, there existed no independent evaluation of criminal behavior, and even minimal employment was counted as employment. Furthermore, addicts within the trial were more likely to have access to essential social services than those outside of the heroin handout which gave them a greater chance of appearing productive in the study.
Holland has been the poster child of Harm Reduction policies especially as it relates to marijuana. While marijuana use has not been frankly legalized, the general atmosphere of acceptance has created numerous social problems. Numerous marijuana-selling coffee shops have emerged which provide marijuana. From 1990 to 1995, youth marijuana consumption increased by 142%. The number of organized crime groups rose from 3 to over 90. From 1997 to 2001 lifetime marijuana use increased 32%, cocaine use increased 121%, and methamphetamine increased 52%. Holland is now the leading exporter of the drug ecstasy (MDMA). As expected, HIV rates have risen 45% from 2001-2002.
The lax policy in Holland has resulted in a vexing problem of “drug tourism” involving mostly young people coming into the country specifically to use drugs or to purchase and take them. Ironically, tighter controls have been imposed to try to curb this substantial problem.
The bigger question when there is any consideration of drug policy changes is who will be the winners and who will be the losers. The winners will be clear. As we have also learned from the tobacco and alcohol industries, those who would step up to distribute and sell marijuana, or other illegal drugs, those who could profit from a futures or investment market, and those who want to continue using the drugs would profit to the detriment of the rest of us. Tough questions should be asked of the supporters of such changes.
Kids, families, and drug users themselves will be the losers with any policy that embraces decriminalization or legalization of drugs as an element. That, in turn, threatens the very viability of our nation.
In summary, a Harm Reduction policy is essentially a harm production policy. Hopefully Congress will ignore those who contend that current drug policy has failed, and will continue to support restrictive drug policy which embraces harm prevention through primary prevention, and harm elimination through treatment and enforcement efforts. Our goal should be no use of illegal drugs and no illegal or unhealthy use of legal drugs.
2.Drug Legalization, Harm Reduction, and Drug Policy
Annals of Internal Medicine 1995;123:461-465
Reproduced by the International Drug strategy Institute with the permission of the Annals of Internal Medicine
PURPOSE: To review the current policy options available regarding drug use in the United States in the context of the history of drug policy in the United States.
CONCLUSIONS: Restrictive drug policy serves as a deterrent to drug use, and it aids in the reduction of drug-related costs and societal problems. While legalization or decriminalization of drugs might reduce some of the legal consequences of drug use. Increased drug use would result in harmful consequences.
Two alternative policy options shape the current debate about how to move forward in addressing the Nation’s problems with drug use(1). One school of thought, broadly labeled as “prohibition,” supports widening interdiction, treatment and prevention efforts while keeping drugs such as marijuana, cocaine, LSD, and heroin illegal. A conflicting viewpoint labeled “legalization” supports the elimination of restrictive drug policy while trying to limit the harms associated with non-medical drug use. Understanding the history of drug control in the United States places into perspective today’s debate about drug policy options, which include legalization and the related policy called “harm reduction(2).”
Modern drug prohibition began in the 19th century when medicinal chemistry began to produce an enormous array of potent and habituating drugs. This array included heroin, which was first sold in the United States in1898. These drugs were sold as ordinary items of commerce along with a popular new drink, cocaine-containing Coca-Cola. Physicians at that time prescribed addicting drugs freely to their patients producing a large group of medical addicts. The use of drugs such as cocaine originated with legitimate medical indications. Drug use by the public later grew rapidly to include the compulsive use, illegal activity to support the non-medical use, and consumption despite clear 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 dealt with the labeling of drugs. In1914, 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 which also included the rights of women to vote.
Under this new social contract, habituating drugs were not available except through a physician’s prescription, and then they were used sparingly in the treatment of illnesses other than addiction. In 1933 alcohol was removed from the group 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 for drugs of abuse and supporting laws served the country well by virtually ending the first drug abuse epidemic. The American 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 the19th century, was dramatically reduced in the United States from 1920-1965 (5).
The nation was lulled into complacency by the great and prolonged success of this drug abuse policy. American public and policy leaders entered a period of amnesia for the tragic consequences of widespread drug use. By the 1960s, most Americans had no personal memory of the earlier American addiction epidemic. Strict non-alcohol drug prohibition was respected broadly 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 grew to be the focus of a call for legalization based on unsubstantiated claims that they were “no worse than alcohol and tobacco.” The substantial health and addiction problems currently recognized to result from the use of crack cocaine and marijuana, and extensive research now available on the harmful effects of many drugs are testimony to how society was misled in the 1960s(7). These effects include but are not limited to addiction. vehicular trauma, disease, suicide, and specific negative physical effects of drugs themselves(8-15).
