Assumptions About Drugs and the Marketing of Drug Policies
In: W.K. Bickel & R.J. DeGrandpre, Drug Policy and Human Nature, New York: Plenum, 1995, pp. 199-220.
In 1972, Edward Brecher -- under the aegis of Consumer Reports -- published a remarkably forward-looking book entitled Licit & Illicit Drugs. Among the many myths of addiction he punctured was that of heroin overdose. To accomplish this, Brecher reviewed evidence that (1) deaths labelled heroin overdose "cannot be due to overdose; (2) there has never been any evidence that they are due to overdose; (3) there has long been a plethora of evidence demonstrating that they are not due to overdose" (p. 102).
In category (1) are historical and pharmacological data. In New York City prior to 1943, very few deaths of heroin addicts had been attributed to heroin overdose; in 1969-1970, 800 overdose deaths were recorded in New York. But over this time span, heroin purity declined steadily. In research conducted at Jefferson Medical Center in Philadelphia in the 1920s, addicts reported daily doses 40 times as concentrated as the usual New York City daily dose in the 1970s (Light & Torrance, 1929). Addicts in this research were injected with 1800 mg in a 2 1/2-hour period. Some subjects received up to 10 times their ordinary daily dosage and showed insignificant physiological changes.
In category (2) are the standard regimens of big-city coroners of simply recording as overdose deaths cases in which an addict died and had no other obvious cause of death. According to Brecher (1972),
A conscientious search of the United States medical literature throughout recent decades has failed to turn up a single scientific paper reporting that heroin overdose, as established by...any...reasonable methods of determining overdose, is in fact the cause of death among American heroin addicts (p. 105).
In category (3) are results of research conducted by two prominent New York City Medical Examiners, Drs. Milton Helpern and Michael Baden, based on the examination of New York City addict deaths, which found that (1) heroin found near dead addicts is not unusually pure; (b) the body tissue of the addicts shows no undue concentration of heroin; (c) although the addicts usually shoot up in groups, only one addict at a time dies; and (4) dead addicts are experienced--rather than novice--users who have built up tolerance to potentially large doses of heroin.
Yet, when we move from the 1920s and 1970s to the 1990s, we find in the New York Times on August 31, 1994, a front-page headline about the deaths of 13 New York City heroin users, part of which read: "They call it China Cat, an exotic name for a blend of heroin so pure it promised a perfect high, but instead killed 13 people in five days" (Holloway, 1994, p. 1). Brecher (1972) would seem to have laid to rest claims about epidemics of "multiple overdoses" of heroin like this one reported in the New York Times. Not surprisingly, two days later, the New York Times announced: "Officials Lower Number of Deaths Related to Concentrated Heroin" (Treaster, 1994, p. B3).
By this time, published reports had attributed 14 deaths to China Cat. The second New York Times article stated, "authorities yesterday lowered from 14 to 8 the number of deaths in the last week that the police believe are related to highly concentrated heroin" (Treaster, 1994, p. B3). The Medical Examiner discovered that
two of the 14 men originally suspected of having died from taking the powerful heroin had actually died of natural causes. Four others died of overdoses of cocaine.... Of the eight whose deaths apparently did involve heroin, seven also had traces of cocaine in their system" (Treaster, 1994, p. B3, emphasis added).
The follow-up article is notable in that: (1) deaths definitely attributed to overdose on the front page of America's leading newspaper were now only "suspected" overdose deaths, (b) the New York Times, after featuring and embellishing on overdose deaths on its front-page now attributed the overestimate to "authorities," (3) 6 of 14 people (42%) reported to have died of heroin overdose deaths had in fact not taken any heroin (two hadn't had any drugs), (4) 92% of the men who died after taking drugs had taken cocaine, compared with 67% who had taken heroin.
Was this in fact a cocaine rather than a heroin overdose epidemic? Or, alternately, was it an epidemic of deaths due to combining heroin and cocaine (and alcohol along with other drugs)? The follow-up article raised the more basic question of how the "authorities" decided that so many men had died of China Cat in the first place. According to the article, "The police said they found packets of China Cat, the street name of a powerful heroin blend, and a syringe" besides the body of one dead man. However, "they had no similar evidence connecting the China Cat brand to the other victims, but ... they considered it probable that a purer blend of heroin was involved" (even with the six men who it turned out had taken no heroin) (Treaster, 1994, p. B3).
