Redefining the Goals of National Drug Policy: Recommendations from a Working Group
Use reduction is inadequate as the only guiding principle for drug policy because it is unidimensional and tends to overlook real differences among drugs, drug use patterns (including modes of administration), populations, and the many harms associated with drug distribution, enforcement, and control as opposed to drug use. In terms of harms, shifting a drug injector to a less dangerous form of drug use may be more important than persuading an occasional user of marijuana to cease consumption. At a programmatic level, use reduction invites a focus on the most easily deterred users, generally those at least risk of harming themselves or others, and a neglect of the most problematic users, those whose desistance can be achieved only at substantial cost. Generally speaking, use reduction slights drug treatment efforts, which lower the total number of users only moderately but may have a substantial impact on the total amount of drug-related damage.
Conceptually, harm reduction is much more attractive. Each policy or programmatic decision is assessed for its expected impact on society. If a policy or program is expected to reduce aggregate harm, it should be accepted; if it is expected to increase aggregate harm, it should be rejected. The prevalence of drug use should play no special and separate role. However, the harm reduction philosophy itself is intrinsically unacceptable to those who oppose drug use on moral grounds, can be stalled by an inability to quantify and compare various kinds of harm, and may be difficult to sell politically. Furthermore, reducing use -- when harm per use does not rise -- is one way of reducing harm. Hence, we recommend that both harm and use reduction goals be pursued and, thus, that the 1988 Anti-Drug Abuse Act be amended to focus goals on reducing drug abuse and related harms, and not just on abuse.
General harm reduction goals include reducing violence related to drug distribution, lowering mortality and morbidity (particularly the prevalence of infectious diseases) among the drug dependent, reducing the harms borne by innocent others (including family members), and reducing the costs stemming from and created by drug control interventions themselves. Clearly, these are broad categories that can be broken down into more specific subgoals, such as lowering the incidence of human immunodeficiency virus related to needle use, the incidence of tuberculosis among the drug dependent, and the number of homicides related to cocaine selling. Thus, whereas use reduction can be seen as a pragmatic and measurable goal toward the ultimate end of reducing harm and is particularly appropriate for adolescents, harm reduction may be seen as the primary goal for adult populations.
The goals should reflect the integration of all psychoactive substances, regardless of legal status. For example, instead of trying to reduce the number of infants damaged by their mothers' illicit drug use during pregnancy, the appropriate goal should be to reduce the number of infants damaged by any substance abuse (including alcohol and cigarettes), given that the relevant programs and high-risk populations overlap.
We do not suggest that every goal falls within a framework that combines use and harm reduction. For example, minimizing the invasion of privacy that is a by-product of drug enforcement does not directly relate to reducing the prevalence of drug use or the harm done by drug abuse. Likewise, neither use nor harm reduction addresses the need for programs to be equitale (e.g., in their treatment of different ethnic and economic groups). Equity, like a number of other values (e.g., privacy and procedural fairness), should be a major consideration in making decisions about achieving goals.
It is clearly desirable to incorporate indicators and other quantitative information into policy-making. Yet it would be a mistake to tie policy too closely to indicators for the simple reason that there are so few good indicators available. Existing data on harms may reasonably be termed "woeful"; no plausible measures exist for the number of child abuse or neglect cases related to drug abuse or for the share of homicides related to drug distribution, and information about lost productivity and property crime attributable to drug use is weak (12). Some surveys contain items on perceptions of harms incurred by respondents and their intimates; these may provide a useful start in developing indicators and tracking their trends, but they have been underused to date.
The weakness of the indicators does not preclude the pursuit of harm reduction policies. Indeed, in other countries, data are even less available, yet at least some countries, such as the Netherlands, have implemented harm reduction policies that are highly regarded (13). Since policy decisions are informed not just by data but also by intuition, anecdote, expert judgment, and (we hope) reason, a paucity of data does not reduce policymaking to coin tossing. Indicators can and should serve policy, but they should not be allowed to drive it.
We do not aim to be comprehensive in our recommendations here but to suggest some of the changes for both federal and lower levels of government that flow from having explicit harm reduction goals.
Inclusion of Alcohol and Tobacco. A major step toward developing sounder policy with respect to drugs would be to use that label for alcohol and nicotine (as the scientific literature already does), and to make an augmented Office of National Drug Control Policy responsible for coordinating federal policy toward alcohol and nicotine as part of the overall national drug control strategy. This extension of that agency's responsibility might reduce its ability to unite political constituencies under a banner of moral indignation, but that may actually be a desirable outcome and is, in our opinion, outweighed by other considerations. Alcohol and nicotine account for the vast majority of drug-related negative health outcomes and economic costs (14), and for a large part of the drug-related dangers faced by juveniles (15). Alcohol (but not nicotine) also plays a major role in causing violent crime and disrupting families, schools, and neighborhoods.
Including alcohol and cigarettes would allow integrated policy and ensure that all drugs are given proper emphasis in the key decisions about health care and crime control. For example, alcohol treatment can reduce crime; decisions about funding such treatment should reflect that gain. Similarly, well-designed drug enforcement at the local level can help reduce the spread of sexually transmitted diseases. The integration would also allow society to be tougher on alcohol and cigarettes, as it would help diminish the power of alcohol and cigarette producers to impede regulation.