LEGALIZATION OF ILLEGAL DRUGS:
During 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 labeling the opponents of legalization as prohibitionists. For purposes of this discussion, prohibition is a restrictive policy which maintains legal restrictions against non-medical 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 wide-open access to all drugs for all people as was seen at the end of the 19th century. Partial legalization could entail such changes in drug policy as making currently illegal drugs available in their crude forms to certain types of medical patients. It might include the maintenance of addicts on heroin or their drug of choice, handouts of needles to addicts without the requirement of cessation of drug use, or marked softening in sentencing guidelines for drug-related offenses short of frank legalization.
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 mostly paid in lost productivity, illness, and death. About 125,000 deaths annually in the United States are attributed to alcohol, while tobacco is estimated to cause 420,000 deaths annually. The deaths resulting from all illicit drugs combined total less than10,000 annually. The social costs from alcohol use in the United States are estimated at 86 billion USD while the costs of prohibiting illegal drug use (including enforcement and incarceration) are annually 58 billion(17,18). The social costs of smoking tobacco are estimated to be $65 billion annually(17). If one of the goals of a drug policy is to reduce the harm to society resulting from drug use, then alcohol and tobacco must be a top priority within this strategy.
Considering the numbers of users of illegal and legal drugs in the United States and the trends in the rates of use from 1985 to1991 (Table1), it becomes apparent that prohibitive drug policy actually has maintained lower levels of use compared to relatively widely available habituating substances. Equally important are the rates of use of illicit drugs which have fallen faster in comparison to the rates of legal drug use(19).
Table 1: Drug use in the US prior 30 days (in millions)
Drugs legal for adults
Alcohol: decline 9% from 1985 (113) to 1993 (103)
Cigarettes: decline 17% from 1985 (60) to 1993 (50)
The most widely used drugs that are illegal for all ages
Marijuana: decline 50% from 1985 (18) to 1993 (9)
Cocaine: decline 78% from 1985 (6) to 1993 (1.3)
SOURCE: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. National Survey Results on Drug Use, from The Monitoring the Future Study 1975-1993. NIH Publication No. 94-3809 1994.
Substantial progress was made in the reduction of adolescent drug use from 1978 to1992 (Table 2). That success was due to a relatively clear national message and broad-based anti-drug efforts in both the public and private sectors. Since 1992, a recent rise in adolescent drug use and more accepting attitudes toward drug use(20) has occurred. While the causes are multifactoral, the reduction of government and media anti-drug efforts coupled with increases in pro-drug media campaigns have played a role.
Table 2. Drug use rates: Marijuana
Percent of high school seniors use of marijuana
|Last 12 MOS
|Last 30 days
SOURCE:U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. National Survey Results on Drug Use, from The Monitoring the Future Study 1975-1993. NIH Publication No. 94-3809 1994.
While reducing the harm caused by drug use is a universal goal of all drug policies, policy proposals which are currently termed “harm reduction” include a creative renaming for the dismantling of legal restrictions against drug use and sale. The essential components of legalization policies are couched within the concept termed “harm reduction.” Much of the driving force behind the harm reduction movement also centers around personal choice and “safe” drug use habits.(21)
Paradoxically, some public policy attempts at reducing the harms associated with use of alcohol and tobacco involve tightening restrictions on events such as intoxicated driver legislation and smoking restrictions(22), while current harm reduction proposals involving illegal drugs, to the contrary, generally involve softening the restrictions on use of illegal drugs.
The current proposals for harm reduction focus heavily on reduction or elimination in criminal penalties for drug offenses, softening of sentencing guidelines, addict maintenance programs, needle exchange programs for intravenous drug users, and removal of workplace drug testing programs(23). The efficacy of any of these modalities is yet to be established.
Harm reduction policy as it is represented in the current policy debate, also attempts to mitigate the negative effects of non-medical drug use without reducing the use of illegal drugs. It is based on the assumption that most of the harm caused by non-medical drug use is the result of the societal efforts to stop drug use rather than the result of drug use itself. Those harms are considered generally to be associated with arrests and legal consequences from illegal behavior and incarceration(24).While harm reductionists contend that essentially innocent drug users are targeted by prohibition, only 2% of federal inmates are incarcerated for possession-related crime while 48% are incarcerated for trafficking. Despite the clear deterrent effect of legal penalties, some positive outcomes can be attributed to the criminal justice system. For example, 35% of drug related inmates obtain treatment while incarcerated(25).
The Netherlands has been the international model for decriminalization and harm reduction. Their experience with decriminalization has included an increase in crime and drug use associated with decriminalization. From 1984 to 1992 cannabis use among pupils in the Netherlands has increased 250%. Between 1988 and 1993, the number of registered addicts has risen 22%. Reflecting the decriminalization of marijuana, the number of marijuana addicts has risen 30% from 1991 to 1993 alone. As we see in the United States, the harms of increased drug use go beyond the user alone. Since the onset of tolerant drug policy in that country, shootings have increased 40%, hold ups have increased 69%, and car thefts have increased 62%(26).
