New England Journal of Medicine - February 3, 1994
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After nearly 10 years of escalation, the government assault on illicit drugs has proved to be a costly failure. We have all been paying the price in misdirected resources, social tension, violent crime, ill health, compromised civil liberties, and international conflict.
The war on drugs is, in effect if not in intention, a war on drug users. The federal budget for the control of illicit drugs has increased more than eightfold since 1981, and more than two thirds of the total is devoted to the enforcement of increasingly harsh criminal laws. These laws needlessly make criminals of at least 20 million Americans a year. Of the 1 million drug arrests each year, about 225,000 are for simple possession of marijuana, the fourth most common cause of arrest in the United States.
In the 1980s, while the number of arrests for all crimes was rising 28 percent, the number of arrests for drug offenses rose 126 per cent. Largely because we imprison so many drug users and petty drug dealers, the United States has a higher proportion of its population incarcerated than any other country in the world for which reliable statistics are available.
Mandatory sentencing laws force judges to impose excessive penalties. Under federal law the sentence for possession (not sale) of a teaspoonful of "crack" cocaine is a mandatory five years with no chance of parole. Since drug offenders now have far less incentive to accept guilty pleas, the number of trials in federal district courts is rapidly increasing. Judges feel both the burden of conscience and the burden of labor; in every federal judicial circuit they have urged Congress to reconsider mandatory sentencing.
As everyone knows, prohibition of drugs also enriches gangsters, while promoting burglary, theft, and violence in the streets. Furthermore, relentless enforcement of the criminal law encourages the use of the most dangerous and addictive drugs in the most concentrated forms. Bulky marijuana is less profitable and more risky for smugglers and dealers than cocaine and heroin. These drugs are easier to conceal and adulterate, easier to discard during a raid, and since their traces do not last as long in the body, less likely to be exposed by drug testing.
The international campaign is a particularly futile and destructive feature of the war against drugs. Drug crops are repeatedly eradicated in one place, only to be cultivated in another; the total acreage needed to supply the U.S. market is relatively small. Vast resources devoted to a hopeless attempt to seal our southern borders have had little effect on the price of cocaine. By urging South American countries to militarize the enforcement of anti drug laws, the U.S. government promotes large scale corruption and violation of human rights. The threat to the livelihoods of peasants heightens endemic social conflict and civil violence.
Enforcement of anti drug laws is also restricting the liberties of U.S. citizens. The Bill of Rights is in danger of becoming meaningless in cases involving drugs. Tenants charged with no crime are evicted from homes where police believe drugs are being sold. Public housing projects are sealed for house to house inspections The Supreme Court has permitted warrant-less searches of automobiles, the use of anonymous tips and drug courier profiles as the basis for police searches, and the seizure of lawyers' fees in drug cases. Property on which marijuana plants are found can be forfeited even if the owner is charged with no crime. Prosecutors have been allowed to try the same person at the state and federal levels for the same drug related crime.
Random drug testing is a spreading blight on civil liberties. In a 1989 case in which the Supreme Court allowed random urinalysis of Customs Service employees, Justice Antonin Scalia, who is not known as a liberal, correctly stated in his dissent that no evidence had been presented to show that this violation of privacy and human dignity served to improve job performance, the purpose for which it was ostensibly intended. Drug testing is, in any case, dangerously unreliable. Since the proportion of workers using illicit drugs is low, any test with less than 100 percent specificity is likely to produce a high percentage of false positives.
Present drug policies also have disastrous effects on health and health care. The American College of Physicians and two organizations concerned with prisoners' health have objected to mandatory sentencing in a recent joint position paper; they point out that a new epidemic of tuberculosis is incubating in jails and prisons crowded with drug law offenders. Infection with the human immunodeficiency virus is spreading rapidly among intravenous drug users who cannot legally exchange contaminated for sterile needles. Federal laws and policies have strangled the medical potential of marijuana, a remarkably safe substance that is useful to patients with cancer, AIDS, glaucoma, multiple sclerosis, and other disorders. It remains officially a forbidden medicine in the United States for all but nine persons who are still receiving it under a Compassionate Investigational New Drug program that was discontinued in 1991.
The benefits of a truce in the war against drugs are obvious. Police could spend more of their time and effort on the kinds of crime that most immediately threaten public order and safety. Resources now devoted to law enforcement could be devoted to combatting the chief causes of drug abuse and related social problems--poverty, unemployment, poor housing, illiteracy, and family disintegration. Gang warfare and drive by shootings would no longer spread every day terror in our cities. The profits of organized crime would decline precipitously. A threat to the Bill of Rights would be removed, and the prisons would be half empty. The many people for whom marijuana is medically useful could obtain it without fear of arrest or the need to bargain with illicit drug dealers. Funds would be available for more and better treatment of drug abuse. Drug education would be more plausible and convincing when freed of the false assumption that all currently illegal drugs have only destructive uses.
