"Benign Neglect" means Danger

By Herbert D. Kleber

Peter Reuter, describing the country's drug policies of the 1980s as "costly and largely ineffectual", suggested in a recent Outlook piece that the drug issue could do with a little benign neglect - that is to say, a change in focus from public intolerance of drugs to reducing the harm they cause society.

Specifically, this would mean cutting down on enforcement activities and improving the public treatment system - including use of law enforcement to push addicts into tratment instead of jailing them. While Reuter's goal of expanded treatment is good, his suggestions for getting us there don't stand up to much scrutiny. In fact, if the country adopts a posture of benign neglect and backs away from public intolerance, there is a big danger that the recent progress made against drugs will be slowed or reversed.

Reuter attributes the sharp decrease in drug use in the general population to increased health concerns and greater awareness of the dangers of cocaine and marijuana. But he leaves out a more crucial factor: "denormalization". In the 1960s, '70s and early '80s, drug use became normalized throughout our country. It was acceptable behavior in many circles to use marijuana and cocaine at school, in the workplace and at social gatherings.

The change in this point of view was brought about by a number of factors, including the work of the Partnership for a Drug Free America, the public pronouncements of both Democratic and Republican leaders, the stance taken by our last two presidents and, most important, outspoken community leaders, parents and teachers. Not only were employers no longer willing to tolerate drug use in their workplaces, the workers themselves became more intolerant of use by their co-workers, recognizing both the heightened accident risk and the likelihood that their companies would become less competitive. Social norms at parties changed, as did teenagers' tolerance for drug use among their peers.

To assume that these events occurred simply because of changing general attitudes about health is to misread the message of these years.

Reuter pointed out, and I agree, that we have not been successful in making drugs physically unavailable. But we can help make them "psychologically unavailable" through denormalization and the stigmatizing of their use. The difference in numbers between alcoholics (18 million) and cocaine addicts (2 million) shows what happens when addicting drugs are "normalized" and not stigmatized.

Nor would the funds badly needed for treatment be forthcoming under benign neglect. As Reuter pointed out, many of the people who need drug treatment are not seen as worthy recipients by the public at large. Funding for treatment has been a bipartisan failure, with Republican administrations asking for inadequate funds and Democratic Congresses providing even less. Would neglect improve this situation?

It is also evident to treatment professionals that, while many people need treatment for drug abuse, the demand for it is not great. Most people using illicit drugs don't come into treatment voluntarily. Many need some push from the criminal justice system. If the justice system relaxes its sanctions and the addicts know the threat has little to back it up, their willingness to go into involuntary treatment will be substantially less.

There is good data showing that individuals who go into treatment under pressure do just as well as those who enter voluntarily. While it makes sense to shift priorities so that treatment, prevention and research receive 50 percent rather than 30 percent of federal dollars, this is unlikely to happen unless the public intensifies its pressure rather than just ignoring the drug problem.

The effectiveness of the European harm reduction attempts that Reuter advocates is also overstated. The Swiss recently closed their "needle park" because the tolerance of drug abuse it represented had led to up to 20,000 people congregating there, instead of the few thousands they had predicted. The Italians have paid for their decriminalizing possession of small amounts of heroin for personal use with the highest heroin overdose death rate and one of the highest addiction rates in Western Europe.

It is difficult to determine just what drug policy will be like in this era of new leadership. While the Office of National Drug Control Policy has been proposed for Cabinet level, it has been reduced in size, and no one has yet been named to head it. The House of Representatives has voted to eliminate its Select Committee on Narcotics Abuse and Control.

The change at the drug policy office may not be for the worse if a strong and articulate leader there has President Clinton's support and sufficient funding. But the elimination of the House select committee could do great harm. While 18 or so congressional committees and subcommittees have some aspect of the drug issue within their purview, drugs cannot be adequately covered in such a frgmented fashion, the problem that brought the select committee into being. One committee in Congress needs to remain focused on the drug issue.

While the economy and health care reform get the headlines, neither will be adequately resolved without attention to substance abuse. Every drug treatment professional, every law enforcement officer on the beat, every family with a member struggling to overcome the problem of drug abuse, every social service worker who must go into homes racked by drugs, AIDS and tubercolosis, every community leader worried about drugs and crime in his or her neighborhood should be worried about benign neglect.

The writer is executive vice president and medical director of the Center on Addiction and Substance Abuse at Columbia University.