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 emergency room drug mentions as compared to metropolitan areas not having decriminalization(27).
The current and still dominant drug policy seeks to curb drug use and the associated harms by using the legal system and other means such as workplace drug testing and treatment to reduce non-medical drug use in society. In contrast to the advocates of harm reduction or legalization, supporters of the current restrictive drug policy emphasize that most drug-related harm is the result of drug use and not simply the result of the prohibition of drugs(28).
The legalizers and the prohibitionists find some common ground in the support of drug education and treatment. Supporters of restrictive drug policy teach avoidance of non-medical drug use entirely, and harm reductionists support teaching “responsible use” of currently illegal drugs. Many harm reductionists admit that they seek the ultimate legalization of illegal drugs, especially marijuana. A distinct subset of harm reductionists support harm reduction because of the element of decriminalization which takes legal pressure off of their own drug use. Those individuals 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 governmental attitudes against non-medical drug use and the availability of currently illegal drugs.
COSTS OF DRUG POLICY:
Those who support legalization correctly point out that prohibiting the use of our currently illegal drugs is an expensive strategy. Table 3 demonstrates the sources of overall costs produced by the use of legal drugs as compared to illegal drugs. These data also illustrate the fact that restrictive drug policy shifts the costs of drug use related to health and productivity to the criminal justice system.
Table 3: Economic costs of addiction in the US 1990
|Total costs (billions USD)
|Medical care (percent)
|Lost productivity (percent)
SOURCE: Institute for Health policy, Brandeis University. Substance abuse: the Nation’s number one health problem – key indicators for policy. Prepared for the Robert Wood Johnson Foundation, Princeton, NJ. 1998
Augmenting a restrictive drug policy by broadening the drug treatment available to addicts may be a beneficial and cost-effective policy decision. A recent study by Rand estimates that the current societal costs and actual costs of controlling cocaine use alone total 42 billion USD annually (13 billion for control costs and 29 for societal costs). Rand also estimated that the net control and societal costs related to cocaine could be reduced to 33.9 billion(29) by maintaining our current enforcement policies and adding to it treatment for all addicts. The Rand study further concluded that treatment is effective in reducing the costs to society not only by reducing the demand for drugs, but in removing the addict from drugs for sustained periods of time.
The supporters of restrictive drug policy must acknowledge that prohibition alone does not end either the use of prohibited drugs or the high cost to society resulting 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 some restriction of personal choice. Prohibiting the use of some drugs is undeniably costly, but it is well worth the cost given the fact that the overall level and the total societal costs of drug use are reduced.
DRUG POLICY OPTIONS:
Recognizing the range of options available within legalization and drug prohibition policies, it is important to look at the big picture of drug policy. We must ask if prohibiting the consumption of some drugs is effective in reducing social costs, or “harm,” and if restrictive policy is cost-effective. Two models for drug policy exist which help provide answers to these questions.
The first model looks back at life in the United States one hundred years ago to a time when habituating drugs were sold like toothpaste or candy. The problems with freely available habituating drugs at the end of the19th century were judged by Americans at that time to be unacceptable. In the context of today’s debate on drug policy, recall that prohibition policies were the result of 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, non-alcohol drug prohibition was successful in reducing drug use, and it was almost universally supported by all political parties in the United States and throughout the world for half a century.
To a large extent, alcohol prohibition was also successful from a health perspective while it lasted. As examples, deaths from cirrhosis of the liver fell from 29.5 per 100,000 in1911 to10.7 in1929. Admissions to state mental hospitals for alcohol psychosis fell from 10 per100,000 in1919 to 4.7 in 1928 (30). The main failure of alcohol prohibition was in attempting to remove availability of alcohol from the public after it had been legal, accepted, and deeply integrated into society for many years. Our currently illegal drugs do not share that same level of acceptance and integration.
The second model compares the costs generated by the drugs which are now legal for adults to those which are not. This entails comparing the social costs resulting from the use of alcohol and tobacco (legal drugs), to 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. They are more widely used because they are legal. Being 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 throughout the world.
Because of the deep integration of alcohol and tobacco into society, prohibiting their use is unrealistic politically. However, major constraints on their use such as total elimination of advertising, high taxation, restriction on smoking locations, designated drivers programs, and product liability by manufacturers and distributors of these products show some promise in reducing the harm produced by these legal drugs(23).
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 demonstrate that legalization would increase the use of currently prohibited drugs(3,20,26,27).