Merging authority for illicit drugs with that for alcohol and tobacco does not have to result in the former receiving less attention. As enumerated above, the damages caused by illicit drugs are many, and few of those damages are given appropriate weight in decisions about the levels and programmatic forms of funding for control measures. For example, the gains to a community from reduced drug market-related disorder are not currently factored into evaluations of treatment effectiveness. However, once these illicit drugs are viewed as part of the family of psychoactive substances that cause a wide variety of individual and social damages, the potential reductions in tuberculosis, hepatitis, and sexually transmitted diseases, as well as in community quality of life, can be given full consideration. Finally, we believe that the integration will help ensure that for illicit drugs, the public will be alerted to the distiction between use and harm, while for alcohol and tobacco, the public will be reminded that all use has some risk of harm.
Programmatic Design. Secondary prevention is underused, yet it is a low-cost intervention that may have high payoffs. For example, doctors and other health care professionals rarely include questions about the use of alcohol, cigarettes, and illicit drugs when taking medical histories. However, evidence from research in the alcohol field suggests that even a 5-minute lecture, along with provision of information leaflets, can make a difference (16).
Similarly, efforts to inform current users about harms associated with different modes of drug use should be encouraged. Just as the government now funds programs to reduce the risk of harm from adolescent sexual behavior while encouraging abstinence, so must it strive to apprise determined users about less harmful ways (e.g., mode of administration, time, and setting) of using drugs. Needle exchange programs, for which evaluations provide increasingly strong evidence, are just one example of this kind of program (17,18).
The concerns with communicable diseases associated with frequent use of illicit drugs suggest aggressive screening and prophylaxis for tuberculosis (and probably other diseases as well) particularly targeted at drug-positive arrestees and drug treatment clients. These are the highest-risk populations, and their involvement in the criminal justice system provides an opportunity for increasing their compliance with medical regimes.
Drug enforcement at all levels should be more targeted toward harm reduction goals. Similarly, prosecutors and courts should seek means of using arrest as a way of pushing drug-involved offenders to abstinence, with incarceration as a threat rather than the first choice; the well-regarded Miami drug court represented such an innovation (19), which has also been a staple of Dutch enforcement.
Federal Programs That Deal with Illicit Drugs. Source-country drug control programs seem to be very ineffective in raising the price of illegal drugs, and they offer few other benefits as well (11). Slightly weaker but similar statements can be made about interdiction (20). At least for cocaine, treatment compares very favorably with these programs and even with domestic enforcement in its ability to reduce consumption per dollar spent on the effort (21). Some prevention programs also appear to be cost-effective (22). Hence, expenditures for more carefully targeted treatment and prevention efforts should be increased. Additionally, federal enforcement should shift resources away from marijuana and toward heroin; and investigative agencies should give higher priority to the violence of organizations than to the quantity of drugs they ship.
The primary budget issue, however, it is not so much balancing federal drug expenditures across difference categories; rather, it is raising the priority of treatment and prevention within the health and education budgets and lowering it within the enforcement budget (23). This is true in other levels of government as well. Drug enforcement may account for as much as one third of national law enforcement expenditures; drug treatment, on the other hand, accounts for less than 1% of the nation's health care expenditures, and drug prevention accounts for a similarly minuscule share of national educational and community development expenditures.
Federal sentences for drug offenders are often too severe; they offend justice, serve poorly as drug control measures, and are very expensive to carry out. Prison costs form the most rapidly increasing element of the federal budget, and this trend will likely continue unless action is taken promptly. More than 40% of drug offenders serving 5-year sentences in federal prisons are relatively minor participants in the business (24). This results in both an inefficient use of federal prison space and an important sense of inequity about federal drug enforcement. Congress should review the harsh mandatory minima that it imposed in 1986 and 1988, particularly for those caught selling small amounts of crack and for low-level participants (e.g., drivers and couriers) in large-scale transactions. The U.S. Sentencing Commission should eview its guidelines to allow more attention to the gravity of the offense and not simply to the quantity of the drug. Federal prosecutors should be discouraged from bringing minor drug offenders into federal court.
In theory, harm reduction, unlike use reduction, is compatible with legalization. However, there is no evidence that legalization is, in fact, a harm-minimizing strategy, and no analytic approach offers promise of resolving that issue in the near future.
Any time that multiple objectives are identified for policy, weights or priorities have to be assigned to each. Although determining those weights is beyond the scope of this paper, moving from the rhetoric of a "drug-free America," a common slogan since the mid-1980s, to a policy focused on reducing the damage created by the production, distribution, consumption, and control of drugs could help ensure a more balanced policy.
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19. Miami's drug court: a different approach. Washington, DC: National Institute of Justice; 1993.
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24. Special Report to Congress: Mandatory Minimum Sentences in the Federal Criminal Justice System. Washington, DC: U.S. Sentencing Commission; 1991.