The cavalier attitude with which a leading newspaper reported misinformation as fact is a phenomenon worth examining. To put it simply, saying bad things about drugs is never questioned, and disconfirming information never requires revision of original claims. The paper acts as though its drug reporting is part of its moral mission, one not related to facts. But this absence of a factual basis for its earlier report did not even slow the newspaper after the discovery of the many mistakes in the original article.
In a follow-up front-page report on September 4, the New York Times drew further conclusions about this case of "multiple drug overdose," now involving eight people (Treaster & Holloway, 1994). Only now, more of the original report had been found to be incorrect.
At first, the police suspected that the men ... had all died after using an extremely potent blend of heroin called China Cat.... Now the police and the New York City Medical Examiner, Dr. Charles Hirsch, say the men may have been victims of that brand or some similar, equally powerful blends of heroin.... But as one police officer put it: "They're all still dead." In the end, drug experts said, the brand name probably has little significance (p. 1, emphasis added).
While this may be so, the New York Times did identify China Cat as the cause of 13 men's deaths on its front page. Moreover, by the time this third article appeared 4 days later, it was still not clear on what basis the deaths of these men had been attributed to heroin overdose from any source (which Medical Examiner Hirsch says "may" have been the cause of the deaths). For example, the men all died singly, even though addicts typically use drugs in groups. The third article described the supposed heroin overdose death of Gregory Ancona, the only one of the cases for which eyewitness accounts were available:
[Ancona] and a young woman went to a club ... and went back to Mr. Ancona's apartment.... The woman injected her heroin.... Mr. Ancona, who ... was already staggering from the effects of cocaine and alcohol, snorted his. Soon after, he nodded off and never woke up. The woman ... suffered no more than the usual effects of heroin (Treaster & Holloway, 1994, p. 37).
The lethal effects of a brand of heroin are not supported by a case in which a man--who generally weighs more than a woman and shows less acute reactions to a given drug--died after snorting the drug while a woman who simultaneously injected the same batch of the drug showed no unusual effects. A more likely cause of Mr. Ancona's death under these circumstances would be the interaction of drug effects, and particularly those of alcohol and narcotics. Not only has research suggested the alcohol-narcotic link may be lethal, but addicts themselves generally suspect it and typically avoid drinking when taking narcotics (Brecher, 1972, p. 111).
This retailing of such dubious drug information can occur in a major newspaper with no risk of embarrassment. This is because the New York Times, its readers, and public officials share certain unquestioned assumptions--the assumptions that underlie our past and current drug policies, to wit:
- Drugs are so bad that any negative information about them is justified. The New York Times will not be called to task for inaccuracy in reporting about drugs, as it might, for example, in reporting with similar credulity, even deception, about crime or politics.
- Heroin is the worst drug. The New York Times could seemingly have made a better case for the toxicity of cocaine based on the original 14 deaths reported, yet it choose to focus on heroin. This may express a permanent bias against heroin, or a return to demonizing heroin after a period of concern about cocaine.
- Blaming drug deaths on overdose is highly desirable for propaganda purposes. If drugs are becoming purer, and deaths due to overdose are epidemic, then people should be more reluctant to take heroin.
- Middle-class heroin users in particular should beware. A focus of this and many other news features has been the perennial concern that street drug use is spreading to the middle class. The middle class status of a number of the dead men was a special feature of the New York Times articles.
One of the nation's most prestigious newspapers confidently misreports this story while it probably feels it is performing a valuable public service. But does the New York Times article actually present a safety hazard? If an addict believed that taking a specific dose of heroin is safe, he might not recognize that combining drugs can be dangerous. In Mr. Ancona's case, for example, he might have felt safe from a heroin overdose by snorting the drug rather than injecting it.
But there could be even more perverse consequences from labeling drug deaths as overdoses. Drs. Helpern and Baden interpreted their data as making it more likely that the impurities in the injectable mixture (particularly quinine), rather than the narcotic itself, which had been found to be relatively safe over a wide range of concentrations for regular users, were the source of heroin-related deaths (Brecher, 1972, p. 110). In that case, the most adulterated (impure) doses rather than the most concentrated (pure) doses of heroin would be most dangerous, exactly the opposite of the New York Times'warning.
