October 8, 1993

M E M O R A N D U M

To: Joycelyn Elders, M.D.

Surgeon General of the United States

Public Health Service

From: Eric E. Sterling, J.D.

President, The Criminal Justice Policy Foundation

Re: Public Health Dimensions of the "War on Drugs"

Use and abuse of "illegal" drugs has a negative impact upon public health. The public is well aware of the more obvious horrors associated with drugs. This illuminates some of the "below the tip of the iceberg" health consequences of illegal drug use and the "war on drugs".

The American strategy to address drug abuse has, since the early 1980, been characterized as the "war on drugs". Most American's recognize that our strategy has largely failed to address key issues. The costs and consequences of prohibition on drug production and distribution are multifold.

One of the most horrific results of the prohibition approach is the loss of life. In the absence of government regulation, the American drug trade remains in the hands of frequently violent criminals. As a result, many innocent people are killed by drug traffickers in competition for business.(1) Furthermore, a small number of people are killed by drug users in the course of robberies.(2)

Many people also die from drug overdoses (4,242 persons in 1991 according to DAWN Medical Examiner Data).(3) Because of prohibition there are no regulatory controls on the manufacture, packaging or distribution of illegal drugs. Consequently, overdoses from batches of illegal drugs of unknown strength are widespread. Sixty-one percent of the DAWN emergency room episodes in 1990 were for overdoses.(4) Poisonings from contaminated illegal drugs are also widespread.

Prohibition produces more crime. Drug users frequently resort to robberies, burglaries, shoplifting, embezzlement, fraud, and prostitution in order to raise enough money to buy drugs sold at prohibition-inflated prices. Twenty-six percent of prison inmates convicted of property offenses reported in a 1991 BJS survey that they committed the offense for which they were incarcerated to get money to buy drugs. This was true for 30% of the burglars and 31% of those convicted of larceny.(5)

There are more pharmacy robberies and thefts. Use of legal pharmaceutical narcotics poses much lower health risks to illegal users than the use of "street" drugs because their strength and purity are dependable. For example, legitimate pharmaceutical pain relievers like Percodan or Dilaudid, which substitute for heroin, are very popular among addicts as the pills are of known strength and purity. Moreover, such well-marked dosages are significantly more valuable on the street drug market than heroin, selling for as much as $60 per pill. Consequently, they are often stolen from pharmacies, either for use by the thief or for profitable resale.(6)

All of these circumstances mean that patients who legitimately need these legal drugs, which are extremely important in the treatment of pain, find them much harder to obtain. These consequences are aggravated by a strict prohibition approach toward the use of such drugs. Reportedly pharmacies in some neighborhoods will not carry drugs like Percodan and Dilaudid so as to discourage robberies and burglaries.(7) In addition, to prevent prescription diversion of these drugs, regulators require physicians to use triplicate prescription blanks. Many physicians fear that prescribing such drugs may subject them to regulatory scrutiny or even harassment. Thus, patients needing pain relief are less likely to get it. This has been confirmed by the World Health Organization as an international problem, and it is a serious problem throughout the United States.

The increased risk to pharmacies and wholesalers of carrying such prescription painkillers makes them more expensive to legal customers. The increased price, plus the increased security costs, plus the cost of stolen inventory, all result in higher costs to insurance companies, which means higher health insurance premiums for all of us. This problem is further exacerbated by false medical claims filed by addicts in order to obtain drugs. The false medical claims become false health insurance claims, again increasing costs and premiums.(8)

One of the biggest consequences of the prohibition approach to drugs is the extensive spread of HIV (9) and other blood borne diseases such as hepatitis.(10) IV syringes, i.e. needles, are classified as drug paraphernalia, and are hence illegal. That makes clean injection equipment scarcer and more expensive, and discourages addicts from carrying their own. Possession of needles, because it is illegal, is probable cause for arrest.

The National Commission on HIV and AIDS has called for clean-needle exchanges as an HIV transmission prevention measure.(11) However, "war on drugs" doctrine considers sending the right "message" to be of paramount importance. The "message" that sale and possession of injection equipment is prohibited is more important than preventing the spread of HIV through the sharing of needles. Consequently, section 2025 of the Anti-Drug Abuse Act of 1988 (12) denies any drug treatment funds to States which distribute sterile needles or bleach to clean needles. Nevertheless, a growing number of American cities have recognized the importance of needle exchange and have adopted programs. According to recent University of California study, there are 37 needle exchange programs operating at over 100 sites nation-wide (13).