Legalization or decriminalization creates a particular risk among young people whose social adaptation and maturation are not yet complete. This fact can be illustrated by comparing the levels of the use of currently legal drugs by young people (alcohol and tobacco) to the levels of illegal drugs. The use of all of these drugs is illegal for youth, yet the drugs that are legal for adults are more widely used by youth than the drugs which are illegal for both adults and youth(Table 4).
Table 4. Prevalence of drug use in the US high school seniors, 1993 (percent)
||Last 30 days
|Any illicit drug
SOURCE: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. National Survey Results on Drug Use, from The Monitoring the Future Study 1975-1993. NIH Publication No. 94-3809 1994.
What is needed today is not the dismantling of restrictive drug policies. Instead, a strong national policy with the goal of reducing the harm of drug use through harm prevention (implementing drug prevention programs) and harm elimination through broader interdiction and rehabilitation efforts(31,32,33). 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 the especially vulnerable parts of the community with a special emphasis on the young.
If those who seek to reform drug policy and harm reduction are sincere in their intent, they would focus their efforts on alcohol and tobacco where there exists an abundant need for “harm reduction” and leave the currently illegal drugs illegal. Unless those who subscribe to the notion of harm reduction move ahead to harm prevention and harm elimination, the global costs associated with any form of drug use will continue to rise. Relaxation of the restrictive policies surrounding the use of currently illegal drugs should only be considered in the context of programs which 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 already have learned from legal alcohol and tobacco. Those experiments have already been done at the cost of great human suffering.
Correspondence and reprint requests should be addressed to:
Eric A. Voth, M.D.,FACP
The International Drug Strategy Institute
Topeka, Kansas 66606
913-354-0525 fax 913 272-3902
First author-Robert DuPont, M.D.
Institute for Behavior and Health
6191 Executive Blvd.
Rockville, MD. 20852
3.Contemporary Drug Policy
1. DeLeon, G. Some Problems with the Anti-Prohibitionist Position on Legalization of Drugs. Journal of Addictive Diseases, 1994;13:35-57.
2. U.S. General Accounting Office, General Government Division. Confronting the Drug Problem--Debate Persists on Enforcement and Alternative Approaches, GAO/GGD-93-82. Report to the Chairman, Committee on Government Operations, House of Representatives. Washington, D.C.: United States General Accounting Office, General Government Division, 1993.
3. Pure Food and Drug Act of 1906, Public Law 59-384.
4. Harrison Narcotics Act. Public Law 63-47.
5. Musto DF, The American Disease--Origins of Narcotic Control. New York, Oxford University Press, 1987.
6. Brecher EM, Editor. Licit and illicit drugs. Boston, Little, Brown, and Co, 1972:267-306, 335-451
7. U.S. Department of Health and Human Services. Drug Abuse and Drug Abuse Research--The Third Triennial Report to Congress from the Secretary, Department of Health and Human Services. Washington, D.C.:Superintendent of Documents, U.S. Government Printing Office, DHHS Publication no. (ADM) 91-1704, 1991.
8. Berman AL, Schwartz RH, Suicide Attempts Among Adolescent Drug Users. AJDC 1990;144:310-314.
9. Rivara FP, Mueller BA, Fligner CL, Luna G, Raisys VA, Drug Use in Trauma Victims. The Journal of Trauma 1989; 29:462-470.
10. Soderstrom, CA, Dischinger PC, Smith GS, McDuff DR, Hebel JR, Gorelick DA, Psychoactive Substance Dependence Among Trauma Center Patients. JAMA. 1992;267: 2756-2759.
11. Committee on Drug Abuse of the Council on Psychiatric Services, Position Statement on Psychoactive Substance Use and Dependence: Update on Marijuana and Cocaine. Am J Psychiatry 1987;144:698-702.
12. Polen MR, Sidney S, Tekawa IS, Sadler M, Friedman GD, Health Care Use by Frequent Marijuana Smokers Who Do Not Smoke Tobacco. Western Journal of Medicine 1993;158:596-601.
13. Nahas GG, Latour C, The Human Toxicity of Marijuana. The Medical Journal of Australia 1992;156:495-497.
14. Schwartz RH, Marijuana: An Overview. Pediatric Clinics of North America 1987;34: 305-317. 15. Council of Scientific Affairs, American Medical Association. Marijuana: Its Health Hazards and Therapeutic Potentials. JAMA 1981;246:1823-1827.
16. Controlled Substances Act, 21 U.S.C. 811.
17. Institute for Health Policy, Brandeis University. Substance Abuse: The NationÕs Number One Health Problem--Key Indicators for Policy. Princeton, NJ: Robert Wood Johnson Foundation, October, 1993.
