By Joseph A. Califano, Jr.
Drug misuse (usually called abuse in the U.S.) infects the world's criminal justice, health care and social service systems. Although bans on the import, manufacture, sale and possession of drugs such as marijuana, cocaine and heroin should remain, drug policies do need a fix. Neither legalization nor decriminalization is the answer. Rather, more resources and energy should be devoted to research, prevention and treatment, and each citizen and institution should take responsibility to combat all substance misuse and addiction.
Vigorous and intelligent enforcement of criminal law makes drugs harder to get and more expensive. Sensible use of courts, punishment and prisons can encourage misusers to enter treatment and thus reduce crime. Why not treat a teenager arrested for marijuana use in the same way that the U.S. treats someone arrested for drunk-driving when no injury occurs? See the arrest as an opportunity and require the teenager to be screened, have any needed treatment, and attend sessions to learn about the dangers of marijuana use.
The medical profession and the public health community should educate society that addiction is a complex physical, psychological, emotional and spiritual disease, not a moral failing or easily abandoned act of self-indulgence. Children should receive education and prevention programs that take into account cultural and sex differences and are relevant to their age. We should make effective treatment available to all who need it and establish high standards of training for treatment providers. Social service programs, such as those to help abused children and homeless people, should confront the drug and alcohol misuse and addiction commonly involved, rather than ignore or hide it because of the associated stigma.
Availability is the mother of use
What we don't need is legalization or decriminalization, which will make illegal drugs cheaper, easier to obtain and more acceptable to use. The U.S. has some 60 million smokers, up to 20 million alcoholics and alcohol misusers, but only around 6 million illegal drug addicts. If illegal drugs were easier to obtain, this figure would rise.
Switzerland's "needle park," touted as a way to restrict a few hundred heroin users to a small area, turned into a grotesque tourist attraction of 20,000 addicts and had to be closed before it infected the entire city of Zurich. Italy, where personal possession of a few doses of drugs like heroin has generally been exempt from criminal sanction, has one of the highest rates of heroin addiction in Europe, with more than 60% of AIDS cases there attributable to intravenous drug use.
Most legalization advocates say they would legalize drugs only for adults. Our experience with tobacco and alcohol shows that keeping drugs legal "for adults only" is an impossible dream. Teenage smoking and drinking are widespread in the U.S., United Kingdom and Europe.
The Netherlands established "coffee shops," where customers could select types of marijuana just as they might choose ice cream flavors. Between 1984 and 1992, adolescent use nearly tripled. Responding to international pressure and the outcry from its own citizens, the Dutch government reduced the number of marijuana shops and the amount that could be sold and raised the age for admission from 16 to 18. In 2007, the Dutch government announced plans to ban the sale of hallucinogenic mushrooms.
Recent events in Britain highlight the importance of curbing availability. In 2005, the government extended the hours of operation for pubs, with some allowed to serve 24 hours a day. Rather than curbing binge drinking, the result has been a sharp increase in crime between 3 am and 6 am, in violent crimes in certain pubs and in emergency treatment for alcohol misusers.
Sweden offers an example of a successful restrictive drug policy. Faced with rising drug use in the 1990s, the government tightened drug control, stepped up police action, mounted a national action plan and created a national drug coordinator. The result: "Drug use is just a third of the European average."
Almost daily we learn more about marijuana's addictive and dangerous characteristics. Today's teenagers' pot is far more potent than their parents' pot. The average amount of tetrahydrocannabinol, the psychoactive ingredient in marijuana, in seized samples in the U.S. has more than doubled since 1983. Antonio Maria Costa, Director of the UN Office on Drugs and Crime (UNODC), has warned, "Today, the harmful characteristics of cannabis are no longer that different from those of other plant-based drugs such as cocaine and heroin."
Evidence that cannabis use can cause serious mental illness is mounting. A study published in the Lancet "found a consistent increase in incidence of psychosis outcomes in people who had used cannabis." The study prompted the journal's editors to retract their 1995 statement that, "smoking of cannabis, even long term, is not harmful to health."
Drugs are not dangerous because they are illegal; they are illegal because they are dangerous. A child who reaches age 21 without smoking, misusing alcohol, or using illegal drugs is virtually certain to never do so. Today, most children don't use illicit drugs, but all of them, particularly the poorest, are vulnerable to misuse and addiction. Legalization and decriminalization—policies certain to increase illegal drug availability and use among our children—hardly qualify as public health approaches.
Appeared on BMJ.com on November 9, 2007