The assumptions relayed by the New York Times article are actually quite common. They and similar popular assumptions about drugs underlie much of current drug policy. Policies for dealing with drugs, while presented as rational models built on empirical bases and offering sensible plans to improve American society, are actually largely determined by policy makers' wrongheaded assumptions about drugs use, abuse, and addiction. As a result, policies with long histories of failure and no chance for improving conditions in the United States are taken for granted because their assumptions correspond so well with popular drug myths (Trebach, 1987).
Indeed, the programmatic failure of these policies is directly related to their empirical failures in accounting for human drug use. This chapter outlines the assumptions underlying both our dominant drug policies and more useful, alternative models built on sounder assumptions about drug effects, human motivation, and the nature of addiction (Peele, 1992). It also suggests marketing alternative drug policies based on the appeal of their assumptions.
How we think about drugs, about their effects on behavior, and about their pathological use (as in addiction) is critical for our drug policy. Much of American drug policy has been driven by a specific image of how drugs--illicit drugs--work. This image has been that drugs cause addictive, uncontrollable behavior leading to social and criminal excess. Under these circumstances, drugs should be illegal and drug users imprisoned, which is how we principally dealt with drugs for the first half of this century. This is the punitive model, which has evolved into the modern law enforcement model of drug policy, which also incorporates massive efforts at interdiction to eliminate the supply of drugs to the U.S.
But the belief that drugs lead inexorably to uncontrollable consumption and antisocial behavior creates the potential for a wholly different model. In this model, since drug use is biologically uncontrollable, people must be excused for their drug taking patterns and their behavior when intoxicated. Their urges for continued drug use must be addressed through treatment. American society is characterized, simultaneously, by strong urges for self-improvement, by religiomoralistically oriented social groups, and by a belief in the efficacy of medical treatments. The disease model of addiction, which grew in dominance throughout the second half of this century, pulled all of these strands in American thought together successfully for marketing, institutional, and economic purposes (Peele, 1989b).
When public figures in the United States discuss drug policy, they generally veer between these two models, as in the debate over whether we should imprison or treat drug addicts. In fact, the contemporary U.S. system has already taken this synthesis of the law enforcement approach to drug abuse and the disease approach almost as far as it can go. In America today, large components of the prison population are drugsusers or dealers, and treatment for substance abuse--including 12-Step groups like Alcoholics Anonymous (AA)--is mandated for those in prison and many who avoid prison by entering diversionary programs (Belenko, 1995; Schlesinger & Dorwart, 1992; Zimmer, 1995).
While legal, penal, and social service institutions are able easily to incorporate drug treatment in their policies since drug use is illegal, the same synthesis of disease and law enforcement models also prevails for alcohol. Treating alcohol and drug use in the same way, despite their different legal statuses, is possible because the disease theory was made popular with alcohol and was then successfully applied to drug use (Peele, 1989a; 1990a). Meanwhile, the punitive law enforcement model developed with drugs was similarly applied to alcohol. Drunk drivers and even felons who drink excessively are given treatment in place of prison sentences (Brodsky & Peele, 1991; Weisner, 1990), while the many alcohol abusers already in prison are channeled through AA as the modern form of prison rehabilitation.
The differences in the origins and goals of the law enforcement and disease models guarantee that combining them will yield contradictions. But there are also broad similarities in their views of drugs, addictive behavior, and drug policy. Table 1 explores these differences and similarities according to the categories of causality, the responsibility of the individual drug user, the primary modality and policy recommended by the model, and the nature and extent of treatment inherent in the model. (Table 1 also examines two alternative models -- the libertarian and social welfare models -- which are discussed below).
|Model||Causality||Responsibility||Primary Modality||Treatment||Attitudes Toward New Policies|
|- Individual susceptibility: genetic||Internal biology||Individual
|Necessary (no self-cure)
Coercive (because of "denial")
|- Exposure: pharmacologic||External biology|
|- Punitive||User||Individual||Legal system||Coercive/Punitive (in place of or along with punishment)||Anti-legalization|
|Current policy -- combined disease/law enforcement||External (uncontrollable)||External
|Social Welfare||External/society||Society||Social services||Paternalistic
|Proposed policy -- combined libertarian/social welfare||Internal (lack of self-control)
External (lack of opportunity)
|Individual with social supports||Available
- Causality. The disease model claims that people are driven to consume drugs by uncontrollable biological urges. Since its founding in 1935, AA has implied that the source of alcoholism lies in the individual's biological make-up. And with the behavioral genetic revolution of the last quarter of the century, a largely genetic basis has been proposed for much addictive behavior. While the extreme form of this model--as represented by Blum and Payne (1991) in what they term the "addictive brain"--cannot be sustained, the spirit of Blum's analysis is broadly popular and in key elements is not that far from mainstream behavioral genetic models.