18. U.S. Department of Justice, Bureau of Justice Statistics. Chapter III, Section 5--The Costs of Illegal Drug Use. In: Drugs, Crime, and the Criminal Justice System, NCJ-133652, 126-127. U.S. Department of Justice, Bureau of Justice Statistics, 1992.
19. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: Main Findings 1991, DHHS Publication No. (SMA) 93-1980. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 1993.
20. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. National Survey Results on Drug Use, from The Monitoring the Future Study 1975-1993. NIH Publication No. 94-3809 1994.
21. Erickson PG, Prospects of Harm Reduction for Psychostimulants. In Nick Heath (ed) Psychoactive Drugs and Harm Reduction: From Faith to Science. London, Whurr Publishers, 1993:196.
22. Gostin LO, Brandt AM. Criteria for evaluating a ban on the advertisement of cigarettes. Journal of the American Medical Association 1993;269:904-909.
23. Nadelman E, Cohen P, Locher U, Stimson G, Wodak A, and Drucker E, Position Paper on Harm Reduction. The Harm Reduction Approach to Drug Control: International Progress. The Lindesmith Center, 888 Seventh Ave, New York, NY. 10106. 1994
24. Kleiman MAR, The Drug Problem and Drug Policy: What Have We Learned from the Past Four Years. Testimony to the United States Senate Committee of the Judiciary, April 29, 1993.
25 Maguire, K., ed. Sourcebook of Criminal Statistics Bureau of Justice Statistics, U.S. Department of Justice. 1992:491.
26. Gunning KF, Dutch National Committee on Drug Prevention. Personal Communication. September 22, 1993.
27. Model KE, The Effect of Marijuana Decriminalization on Hospital Emergency Room Drug Episodes: 1975-1978. Journal of the American Statistical Association. 1993; 88: 737-747.
28. Kleber HD, Our Current Approach to Drug Abuse-Progress, Problems, Proposals. NEJM 1994;330:361-365.
29. Rydell CP, Everingham SS, Controlling Cocaine: Supply Versus Demand Programs. Santa Monica, Ca.:Rand 1994.
30. Gold MS, The Good News About Drugs and Alcohol. New York, Villard Books, 1991: 245.
31. Board of Trustees, The American Medical Association. Drug Abuse in the United States: Strategies for Prevention. JAMA 1991;265: 2102-2107.
32. Romer D, Using Mass Media to Reduce Adolescent Involvement in Drug Trafficking. Pediatrics. 1994;93: 1073-1077.
33. Voth E, Drug Policy Options. Letter to the Editor in JAMA 1995;273:459.
Drug Policy Options
The question facing us today is whether or not United States drug policy can be effective on both the domestic and international fronts, and whether and how international counter-narcotics efforts can contribute to reducing drug abuse.
International drug policy faces a critical juncture in terms of fundamental policy decisions, which could reduce drug use on one hand or conversely risk increases of drug use and its inherent harms on the other. Our careful assessment of drug policy options suggests that restrictive drug policy in which both traffickers and users are held accountable affords the greatest potential to reduce drug use and its harms to society. This policy focuses its law enforcement efforts on the drug trafficking chain, and while it does not advocate locking up every first-time user of drugs, it does hold users accountable for their actions through a range of penalties and sanctions. Dubbed "prohibitionist" policy by its detractors, restrictive drug policy seeks to find a balance between drug education and prevention, abstinence-based rehabilitation, law enforcement and supply reduction.
At the other extreme of drug policy is drug legalization. This type of policy draws its support from several constituencies. The broadest group supports the notion that drug use is a personal choice and that people should have the right to whatever intoxication and self abuse they so desire. Much of the drive of that group is to allow personal gratification through drug use and even trafficking. Many legalization proponents hide under the shield of political activism to gain protection for their own illegal and destructive habits and activities. The second group largely consists of libertarians who consider that intervention upon drug use is a violation of personal liberties. Some take a cynical view of drug use as a Darwinian phenomenon. They mistakenly consider drug use as a victimless event. The third group are those looking for a place to land who neither have studied nor understand the phenomena associated with drug use, and who consider legalization as a fashionable alternative to fighting a concerted drug war. Their claim is that legalization will reduce both crime and drug abuse.
A new version of legalization policy is the drug policy option referred to as "harm reduction." The basic orientation of harm reductionists is that more harm comes to society from the drug policy than from drug use itself. Harm reduction policy had its origins with those who were frustrated with some of the failures of modern policy, but it also has supporters from the legalization movement. Finding that society was not accepting of the broad legalization of drugs, legalization proponents have moved into a perceived middle ground. This policy shift has had the net effect of breaking permissive drug policy into component parts and then selling them piecemeal to the public.