The most thoughtful and candid defenders of the war on drugs acknowledge its deleterious effects, while insisting that it is a burden society must bear. They admit that harsh enforcement policies promote corruption, endanger civil liberties, and increase violence among drug dealers. They admit that no more than a small fraction of the international traffic can be interdicted. They acknowledge that the campaign against illicit drugs does not necessarily reduce crime and in some ways endangers the public health. But they contend that any retreat from the struggle would lead to an enormous increase in the use of illicit drugs, with disastrous consequences for the moral and social order. They say that any control system short of prohibition could not be enforced; if drugs were taxed at a rate high enough to cover their social cost, abusers would still have to commit crimes and turn to a black market.
But defenders of the war on drugs have not been able to prove that substantial changes in the laws or their enforcement would greatly increase the use of drugs that are now illegal. The percentage of the population using opiates in 1914, when they were first banned under federal law, may not have been very different from today's percentage, and the social consequences of addiction were less serious. During the 1970s 10 states effectively decriminalized the possession of small amounts of marijuana by reducing the penalty to a fine (in Oregon, to a civil violation). The most careful study of these legal changes concluded that they led to a substantial reduction in the costs of law enforcement and criminal justice but did not affect the rate of marijuana use or public health and safety. " In 1983, 5.5 percent of American high school seniors smoked marijuana daily, as compared with 0.5 percent of students at a roughly equivalent educational level in the Netherlands, where marijuana laws were rarely enforced and
marijuana was sold openly in coffee shops.
Public opinion surveys also suggest that few people who do not now use illicit drugs would use them if the laws changed. The 1985 Household Survey of the National Institute on Drug Abuse found that only 3 percent of 18 to 25 year olds who had ever used cocaine and only 10 percent of those who had used it in the past month had ever habitually used it even once a week. Only 2 percent of people who do not use cocaine say they might try it if it were legalized, and 93 percent state vehemently that they would not. Even if the use of some drugs increased, any resulting dangers might be offset by a decline in the use of drugs that are now legal. At least one study suggests that high school students use less alcohol when they smoke marijuana; there are some good reasons to regard this as a desirable trade.
Cocaine is far more dangerous than marijuana, but even its addictive potential and health hazards are often overstated, especially when it is blamed for ills caused by poverty, unemployment, shattered families, and disintegrating neighborhoods. In one survey 4 percent of high school students who had used cocaine, as compared with 18 percent of cigarette smokers, said they had tried to stop but could not. Most cocaine users do not become dependent, and most who do eventually free themselves. Although it is undesirable for pregnant women to use this or any other drug, recent research suggests that the dangers of exposure to cocaine in the womb have been exaggerated in both scientific reports and the popular press. It appears that the effects of the drug are hard to distinguish from those of poor prenatal care, low birth weight, alcohol abuse, venereal disease, and the adverse family and social circumstances of the mother. There is little evidence that the vast majority of infants exposed to cocaine during preg
nancy have permanent brain damage or suffer other irreparable harm. Certainly no effect of cocaine on the fetus has been shown to be as severe and as common as fetal alcohol syndrome.
There is evidence that the use of illegal drugs alone does not necessarily hurt job performance or reduce earnings. Studies purporting to prove that it does often confuse association with cause. Some research suggests that adolescents who occasionally use illicit drugs, especially marijuana, are actually healthier psychologically than those who have never used illicit drugs (as well as those who use them habitually). Other research shows that college students who use illicit drugs and those who do not have similar grades and participate to the same extent in college activities.
All sides of the debate on drugs can cite the precedent of national alcohol prohibition, because the historical evidence is scanty and unreliable. Everyone acknowledges that Prohibition, like our present drug policies, increased corruption and crime. Although Americans probably drank less in the 1920s than before, it is doubtful that Prohibition was the reason. As measured by deaths from cirrhosis of the liver, hospital admissions for alcohol related psychosis, and arrests for drunkenness, consumption seems to have declined mainly in the early years of Prohibition. It began to rise again in the late 1920s and continued to rise more slowly, if at all, after repeal and the establishment of the present state regulatory systems for alcohol. In 1937 through 1940, years after repeal, consumption was at about the level it reached in the last years of Prohibition. It did not reach 1915 levels again until the late 1960s.
In 1920, when the 18th Amendment went into effect, alcohol use had already been declining steadily in the United States for years. Alcohol related admissions to Bellevue Hospital in New York City fell from 5.0 per 1000 population in 1910 to 0.73 per 1000 in 1920 and then rose to 2.4 per 1000 in 1933. The few countries that instituted national prohibition were not the only ones in which alcohol consumption fell during the first quarter of the century. In the United States the death rate from cirrhosis of the liver fell from 14 per 100,000 in 1910 through 1914 to 7 per 100,000 during the Prohibition years. But in Great Britain, where alcohol remained legal, the rate fell from 10 per 100,000 in 1914 to 5 per 100,000 in 1920 and 2 per 100,000 in the 1940s, before it began to rise again. Historical changes in alcohol consumption show that other influences are more important than availability and price. Although the rate of taxation on alcohol has fallen in real dollar terms during the past 40 years, and although
the availability of this drug has certainly not decreased, its use has begun to decline along with use of illicit drugs.