The disease model has several different guises. Table 1 lists the individual susceptibility version, which includes genetic models, as opposed to exposure models, which emphasize the pharmacologic properties of drugs. The exposure model maintains that pharmacologic properties of drugs directly cause continuous, escalating, and destructive drug consumption for everyone. The law enforcement model also assumes an exposure model of drugs and addiction.
- Responsibility. The law enforcement model faces a contradiction. On the one hand, the society is obligated to prevent citizens from being tempted by drug availability. But it is also the individual's responsibility not to take drugs, and therefore people are responsible and punishable when they do. However, both the law enforcement model's view that all drug use is uncontrollable and the burgeoning influence of the disease model have seriously undercut the personal responsibility and blame that underlie the punitive component of the law enforcement model. The assumptions that both excessive use of drugs and behavior when intoxicated are uncontrollable have allowed many drug users/addicts to claim such loss of control is responsible for their behavior.
- Primary modalities. The disease model strongly opposes the possibility of controlled use, as does the law enforcement model. Like the exposure versions of the disease model, the law enforcement model thus strives to prevent everyone from taking drugs and recommends abstinence as the key--indeed the sole--preventive and treatment measure. (Although the disease model ostensibly requires only inbred addicts to abstain, the disease view nonetheless tends to support abstinence from all illicit drugs.) For the law enforcement model, drugs must be prevented from entering the country through interdiction, and criminal sanctions must discourage all drug use. In the disease model, the addict must be treated--or join an AA-type group to spiritually reform users and socially support abstinence--in order to achieve wholeness.
- Treatment. The disease and the law enforcement models share a paternalism that focuses on peoples' inability to control themselves. In the disease model, the addict who rejects treatment is posited to be in denial, and the life-threatening nature of the disease makes treatment necessary. Adding this element to the law enforcement model, since abstinence is legally required, the addict is forced into treatment oriented towards achieving abstinence. Thus, while the disease and the law enforcement models are often thought to be opposed in their views of treatment, and the 12-Step movement originally emphasized voluntarism, all three currently coalesce in supporting coercive treatment.
The modern synthesis of the disease and law enforcement models dominates drug policy in the United States and is firmly entrenched among the public and policy makers. However, several social/economic factors have challenged the consensual support of drug policies this synthesis has garnered. These factors include:
- Cost. Interdiction, legal sanctions such as prison, and treatment (particularly of the medical kind) are all very expensive policy options. In an era of economic decline, like the one the United States faces, expensive policies-- even when broadly consensual--have come under scrutiny.
- Effectiveness. Ineffective drug policies have long been tolerated (Trebach, 1987). However, economic pressures to reduce government spending have caused some critical assessment of current drug policies. And the interdiction, prison, and treatment mix seems to do nothing so well as to produce greater need for the very same policies. Despite growing prison rolls of drug offenders and the constant recruitment (or return) of drug users for treatment, there is a steady call for acceleration and intensification of current police, interdiction, and treatment efforts. The contradiction between claims of effectiveness and worsening drug problems has led to a questioning of current policies.
- Paternalism. Both the disease and the law enforcement models deny the ability of individuals to resist or control drug use. Only the state, in the form of its policing or its treatment apparatus, is capable of making decisions about drugs for people. But such paternalism violates fundamental American precepts of self-determination. Moreover, it implies an endless battle between the state and its citizens that has become wearying.
In the United States, private and public treatment for drug, alcohol, and other compulsive behaviors (such as gambling, shopping, eating, and sexual behavior) modeled on the drug addiction model, as well as treatment for other mental health problems, is more abundant by far than that provided in any other country in the world (Peele, 1989b). Moreover, a growing majority of substance treatment recipients today--including those in AA and related groups--are forced into treatment. In addition to large numbers diverted by the court system for crimes from drunk driving up to and including serious felonies, social welfare agencies, employee assistance programs, schools, professional organizations, and other social institutions insist that members seek treatment at the cost of denial of the benefits of membership or expulsion (Belenko, 1995; Brodsky & Peele, 1991; Weisner, 1990). Healthcare cost controls on private drug and alcohol treatment and several scandals among psychiatric hospital chains shook the industry after the late 1980s (Peele, 1991a; Peele & Brodsky, 1994). Nonetheless, more Americans continue to be treated for substance abuse than have citizens in any other society in history, and this gargantuan treatment apparatus, both public and private, is maintained by coercing patients into the treatment system (Room & Greenfield, 1993; Schmidt & Weisner, 1993).