The philosophy of the harm reduction movement is well summarized by Ethan Nadelman of the Lindesmith Center (funded by billionaire George Soros) who is considered the godfather of the movement to legalize drugs
"Let’s start by dropping the "zero tolerance" rhetoric and policies and the illusory goal of drug-free societies. Accept that drug use is here to stay and that we have no choice but to learn to live with drugs so that they cause the least possible harm. Recognize that many, perhaps most, "drug problems" in the Americas are the results not of drug use per se but of our prohibitionist policies…." (Learning to Live with Drugs by Ethan Nadelmann Tuesday, November 2, 1999; Page A21 The Washington Post)
It is noteworthy that those advocating legalization rarely speak or write about the details of the regime they would have see replacing zero tolerance policies. This is primarily because their theory involves making currently illegal drugs widely available and cheap in order to "take the crime out of drugs" and supposedly undermine criminal trafficking networks by taking away their profits.
The Drug War
We believe that the use of the "drug war" metaphor is quite appropriate both in terms of domestic and foreign policies. Wars incite public opinion and action and focus attitudes on a problem. They require mobilization and the marshalling of assets and funds, and strengthen political will toward the elimination of a common threat. Some criticize the drug war mentality as exerting unnecessary violence on a medical problem. Police who face the violence of crack houses and methamphetamine labs understand that we are facing a war. DEA agents in South America and the policy makers and judges in countries like Columbia understand that we are waging a war as well.
We should first consider the successes and perceived failures of domestic drug policy. Consistently, drug culture advocates assert that drug policy has failed and is extremely costly. This is calculated strategy to demoralize the public and turn public sentiment against restrictive policy. The real question is, has restrictive policy failed? To determine cost effectiveness we can compare the costs to society of legal versus illegal drugs. Estimates from 1990 suggest that the costs to society of illegal drugs were $70 billion as compared to that of alcohol alone at $99 billion and tobacco at $72 billion. Estimates from 1992 put the costs of alcohol dependence at $148 billion and all illegal drugs (including the criminal justice system costs) at $98 billion.
According to National Household Survey data from 1998 there were 13.6 million current users of illicit drugs compared to 113 million users of alcohol and 60 million tobacco smokers. There is one difference legal status of the drugs. The Monitoring the Future Survey data of high school seniors suggest that in 1995 52.5% of seniors had been drunk within the last year as compared to 34.7% who had used marijuana. Yet, alcohol is illegal for teenagers. The difference is, again, the legal status of the two substances. One can safely make the assumption that legalized – and readily available – marijuana (even if illegal for teenagers) would be used by a far higher percentage of teenagers.
Permissive drug policy has been tried both in the United States and abroad. In 1985, during the period in which Alaska legalized marijuana, the use of marijuana and cocaine among adolescents was more than twice as high as other parts of the country. In 1979, during the height of permissive drug policy in the United States, the daily use of marijuana was 11% among high school seniors. Thirty seven percent of high school seniors had used marijuana in the prior 30 days. These use rates dropped respectively to 1.9% and 11.9%, an all-time low, by 1992 after the institution of no-tolerance and no-use policy. Baltimore has long been heralded as a centerpiece for harm reduction drug policy. Interestingly, the rate of heroin found among arrestees in Baltimore was higher than any other city in the United States. Thirty-seven percent of male and 48% of female arrestees were positive as compared to 6%-23% for Washington D.C., Philadelphia, and Manhattan.
Clearly, better advances need to be made at broadening drug prevention with a focus on eliminating or delaying intoxicant use. The current availability of effective programming is woefully inadequate. DARE for example, has been criticized in some arenas, yet it is almost always a highly circumscribed and limited effort existing with other fragmented efforts. Often, DARE is the only prevention effort that upholds a "No-Use" message.
Treatment availability is also inadequate, and treatment is often little more than a revolving door. It is clear that abstinence-based treatment works, but it is largely unavailable to some of the most severe addicts who fail or rapidly relapse after treatment. Our system does not readily allow for suspending civil liberties to mandate treatment for the most severe addicts. Sweden, on the other hand, has developed creative means to coerce treatment. Hopefully, current efforts to enhance cooperation between the criminal justice system and the treatment community will improve treatment availability to those drug users involved in crime. Unfortunately, some advocates of so-called drug policy reform are willing to cave in to these limitations by handing out needles or even handing out heroin to addicts.
The International Scene
Fighting the drug war on the international front is in many ways more difficult than in the domestic arena. We can influence but not control the efforts of other governments. Corruption and violence in a number of drug producing and transit countries undermine the political will of governments to tackle powerful trafficking organizations. Since drugs flow across borders without regard to sovereignty, multilateral cooperation is necessary to stem their flow, but the mechanisms and will to do so are often lacking. Finally, there is such an over production of drugs worldwide that the losses our and other countries’ efforts inflict on the drug traffickers often seem marginal.
