Sanctions, Sanctimony, and Health

Abstract

Book Review Health AffairsVol. 11, No. 4 Sanctions, Sanctimony, and HealthPeter Reuter AffiliationsRAND Drug Policy Research Center in Washington, D.C.PUBLISHED:Winter 1992Free Accesshttps://doi.org/10.1377/hlthaff.11.4.251AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InReddit ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPharmaceuticalsDrug useMortalityMorbidityPrescription drugsPrescription drug costsRegulationSubstance use disorder Over the past decade this nation has adopted increasingly harsh policies toward illicit drugs, with scant consideration of the health consequences of those policies. The explicit justification for harshness offered by the federal government, most recently through the annual National Drug Control Strategy prepared by the Office of National Drug Control Policy (ONDCP), is that drug use is morally wrong. Harshness is necessary to combat the attractive qualities of drugs, says the ONDCP report, and it will lead to lower drug use. The fact that drug use can lead to death or illness serves primarily as a supporting prop for the moral arguments. One reason that official documents make little of mortality and morbidity is that drug control itself can have deleterious health consequences. Heroin, for example, seems to be physiologically safe if taken under medical supervision, with constipation one of the more serious consequences. However, under the conditions created by harshly prohibitionist policies—with dirty needles, uncertain purity, and possibly toxic diluents— heroin use greatly reduces life expectancy. Federal strategists have not contemplated the fact that there might be a tradeoff between the stringency of prohibitions and the nation's health. The implicit argument seems to be that lowering drug use will reduce harms associated with drugs, including morbidity and mortality. Clearly that is a naïve, or at least an incomplete, argument, but it has attracted surprisingly little attention from the critics of current policies, apart from the band of legalizers whose prescriptions are so radical that their sensible diagnoses have little impact. This new book provides a thoughtful critique of this lacuna in federal drug policy formulation, as well as a host of other insights. The authors are well-known writers on criminology and related topics. Inevitably, the balance of their book is on the criminal justice aspects of current drug policy. How should responsibility for enforcement be allocated between levels of government? To what extent can drug enforcement affect the level of street crime? On these issues they write with considerable insight, but for readers of Health Affairs , their two most interesting topics are the lessons of history and the debate about decriminalization. The authors' examination of history covers not only the period known as Prohibition (1919-1933) but also the less well known 1850s, when thirteen states passed alcohol prohibitions in a five-year period. These prohibitions were enacted after a dramatic decline in per capita alcohol consumption, which fell from 7.1 gallons of absolute alcohol per capita in 1830 to 2.1 gallons in 1850. Temperance advocates, not satisfied with these results from their efforts to increase awareness of the dangers of alcohol, decided that legal coercion was necessary to achieve their true goal—an alcohol-free society. But here they overreached themselves. In reaction to the demand for abstinence, most of the prohibitionist states had repealed the prohibition by 1860, and per capita alcohol consumption rose nationally by 20 percent between 1850 and 1860.From an examination of four episodes of prohibition (two involving alcohol, two involving other drugs), Zimring and Hawkins reach two conclusions about American drug use: “First, levels of drug and alcohol use in America have varied widely over time and have been subject to rather large fluctuations that cannot be attributed to official control measures. Second, there is no basis in most of American history for the distinction … between beverage alcohol and other psychoactive substances described as drugs.”Both conclusions have become increasingly obvious to most analysts but remain sharply inconsistent with current federal drug policy. The annual drug strategy reports are written as though government actions determine the extent of drug use. I would suggest that the evidence equally favors the opposite proposition—namely, that drug use drives policy; evidence of increased drug use leads to government crackdowns. Unfortunately, tough enforcement—the principal tool of the federal government—can accomplish only modest reductions in drug use once a drug acquires a mass market. Reductions are likely to result instead simply from the internal dynamics of epidemics involving substances whose harms become more evident over time as their attractions become less evident. Moreover, although illegal drugs present distinctive problems (incomes for criminals, violence in marketing, and toxicity in adulterants), their illegality, not their inherent psychoactive properties, is responsible for most of these harms. That does not imply that we should eliminate all prohibitions or that we should also prohibit alcohol, even though its use generates higher social costs than all illicit drugs in aggregate. But a society that allows the use and promotion of alcohol can scarcely take a moralistic stand on the consumption of other psychoactives. Rather, it must pragmatically examine other modes of regulation, including prohibition.Zimring and Hawkins devote a chapter to decriminalization, labeling it “the wrong question. … As a policy centerpiece, the decriminalization debates are flawed because they use inappropriate methods to identify and resolve priority problems in drug control policies.” The authors argue that criminal law will always play a role in the regulation of psychoactive substances, noting that the director of the federal prisons in 1935 reported that the number of confinements for violations of alcohol laws did not noticeably decline after the repeal of Prohibition; only the nature of the offenses had changed. The same can be said for health policy. Repeal of current prohibitions would change some characteristics of the damages related to drugs (the gunshot wounds related to drug use might be the result of more intoxication and fewer territorial disputes), but the demands on the health care system might be very similar. As the authors correctly note, we lack any basis for making credible projections of the consequences of a change as dramatic as legalization of illicit drugs. Zimring and Hawkins have produced an extraordinary number of books over the past twenty years (my own count is ten), each one on a different topic in criminal justice. Their writing is always forceful, their arguments lucid. However, this “topic of the year” productivity—well, every two years— imposes a price in terms of expertise. They show only a modest knowledge of the literature on drug policy. Not only is their bibliography a thin listing, but they occasionally use dated materials. For example, their analysis of the cost of drug abuse focuses on a 1984 study by Hendrick Harwood and colleagues, which is clearly superseded by a 1990 study by Dorothy Rice and colleagues—methodologically a much more sophisticated effort. 1 Their appendix analysis of drug indicators shows little understanding of the vagaries of the Drug Abuse Warning Network (DAWN), which collects data from a sample of emergency rooms and medical examiners' offices. There is no contradiction, as they claim, between the measured decline in the prevalence of cocaine use between 1985 and 1988 and the rise in DAWN cocaine episodes; the cocaine-using population may simply have been later in their careers on average or using larger quantities of the drug as its price declined. These are not minor cavils for the expert. But this is a book that will engage and inform most readers. Perhaps it will also help prepare the nation for a more intellectually serious discussion of the proper stance to take on dependency-creating psychoactives.NOTES1. Harwood H. , et al. , Economic Costs to Society of Alcohol and Drug Abuse and Mental Illness: 1980 ( Research Triangle Park, N.C. : Research Triangle Institute , 1984 ); and , Rice D. , et al. , The Economic Cost of Alcohol and Drug Abuse and Mental Illness: 1985 ( Rockville, Md. : Alcohol, Drug Abuse, and Mental Health Administration , 1990 ). Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 January 1992 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF downloadCited byRussische und GUS-Praxis