Even though restricting treatment to those who want it would greatly reduce demand for substance abuse treatment in the United States, the major American policy thrust is to vastly expand treatment rolls. To most Americans, the existence of a drug problem by itself so clearly implies treatment that other options cannot even be contemplated. One striking example of this unquestioned viewpoint was provided the American Bar Association (ABA) Special Committee on the Drug Crisis, which authored a 1994 report entitled: New Directions for National Substance Abuse Policy (ABA, 1994). The president of the ABA, R. William Ide III, introduced the New directions report by listing eight primary drug problems: (1) health costs, (2) drug use incidence, (3) drug-related crime resulting in (4) homicide, (5) juvenile violence, (6) prison overcrowding, (7) drug-related arrests, (8) and economic costs of drug-related crime.
It seems logical that the ABA would be primarily concerned with criminal aspects and costs of the drug problem. But what is remarkable is the extent to which the ABA conceives these as treatment issues. Following are four of six recommendations in section VII of the report, entitled "New Directions in the Criminal Justice System":
(1) The criminal justice system should provide a continuum of mandatory prevention and treatment services to drug-involved offenders.... (2) Alternatives to incarceration that include alcohol and other drug treatment ... should be expanded.... (5) Voluntary pretrial drug testing programs should be supported as a means of identifying and treating offenders immediately upon arrest.... (6) Court officers should be trained to identify and refer offenders with alcohol and other drug problems at the earliest possible point (pp. 34-35).
As John Driscoll, Chair of the ABA special drug committee, noted: "there was remarkable consensus on many of the most critical questions of drug policy" among committee members and consultants (p. 8). The clearest consensus is that drug use must be stamped out. Section III, "New Directions in Reducing Demand," presented a brief "Rationale" and three recommendations:
(1) The federal government should establish a "no use" standard of illicit drugs. We agree with the Office of National Drug Control Policy that [this] is vitally important.... (2) The federal government should continue to focus on casual users through prevention and treatment efforts.... (3) The federal government should increase its focus on hard core drug users through treatment and coercion efforts (p. 24, emphasis in original).
This section of the ABA report is explicit to the point of redundancy: All drug use should be eliminated, casual drug use should be eliminated, addicted users should be forced to quit, all through government efforts at expanding what is already noted to be official U.S. policy. Typically the report had no assessment of how much these policies would cost, what their chances for success are, and what social costs are entailed. Particularly disturbing is the complete absence of any consideration of the civil liberties of individual citizens: the Constitution is never raised in a report from the leading private legal organization in the United States. Yet Constitutional safeguards include those against invasion of privacy, like illegal searches and seizures, and safeguards of personal freedom of beliefs and religion. In several adjudicated cases, the courts have upheld the right of individual Americans to refuse to be forced into treatments--like AA--that violate their religious beliefs and even their self-concepts (Brodsky & Peele, 1991).
The assumptions motivating the ABA report are those underlying the disease/law enforcement synthesis model of addiction, to wit:
- Illicit drug use is bad. Moreover, it is inherently bad. Nothing about styles of use or the individual's motivation for using drugs is relevant to this determination. In general, this view of drugs is different from the American view of alcohol, which finds moderate, social consumption acceptable. However, as in the ABA report, drinking--particularly among the young--may be assimilated to use of all drugs in being totally proscribed and disapproved and through policies for an overall reduction in drinking levels. Yet, despite the fact that alcohol use has declined steadily for more than a decade, people report having more serious alcohol problems than ever before (Room, 1989), problems that are growing most rapidly in the youngest cohorts (Helzer, Burnham, & McEvoy, 1991).
- Illicit drug use is unhealthy, uncontrollable, and addictive. While the badness of drug use can be defined socially and legally--it is wrong to take drugs--the ABA assumes drug use is unhealthy. Moreover, it is unhealthy in the sense that even if some drug use would not harm the individual, no one can guarantee that drug use will be limited to this level, because drug use holds out the inevitable or irresistible danger of becoming all consuming (i.e., drugs are addictive).