The United States made steady progress in reducing drug use through the eighties and early nineties; despite a disturbing increase in teenage drug use since 1992, overall drug use is down in this country. Unfortunately the trend is not as encouraging in some other countries. In particular, cocaine use in Europe and Russia is steadily rising as increasing U.S. resistance has turned the traffickers’ eyes to the European market traditionally a high-use heroin area. Policy shifts that have entailed higher tolerance of so-called soft drugs have resulted in huge increases in drug use. Holland has suffered an increase in marijuana use since the softening of their marijuana policy. The Dutch are also now one of the major exporters of Ecstacy (MDMA). Several countries are considering accepting marijuana for medicinal purposes despite clear evidence of problems associated with smoking for medicinal applications. Since the liberalization of the marijuana enforcement policies, Holland has found that marijuana use among 11-18 year olds has increased 142% from 1990-1995. Crime has risen steadily to the point that aggravated theft and breaking and entering occurs 3-4 times more than in the United States.
Australia is also suffering widespread drug policy activism geared toward softening drug policy. As a result of such soft policy changes, major problems are developing. This is most dramatically represented in comparison to Sweden, a country that employs a successful restrictive drug policy (figure 1). Lifetime prevalence of drug use in Australia in 16-29 year olds is 52% as compared to 9% in Sweden, a country with restrictive drug policy. (see graph at end of article.)
This difficult situation is not cause to abandon our international efforts. For one thing over the past ten years more countries have come to realize that drug trafficking and abuse are not just an American issue and that their own societies are suffering the consequences of their previous denial that they had a problem. European countries are now more vigorous in their efforts abroad both bilaterally and through UN programs, often in cooperation with the U.S. The body of international law, particularly the 1988 Anti-Trafficking convention which the United States sponsored and pressed forward, has brought a stronger anti-drug ethic to international affairs, which only outlaws and outlaw states ignore. The UN Drug Control Program has become more pervasive and effective and even formerly resistant agencies like the World Bank and the UN Development Program are beginning to understand that drugs undermine development as well as democracy.
The Reasons for International Efforts
-While developments in the international drug arena present a decidedly mixed picture, there are good reasons for the United States to have a strong country-narcotics component in its foreign policy
-First and most obvious, our efforts to reduce demand for illegal drugs in the United States will be undermined if an unrestricted flow of these drugs comes across our borders. Illegal drugs will be cheaper, purer, more widely available and consequently more abused. Even if we cannot cut off the flow of narcotics, we can continue to work with other countries to contain it and make it more difficult for the drugs to get to the street. There is, in fact, good evidence of a correlation between heightened drug control efforts overseas and the price, availability, and use of drugs in the U.S. (see especially the study, Empirical Examination of Counterdrug Interdiction Program Effectiveness published by the Institute of Defense Analysis in January 1997). Without a strong supply reduction effort, prevention, and education programs will suffer
-Similarly helping other countries reduce their own demand can make an important contribution to building international resistance to drug use. Virtually every country in the world has obligated itself to fighting drugs through the ratification of the 1961, 71 and 88 drug conventions. International cooperation to stem drug abuse will help make international laws and the obligations stemming from them a reality Conversely, allowing drug use to grow without counter efforts will simply provide more markets for drug traffickers and make them more powerful.
-A broader reason to attack the drug trade lies in the fact that the illegal drug industry undermines our broad foreign policy goals of building democracy and responsible, effective governments worldwide in order to promote global peace and stability. Drug organizations corrupt civil institutions through bribery and intimidation, while drug use attacks the basis of democracy – an alert, enlightened and involved citizenry. Besides, the proceeds of illegal drugs undermine economies throughout the world through devices such as money laundering, ownership and management of financial institutions and the skewing of exchange rates and financial flows.
Increasingly the illegal drug trade is seen by a number of governments as a national security threat, which attacks the moral fiber of society and undermines civil institutions. This is particularly true in our hemisphere, which is at once the host to major drug trafficking organizations and the victim of their activities. A closer look at the situation in the Americas is warranted.
Several factors must be taken into account
-Our hemisphere has become a network of nodes for the illicit drug industry.
-Drug production, transport, and mony laundering schemes are pervasive. Every country has become enmeshed in the network.
-In virtually every country the drug lords have created their own mini-networks of gangsters, hired assassins, in some cases "guerilla fighters" (especially Colombia), chemists, financial experts, and middle-men to make purchases of legal property and enterprises with illegal money.
-This structure threatens the institutions of most of these countries, intensifying graft and corruption and creating dishonest public officials, judges, legislators, police and military.
-The threat to democracy and effective government in the hemisphere is obvious.
The Western Hemisphere presents a complex picture. As with so many segments of the drug war, successes and setbacks are prevalent throughout the area.
