Redefining the Goals of National Drug Policy: Recommendations from a Working Group
Policy goals matter for many reasons, such as mobilizing popular support, creating occasions for social learning, and developing accountability in government organizations. Here we focus on the ability of U.S. national drug-policy goals to generate targets that guide programmatic choices. A goal should identify an important value for society. Ideally, a set of goals should include all such values -- and only such values -- that are likely to be affected by policy decisions, and in so doing should generate priorities.
The Office of National Drug Control Policy is mandated to publish an annual National Drug Control Strategy, which sets forth the national goals for drug policy. Unfortunately, the goals of the agency have been narrowly focused on prevalence. Although the first Clinton administration Strategy, released in February 1994, differs substantially in focus and rhetoric from those of the Bush administration, it reaffirms the traditional theme of "one overarching goal -- the reduction of drug use" (1, p. 61).
The principal goal for drug policy should instead be to reduce the harms to society arising from the production, consumption, distribution, and control of drugs. Total harm (to users and the rest of society) can be expressed as the product of total use and the average harm per unit of use and thus can be lowered by reducing either component. Attention has been focused on the first; greater attention to the second would be beneficial.
This report briefly reviews the recent history of drug policy in terms of both goals and programs. It then suggests a new set of goals and discusses what indicators might be used to assess progress. Lastly it presents some programmatic recommendations flowing from these goals and indicators.
The Bush administration's first Strategy enunciated a clear, overriding goal for drug control -- namely, to reduce the use of illicit drugs: "The highest priority of our drug policy must be a stubborn determination further to reduce the overall level of drug use nationwide -- experimental first use, 'casual' use, regular use and addiction alike" (p. 8). In conformity with that goal and with the legislative requirement of the 1988 Anti-Drug Abuse Act that the strategy include "long-range goals for reducing drug abuse in the United States" and "short-term measurable objectives which the Director determines may be realistically achieved in [a] two-year period" (section 1005), this Strategy targeted reductions in various survey-based measures of the prevalence of drug use. Of nine goals, five were reductions in National Household Survey on Drug Abuse measures, such as the percentage of 12- to 17-year-olds reporting use of cocaine within the last month. No specific health goals (e.g., reductions in the number of drug-affected births) were included. Neither were tobacco and alcohol included, except for reductions in drinking by those under age 21, which was added to this list of goals in 1992.
In practice, federal policy from 1989 to 1992, like state and local policy, continued its emphasis on law enforcement. In fact, the number of drug-related incarcerations over the last 15 years has increased much more dramatically than the number of persons in drug treatment. Although federal expenditures for treatment have grown rapidly (e.g., from $900 million in 1988 to $1.9 billion in 1992), state and local governments have slacked in their efforts so that total treatment funding has actually grown slowly. Thus, in 1990, more than 100,000 persons were sentenced to state prison for drug offenses, comared with fewer than 10,000 in 1980 (2). In contrast, drug treatment admissions less than doubled between 1980 and 1992 (reaching about 1.5 million) although there was probably a larger increase in the numbers needing such treatment.
Since 1985, as law enforcement has intensified, the prevalence of drug use has fallen substantially (3). The proximate cause for this seems to be increased concern with the dangers of drug use rather than decreased availability of drugs or (except possibly for marijuana) rising prices (4). Little research has been done to explain the change in attitude (5).
Although overall prevalence has fallen sharply, the same cannot be said of heavy or problem use. Certainly, the number of emergency room admissions for drug-related problems has risen (6), the percentage of criminal arrestees testing positive for drugs has declined only modestly (again, except for marijuana (7)), and there has not seemed to be any evidence of reductions in the amount of damage related to illicit drugs. An increased number and percentage of reported acquired immunodeficiency syndrome (AIDS) cases have involved injection drug use (although the long lag time for the appearance of AIDS complicates the task of determining when the virus was contracted), and the occurrence of tuberculosis and hepatitis seems to be growing among the drug dependent (8,9).
Furthermore, reductions in the prevalence of occasional drug use will only slightly ameliorate these drug-related problems in the next few years. The history of heroin use illustrates the problem. The number of addicts in 1985 was close to that in 1975 even though incidence rates for heroin use fell sharply after 1973. Most of the 1975 addicts were still addicts in 1985 (10). Heavy cocaine use may prove to be similarly resilient.
Based on experience since 1985, the rhetorical and policy-oriented emphasis on making drug use less acceptable and drugs less available, as well as the focus on drug prevalence and the dominant indicator of program success, has probably outlived its usefulness. More attention needs to be given now to the problems associated with frequent or high-risk use and to some of the most risky sequelae. Although the Clinton administration's new policy takes important steps in this direction, it still comes up short.
The most important step forward is that "[T]he 1994 Strategy expands the focus away from casual and intermittent drug use and places it more appropriately in the most difficult and problematic drug-using population -- hardcore drug users" (1, p. 61). In particular, the plan calls for a significant expansion in treatment and a reduction in enforcement's share of total federal expenditures. Unfortunately, it also calls for a 21.7% increase in spending on source country control, the least promising programmatic area (11).
The Clinton Strategy's focus on problem users is another step forward. The Bush Strategies lacked such focus, so rhetoric and resources were inefficiently deployed against aspects of drug use that caused relatively fewer problems for society. However, the Bush Strategies were coherent (albeit poorly directed in our opinion), whereas the Clinton Strategy can perhaps best be described as cluttered. It lists 14 goals and 64 bulleted objectives, some of which are more sensible than others.
It is commendable, for example, that the second objective is to "reduce the adverse health and social consequences of illicit drug use" (1, p. 65). On the other hand, another objective is to "[B]etter define the size and scope and work aggressively to suppress domestic marijuana production and trafficking [sic]" (1, p. 69). Not only is this vague and oriented toward process rather than outcome, but there is no measure whatsoever associated with this objective.
The 64 objectives do not flow from a single vision but rather are merely an unprioritized list. Some items on the list are good; some are bad; some are vacuous. They do not, however, do much to direct policy.
As an alternative, we suggest considering two simple goals: harm reduction and use reduction. This would facilitate development of a strategy that is both coherentand focused on the most important aspects of the problem.