The educational campaign against tobacco conducted since the 1960s shows how to reduce drug consumption without the use of force. The campaign has been waged half heartedly: the government still subsidizes tobacco growers and distributors, tobacco advertising is pervasive, and tobacco products are lightly taxed. Nevertheless, a strategy relying on common sense rather than coercion has substantially reduced our consumption of the most addictive drug of all. Unfortunately, it has been largely ignored as a model for the control of other drugs.
The peace process that ends the drug war can begin with some small changes. After the beneficial effects have been assimilated and recognized, we might consider further steps. This approach is modeled on the "harm reduction" policy that has been influential in the Netherlands and other European countries.
Above all, the federal role in drug enforcement should be greatly reduced. Federal involvement emphasizes the unfortunate imagery of a patriotic war in which drugs and drug users are the enemy. Furthermore, the federal government has encouraged some of the most wasteful and self defeating practices in enforcing the laws against drugs. Its withdrawal would give state and local governments an opportunity to adjust their policies to local conditions.
We suggest that the following steps be taken now:
1. The federal government should abandon or at least drastically reduce its effort to seal the borders against drugs and devote at least 90 percent of its drug control funding (rather than the present 30 percent) to prevention and treatment.
2. Marijuana should be made medically available immediately by reclassifying it as a schedule II drug.
3. Cultivation of small amounts of marijuana for personal use should be legalized.
4. Possession of drugs without the intent to sell should not be a cause for imprisonment under federal law.
5. Local governments should be allowed and encouraged to establish needle exchange programs.
6. Mandatory sentences for crimes involving drugs and forfeiture rules inapplicable in other types of crime should be eliminated.
7. Mandatory random drug testing in the workplace should not be permitted for most jobs.
At a later stage, several other steps should be considered. Federal and state laws that prohibit the sale and use of marijuana by adults could be eliminated. The production and sale of less harmful forms of abused drugs, such as coca tea or coca chewing gum, could be legalized. And health professionals could be allowed to provide opiates other than methadone, as well as stimulants (including cocaine), to addicts as part of a treatment program.
As Mayor Kurt Schmoke of Baltimore has suggested, a national commission might be established on the model of the Wickersham Commission appointed by President Herbert Hoover in 1929 to study the prohibition of alcohol. This commission could consider a comprehensive policy for all recreational drugs, which might include such features as a "harmfulness tax"-- a consumption tax adjusted for each drug according to its social cost.
Despite its superficial support of the war against drugs, the public is thoroughly confused about this issue. In a poll of 1401 people taken for the Drug Policy Foundation in 1990, a large proportion said they were willing to restrict civil liberties, and even accept warrantless searches of homes and cars, in order to reduce the use of illicit drugs. Yet more than two thirds preferred treatment and counseling to punishment for drug abusers, and fewer than half favored tougher penalties such as those imposed by recent federal laws.
Fortynine percent agreed that legal alcohol was more harmful than illicit marijuana, and only 33 percent disagreed. Half approved of needle exchange programs for addicts, and two thirds favored the medical use of marijuana.
In the face of this public confusion, as well as the massive evidence that their policies are failing, government officials have continued to raise a war cry. The National Drug Control Strategy of the Bush administration, as presented in 1989 by William Bennett, director of the Office of National Drug Policy, called for an emphasis on discouraging casual users, who were considered "contagious" because their existence conveys the message that it is possible to maintain a career and family while using an illicit drug. The problem, apparently, is that this message is correct. James Q. Wilson, another supporter of the drug -laws, has pointed out that the costs of changing the laws are difficult to measure because they are "to a large degree moral"; the illegality of drugs reflects society's obligation to sustain the character of its citizens.
Taking refuge in this kind of vague and inclusive language sometimes betrays insecurity about one's arguments. It would be hard to justify in any other way a declaration of war on more than 20 million occasional users of illicit drugs (mainly marijuana), the vast majority of whom are harming neither themselves nor anyone else. Such language may also reflect a lack of historical and cultural perspective. Drugs have been used to alter consciousness in most societies throughout history, and different drugs have been considered acceptable at different times and places. In 1930 marijuana was legal in most states and alcohol was illegal; obviously, moral standards and the character of the citizenry did not change radically when the status of the two drugs was reversed a few years later. Of all the Prohibition era mistakes we are now repeating, the most serious is trying to free society of drugs by the use of force. There is no reason to believe that the inclination to ingest substances that alter consciousness ca
n be eradicated. A drug free society is an impossible and probably an undesirable dream. It has been said that the worst and most corrupting lies are problems badly stated. As our contrasting policies on marijuana and alcohol suggest, what we call the drug problem has been very badly stated indeed. The philosopher John Dewey taught that moral ends are not fixed and absolute, but serve as guides that must be judged by the means needed to attain them.
Our present drug policies are immoral because they require a war of annihilation against a wrongly chosen enemy. We will never be able to regulate the use of consciousness altering drugs effectively until our ends are changed along with the means that serve them.
Harvard Medical School Boston, MA 02115
LESTER GRINSPOON, M.D., JAMES B. BAKALAR, J.D.