-Latin America is the only producer and supplier area for cocaine in the world. Three countries – Colombia, Peru, and Bolivia – grow and produce virtually all of the coca, and refined cocaine. Some successes have been seen in the choking off cocaine production substrates from Peru and Bolivia. This has resulted in a decrease of nearly 50% in the coca crop. Unfortunately, Colombia has picked up most of the production; when coca supply dropped Colombian traffickers aided by their paid hired-hand guerillas, began to have their own coca planted locally. Colombian traffickers also increased opium poppy and heroin production as a means of diversification.
-Mexico is a traditional producer of opium/heroin while Colombia has only been a producer since the early nineties, but is gaining a hold on the US eastern seaboard market. Most of the cocaine for the U.S. market comes across the Mexican boarder. Corruption and violence in Mexico is rooted in the illegal drug trade.
-A number of other countries in the hemisphere play important roles in transporting the product to the U.S. The so-called transit countries – Brazil, Argentina, Guyana, Surinam, Central America and the Caribbean – are also sources for chemicals needed to produce cocaine and heroin and often provide off-shore banking facilities for laundering drug money.
-Canada presents another serious enigma. While being a close trade partner, efforts are underway throughout Canada to undermine drug policy. Industrial hemp has been widely accepted, and is now presenting an importation issue for U.S. Customs officials and law enforcement. In Vancouver in 1988, HIV prevalence in IV drug addicts was only 1-2%. In 1997 it was 23% after widely adopting harm reduction policies. Vancouver has the largest needle exchange in North America. Marijuana decriminalization and legalization is being widely considered. The steady increases in drug use in Canada present a considerable problem to the United States in light of the huge and virtually open border.
Here again, despite the apparently bleak situation, there is a brighter side to the picture. Peru and Bolivia have improved their counter-narcotics programs considerably. Peru’s policy of shooting down drug trafficker aircraft has severely damaged the coca airbridge from Colombia. Bolivia and Peru have finally begun to decrease coca growing areas through both repression and programs of inducement to coca farmers. While, as a consequence, coca cultivation has moved to Colombia, the U.S. Congressional pressure on the Clinton Administration to increase substantially anti-guerilla and anti-drug assistance to that country offers the hope of major inroads into the cocaine trade.
U.S. Policy Approaches
We strongly believe the best U.S. approach toward the global drug program is first of all to concentrate on reducing the demand for drugs in our country, the world’s largest drug market. To continue our international leadership in the war against drugs we must keep our own house in order. This means an intensification and broadening of primary prevention, abstinence – based treatment and rigorous law enforcement. Increased drug screening in such venues as schools would improve our efforts. Exposing and combating the efforts of the legalizers, "harm-reducers" and others pressing for tolerance toward drug abuse or "responsible" drug use is absolutely critical.
We must also promote a seamless drug policy in which our international law enforcement and supply reduction efforts work together with demand reduction programs in an effective, coordinated manner. Increasing our cooperation with – as well as keeping the pressure on – the drug producing and transit countries will help advance the goal of world-wide zero tolerance. We adamantly oppose the current administration’s efforts to weaken the drug certification laws and "multilateralize" the performance evaluation process. Such a development would only lower performance standards and cause slippage in the U.S. goal of strengthening the anti-drug political will in other countries.
Above all the United States must adopt a stronger stance of leadership in the global war against drugs. And, at home American political leadership needs to send out a more clear and consistent message of zero-tolerance to drugs as well as to work more vigorously with the Congress, the states and localities and local communities to combat drug trafficking and abuse.
DuPont RL, Voth EA. Drug Legalization, Harm Reduction, and Drug Policy. Annals of Internal Medicine 1995;123461-465.
Janet E. Joy, Stanley J. Watson, Jr., and John A. Benson, Jr., Editors Marijuana and Medicine Assessing the Science Base Division of Neuroscience and Behavioral Health, Institute of Medicine, NATIONAL ACADEMY PRESS. Washington, D.C. 1999
Musto DF. The American Disease Origins of Narcotic Control. New York Oxford Univ. Pr; 1987
Spanjer M., Dutch Schoolchildren's Drug Taking Doubles The Lancet 1996347534
White House Office of National Drug Control Policy, Strategic Writings. May 1999, ONDCP
|Lifetime prevalence of drug use in
16-29 year olds (Sweden) and 14-25 year olds (Australia)
|Use in the previous year, as above
|Estimated dependent heroin users per million population
|Percentage of dependent users aged under 20
|Methadone patients per million population
|Drug-related deaths per million population
|Drug offences per million population
|(Sweden - arrests; Australia - convictions)
|Average months in prison per drug offence
|Property crimes per million population
|Violent crimes per million population
|Cumulative AIDS cases per million population