- Prevention and treatment work and can reduce harmful drug use. The fundamental precept of the ABA report is, "Unless we make a commitment to treat, we will never solve the drug problem, regardless of the number of persons we arrest, convict, or confine" (p. 24). However, the report ignores the actual treatment landscape in the United States and assessments of current treatment efficacy. In fact, particularly with widespread alcohol treatment, there is almost no variety in treatment options, and the least effective treatments, such as compulsory AA, dominate almost entirely (Miller, Brown, Simpson, et al., 1995).
Similarly, while touting greater prevention efforts, the report notes that "statistics indicate that junior high and high school students, in particular, are not paying attention to messages about the consequences of substance abuse" (p. 25). This is not accidental, since the standard programs--which emphasize negative results of drug use-- have been found to be totally ineffective and often counterproductive (Bangert-Drowns, 1988; Ennett, Rosenbaum, Flewelling, et al., 1994). But even if effective treatment/prevention programs exist and are utilized, it is an additional questionable assumption to believe that enough people who would otherwise abuse drugs can be processed by such programs--and that the impact of the programs is robust enough to withstand post-treatment factors--to affect drug problems at a national level (Peele, 1991b).
- Individuals are not able to choose whether or not to take drugs or to regulate their drug use. This is the external view of drug abuse--that it "happens" to people without their choosing it. Drug use is presented first as being both incredibly alluring and pleasurable, so that children and others cannot resist it without constant support and instruction (if drugs cannot be entirely eliminated through interdiction), and second as being maintained by the involuntary motivations of addiction. By accepting this assumption, the ABA must devise policy after policy to prevent people from taking the drugs they want. The alternative assumption is that people will take drugs if they want to and that the best approach is to limit the potential dangers of this use--i.e., harm reduction.
- Coercing people into treatment is justified and effective. The ABA endorses combining "treatment and coercion efforts," so that "hard core drug users who are in the criminal justice system should be required to quit their drug use" (p. 24). This entails even greater efforts than are already in place to force people into treatment within the legal system and to offer treatment in place of usual criminal sanctions. Whether or not coercive treatment administered by the legal system is effective is a lively question (Zimmer, 1995). It also shows a fundamental disregard for traditional notions of voluntarism psychotherapy, as well as the Constitution. Finally, it holds out endless possibilities for gaming by criminals seeking to avoid jail time (Belenko, 1995).
- There is an end to the drug war. Presumably, the ABA expects its recommendations will eventually reduce drug abuse at its sources, and hence the need for constantly expanding drug services and policing efforts. In other words, the goal of the plan is to enable us to cut back on treatment and school programs, on interdiction and the policing of American cities, on the creation of more institutions to house the growing proportion of the prison population convicted of drug offenses, on drug and alcohol research that dominates social and biological scientific agendas, on political negotiations for greater funds for programs like those the ABA endorses. Is there an end in sight, or are these programs a continuation of the never-ending escalation of the drug war?
Because the ABA and its expert panel are engaged more in a symbolic than a policy declaration, the panel feels no need to explore basic policy considerations in its report. After identifying the problem in the "Rationale" part of each section, the report provides no evidence that its recommendations would have any impact on the problems identified. Furthermore, none of the ABA's recommendations is costed out. Even if we had reason to expect the recommended policies would be effective, how can anyone seriously propose that they could be implemented with no regard for cost? The ABA simply states the costs of current drug and alcohol abuse, and these are the rationale for following their recommendations. Interesting figures the ABA could have presented are the spending on remedying drug abuse over the past decades, a projection of the costs of implementing the ABA's programs, and a projection of how much the United States will be spending on drug abuse in the year 2000 and beyond. Any realistic projection of the ABA's proposed policies will inevitably inflate this last figure exponentially.
The ABA's remarkably shopworn bromides simply express long-standing and hard-to-prove assumptions about drug abuse and its solutions. In what way is it beneficial or useful to public opinion, politicians, or public health officials to broadcast alarmist statistics and rote demands for expanded treatment, which is already so widely accepted as a panacea? Presumably, the ABA feels it can gain public relations points by telling people what they already believe, and by boldly labelling this "New Directions." Yet policy alternatives that might directly impact all the problems identified by the ABA--those that normalize users of illicit drugs so that they can work, receive nonemergency treatments, and potentially outgrow drug abuse and addiction, along with reducing or eradicating illicit drug trade and resulting street crime--were not even discussed in the ABA report (Nadelmann et al., 1994). Policy options such as decriminalization and harm reduction (including needle exchange and provision of health services for street drug users) would represent actual new directions in U.S. drug policy.