The nation's blood supply is put at somewhat greater risk for spreading HIV and hepatitis because addicts sometimes can successfully sell their blood to buy expensive illegal drugs. In recent years, the commercial purchase of blood has been greatly reduced, but it still is done, almost exclusively for plasma extraction. Current programs to carefully trace blood have also served to deter drug addicts from selling blood. Even though very reliable screening sistems are in place to test blood - 99.9% reliable - they are not fool proof. Addict sales of blood for a long time were a way for them to afford to purchase drugs sold at prohibition-inflated prices.

Drug prohibition leads to the spread of sexually transmitted diseases such as HIV, hepatitis, syphilis, and gonorrhea through prostitution engaged in to raise money to pay for expensive illegal drugs.(14) Between 1985 and 1988 heterosexual syphilis increased in Washington, D.C. by 91%, and in Philadelphia by 200%. In Washington, in the same period, penicillin-resistant gonorrhea increased by 300%. In 16 rural counties in Georgia, new syphilis cases increased by 800% between 1985 and 1988 due to crack use.(15)

Treatment of HIV + drug users who are sick or injured increases risk of accidental infection to health care workers such as EMTs, surgical and emergency room staff.(16) The risk of HIV infection reportedly has discouraged health care workers from entering such fields.

Drug users avoid medical treatment because their illegal drug use may be detected in an examination and reported to law enforcement authorities. Untreated, their medical conditions become more severe and more expensive to treat. Thus, the people who the drug laws are supposed to be helping are discouraged from obtaining medical treatment. All of us pay a greater price as a result, and are put at greater risk of infection from untreated people carrying infections disease organisms.

More babies are put at risk for death or birth defects as pregnant drug users stay away from pre-natal clinics out of fear of being reported and jailed. Over 25 women have been prosecuted for "delivering" cocaine to their babies. "War on drugs" inspired laws requiring reporting of pregnant drug users, while rationalized as helping to protect babies, actually drive their mothers away from the care that could improve the babies' conditions.

Many public hospital emergency rooms and trauma centers must triage many serious cases because they are overwhelmed with prohibition-fueled gun-shot victims, or with drug overdoses and poisonings. When children are injured on an athletic field, travelers are injured in an automobile accident, a man has a heart attack, or an elderly woman's hip is broken in a fall, when they get to the ER - with those serious injuries - they often get in line behind the terrible cases that the prohibition anti- drug strategy has helped create.

Research into new psychiatric drugs has been delayed or eliminated because of prohibition. Doctors looking at new research about brain chemistry are discouraged from engaging in research with drugs that affect the senses, moods, or feelings.

Thousands of patients suffer because marijuana, and heroin (used in Britain and Canada as a legal pain reliever) are withheld from patients who could benefit from them, in order to send political messages about anti-drug positions.

The "war on drugs" has filled American's prisons with young black men. Nationally, one in four black men age 20 to 29 are in prison, or on probation or parole. In California, ti si one in three suche men. In D.C. it is 2 in 5 such men. The "prisonization" of young black men consigns them to a status of permanent underemplyment, at best. (17) From a public health standpoint, tuberculosis in prison is now presenting a crisis in institutions such as the prisons operated by the Department of Corrections in the City of New York. 16% of the women and 17% of the men entering the New York City prison system are infected with tuberculosis (not necessarily active cases). 115.000 persons are admitted to the city's prison system annually. (18)

Some argue, such as Rep. Charles Rangel (D-NY) (perhaps for rhetorical effect), that a real war on drugs has never been fought. However, Elliot Currie in his excellent new book, Reckoning: Drugs, The Cities, and The American Future, explains convincingly that indeed a war has been fought (pp. 15-20).

Many thoughtful observers argue that the only alternative to prohibition is "legalization", modeled after either the free-market, or some modification thereof, such as the current alcohol models. But advocates for legalization have offered almost no detailed proposals for legalization. For the time being, I suggest that the nation reconceptualize our goal in drug policy to one of "managing the drug problems". Identify the specific harms from drug abuse that are most serious and implement strategies to minimize them, and dispense with such characterizations as "sending the wrong message."

ENDNOTES

1. In the New York Crack homicide study, 34% of the homicide victims (n=148) were identified as drug traffickers. 29% of the perpetrators (n=140) were identified by the police as drug traffickers. Goldstein, P.J., Brownstein, H.H. Ryan, P.J. Bellucci, P.A., Crack and homicide in New York City, 1988; a conceptually based event analysis, CONTEMPORARY DRUG PROBLEMS, Winter 1989, 651, (hereafter "Crack & Homicide in NYC") at 661.

See also Drug-Related Homicide in New York: 1984 and 1988, Goldstein, P.J., Brownstein, H.H., and Ryan, P.J., 38 CRIME AND DELINQUENCY No. 4, October 1992, pp. 459-476, at 469.