Much evidence suggests that U.S. drug policies are wrong-headed and ineffective, or at least nonoptimal, not the least of which is the constant need to escalate these same failed policies. Clearly, some evaluation of alternative policies to accomplish desired goals is in order. Two alternatives to the dominant models of drug policy are fairly well recognized in the United States. One--the libertarian model--is put forward by a well-heeled ideological minority. This model, while politically extreme, can nonetheless call on strong strands in American thought--such as self-reliance and free-market capitalism--for support. The other--the social welfare model--has wide acceptance and has been dominant politically in the recent past. Today, although it has lost its cache and is often presented by political opponents as antediluvian, the social welfare model nonetheless gathers enough support to be present in every policy discussion of drugs and related issues.
Table 1 reviews the major dimensions of the libertarian and the social welfare models. The models contrast not only with the disease and law enforcement models, but also with each other:
- Causality. While the disease model of addiction claims that personal choice has little or nothing to do with continued drug use, the libertarian model regards personal choice as the only explanation for drug use. In this view--as expressed, for example, by Thomas Szasz (1974)--addiction is an unnecessary construct that does not improve our understanding, explanation, or prediction of drug use. The social welfare model, on the other hand, identifies social deprivations as the source of addiction. It counteracts a genetic model of addiction, which must rely on inbred sources as the explanation for epidemiologic differences in susceptibility such as the greater prevalence of intensive drug use in inner cities.
- Responsibility. The libertarian model holds the individual strictly accountable for drug use and antisocial behavior while using drugs. The social welfare model emphasizes the social forces that foster drug abuse and addiction.
- Primary modalities. The libertarian model allows people to choose to use drugs or not on an open-market basis, the logical extension of which is the policy of legalizing all drugs (Szasz, 1992). The social welfare model believes that the key to curing addiction is to create a fulfilling society through social welfare policies, like those designed to enhance the addict's educational, employment, and family resources.
- Treatment. The libertarian model views treatment in free-market terms as a service to be provided as required by market demand. The social welfare model, on the other hand, views treatment as an essential service. It is the most programmatic provider of treatment services, maintaining that the state should provide as much treatment as addicts want whenever they demand it. On the other hand, the social welfare goes beyond the disease model in its view of the panoply of treatment services--including healthcare, job opportunities, skills training, and economic supports. This model of reducing addiction through enhancing potential addicts' environments is more of a social prevention than a treatment model.
While the libertarian model may be gaining ground, it is still a distinctly minority--even radical--point of view. And while the social welfare model is still very apparent in American thought, it is clearly losing ground in a conservative political environment and a declining economy. The factors that limit the acceptance of each include:
- Extremist social positions. Most Americans are too steeped in current drug assumptions to even consider libertarian views of a free market for prescription and illicit drugs. They are furthermore uncomfortable with the libertarian Darwinian social model that would allow the addicted simply to fall by the wayside if they won't stop using drugs. On the other hand, Americans do not seem in a mood to tolerate expanding social welfare services at a time when economic boundaries for Americans in general are contracting.
- Effectiveness. In the view of a clear majority of Americans, the social welfare model has been tried and found wanting. After a period beginning in the 1960s of greatly expanded services to underprivileged sectors of society, large segments of these sectors--perhaps expanding in number and deepening in their despondency--remain unable to engage in mainstream society.
In place of the synthesis of the disease and law enforcement models that dominates current American policy, let us contemplate a synthesis of the best points of the libertarian and social welfare policies (see Tables 1 & 2). The libertarian and the social welfare models appear to be opposite politically (indeed, the social welfare model has similarities to the disease model). But the two models have in common more empirically sound assumptions than the law enforcement and disease models, as well as relying on sound values. The social welfare model makes clear the factors--in the form of personal history, current environment, availability of constructive alternatives--that are the major determinants of the individual's likelihood of abusing drugs (Peele, 1985).
The libertarian model correctly identifies the critical role of personal responsibility in drug use, even in extreme cases of addiction (Peele, 1987). In this way, it maintains the valuable assumption of personal causality for addiction (and along with it personal efficacy) by noting that continued drug use is a personal choice and by demanding personal responsibility for misbehavior. It is significantly different from the law enforcement model in these areas, however, in that it does not contradict itself by simultaneously endorsing the strict exposure model of addiction. Moreover, it is nonmoralistic in that it does not assume drug use per se is harmful (Peele, 1990b).