2. Eight of 414 homicides in New York City studied by Goldstein at al. are believed to have been committed in the course of robberies or burglaries for economic gain. Goldstein, P.J., Brownstein, H.H., Ryan, P.J., Bellucci, P.A., Crack and homicide in New York City, 1988: a conceptually based event analysis, CONTEMPORARY DRUG PROBLEMS, Winter 1989, 651, at 666.

3. Medical Examiner Data, Table 4.02 - Distribution of drug abuse deaths by selected episode characteristis: 1988-1991, in ANNUAL MEDICAL EXAMINER DATA 1991, Data from the Drug Abuse Warning Network, NIDA STATISTICAL SERIES, Series I, Number 11-B, page 50.

4. NIDA, Annual emergency room data, 1990, Data from the Drug Abuse Warning Network, series I, number 10-A, 1991, table 2.03, 22, cited in Drugs, Crime, and Justice System, 1992, p. 11.

5. Bureau of Justice Statistics, Office of Justice Programs, U:S: Department of Justice, Survey of State Prison Inmates, 1991, NCJ-136949, March 1993, p. 22. (BJS Authors: allen Beck, Darrell Gilliard, Lawrence Greenfeld, Caroline Harlow, Thomas Hester, Louis Jankowski, Tracy Snell, James Stephan, Danielle Morton.)

6. In 1992, 3186 thefts of controlles substances were reported to DEA. This number substantially underestimates the actual number since many jurusdictions did not report including New York. These were broken down to include 978 night break-ins, 186 armed robberies, 982 employee pilferage, and 130 customer theft. (Telephone conversation with Frank Shults, DEA Office of Congressional and Public Affairs, July 16, 1993).

7. DEA was unwilling to speculate about this number. But see letter from pharmacist Deborah F. Cartwright (Biphetamine) quoted by U.S. Rep. Henry Hyde (R-IL) in Hearings before the House Judiciay Subcommittee on Crime on "Criminal Penalty for Robbery of Controlled Substances, " 98th Cong. !st Sess., April 7, 1983, Serial No. 73, at pp. 4, 17; letter from pharmacist George T. Lee (Dilaudid) at pp. 31; letter from pharmacist Larry M. Gilbert (Dilaudid, Tuinal, Seconal) pp. 33-34.

8. Ken Hacker, manager of public affairs for the American Insurance Association, reports that increased claims are leading to increased premium costs, but was unaware of anu studies showing the impact of illegal drug use in the increase in the number of claims submitted. (Telephone conversation, July 6, 1992).

9. 32% of adult and adolescent AIDS cases are related to IV drug use. 70% of pediatric AIDS cases related to the mother's HIV are related to the mother's exposure to HIV through IV drug use or sex with an IV drug user. 71% of all female AIDS cases are linked directly or indirectly to IV drug use. 45% of the IV drug use HIV cases are among African Americans. National Commission on AIDS, Report Number Five: The Twin Epidemics of Substance Use and HIV, July 1991.

10. CDC reports the following number of hepatitis cases for 1991: Fepatitis B - 18,003; Hepatitis C (non-A, non-B) -- £,582. (CDC, Historical Tables -- 1982-1991, Table 1, Notifiable Diseases -- Summary of reported cases, United States, at p. 57.) 12% of the reported Hepatitis B cases and 33% of the Hepatitis C cases were from IV drug use transmission. (Telephone conversation with Louis Polish, medical epidemiologist, CDC, July 12, 1993)

11. National Commission on AIDS, Report Number Five: The Twin Epidemics of Substance Use and HIV, July 1991, Recommendation 2.

12. Sec. 1915 8c) of the Public Health Service act, 42 USC 300x-3(c)(2).

13. UCSFNEWS, UC Study Urges Federal, State, and Local Governments to Support Needle Exchange Programs to Prevent HIV Spread Among Injecting Drug Users, University of California, San Francisco, September 30, 1993, pp. 1, pp. 3.

14. James A. Inciardi, "Hooker, whore, junkie, thief: dealer, doper, cocaine freak," in The war on drugs: Heroin, cocaine and public policy, James A. Inciardi, ed. (Palo Alto, CA: Mayfield Publishin, 1986), 156-173 cited in Drugs, Crime and the Justice System, 1992.

15. Currie, Elliott, Reckoning: Drugs, The Cities, and The American Future, Hill and Wang, 1993, pp. 29-30.

16. Nationwide, 36 health care workers are documented to have become HIV+ in the course of providing medical care to their patients, as of March 31, 1993. CDC, HIV/AIDS Surveillance Report, First Quarter Edition, May 1993, Vol. %, No 1, Table 11, page 13. An additional 75 health care workers are identified as possible occupational transmission.

17. Reckoning, p. 19.

18. Telephone conversation with Steven Matthews, City of New York Department of Health, October 8, 1993.