While personal responsibility and motivation are crucial in this synthesized model, social forces are obviously critical to the maintenance or discontinuation of addiction. Together, these characteristics determine the nature of treatment in a combined libertarian/social welfare model. In this synthesis, treatment is part of a panoply of supportive resources, the first goal of which is to maintain all citizens' lives and health, the second to capitalize on addicts' desires to reform if and when they desire and feel capable of change. This outlook influences social, prevention, and treatment policy so that skills training, economic assistance, and healthcare for addicts are included as part of the general social welfare and health systems.
At the same time, the social welfare--and particularly the libertarian--models prefer voluntary choice of treatment. Few people would select the most expensive and repetitive forms of intensive addiction treatment, which would be downplayed as only an extreme resort that is too expensive and limited in its benefits to be justified as the main response to substance abuse. This attacks the mainspring of the disease model. Addiction treatment would also be eliminated for those users of illicit drugs who do not display signs of distress other than that they are engaged in an illegal activity. This is the primary impetus for the law enforcement model. Eliminating the right of the state and other institutions to demand the individual undergo treatment for simply using a disapproved substance implies some form of decriminalization of use of currently illicit drugs.
To practice harm reduction relative to drugs implies (1) acceptance of non-harmful drug use, and (2) continued use of drugs, even by the addicted, with the goal of providing healthcare, clean needles, and other services to intravenous and dependent drug users (Nadelmann et al., 1994). In other words, harm reduction suggests--and begins the path towards--legalization or at least decriminalization of drug use. How do harm reduction and drug legalization play within the four basic models?
- Disease/law enforcement model. The law enforcement and the exposure version of the disease model are obviously opposed to legalization, since they assume any legitimizing of drugs and potential greater use will translate into addiction. The individual susceptibility disease model, on the other hand, would suggest that--since only a preselected minority will become addicted--that no increase in addiction would result from legalization, greater availability, and even greater use. However, harm reduction approaches in the case of alcoholism--which is generally assumed to be genetic in American treatment circles--are completely verboten (Peele, 1995). In this, the U.S. is almost alone among Western nations.
Moreover, while often claiming there is a genetic basis for alcohol dependence, U.S. alcohol education works on a seemingly very different model. For example, all children are warned against drinking on the grounds that it leads to the disease of alcoholism (Peele, 1993). Typically, the only speakers on alcoholism allowed into U.S. schools are members of AA. In fact, the disease model as popularly practiced--while claiming a medical basis--is in fact the old moral model dressed in sheep's clothing (or a doctor's white jacket--see Marlatt, 1983). Likewise, a disease model that purports concern for the individual drug user is so preoccupied with abstinence that it cannot bend to accept harm reduction, as exemplified by needle exchange programs (Lurie et al., 1993; Peele, 1995).
- Libertarian/social welfare model. The libertarian model provides a fundamental philosophical underpinning for legalizing drugs (Szasz, 1992). Libertarians maintain that the government cannot deprive individuals of personal and private activity which does not interfere with the lives of others. The social welfare model is less clear about legalizing drugs. However, harm reduction as an expression of humane and nonjudgmental concern for individual drug users is central to the social welfare philosophy. Indeed, it is this acceptance of legalization and/or harm reduction and the need to change drug policy that most distinguishes these models from the disease/law enforcement synthesis.
The message from the previous sections is that it is impossible to discredit drug myths, since even information that refutes them is interpreted in their support. Two of New York's most prominent medical examiners regularly testified against the diagnosis of drug overdose (see Brecher, 1972, pp. 107-109), and yet New York City is just as likely as ever to resort to this diagnosis--and the New York Times to trumpet the diagnosis and its readers to accept it. Clearly heroin overdose will not disappear from usage. There is a cultural need for the concept, just as there is a need for the "man with the golden arm" stereotype of the heroin addict.
Given the popularity of stereotypes about drugs and treatment, we need to market alternative assumptions in order to create sounder drug policies. Many of the assumptions that underlie the libertarian and social welfare models and conflict with the disease and law enforcement models are not only saner and more accurate, but appeal to fundamental American values. Focussing the discussion of drug policy around these superior assumptions and values offers the best possibility for reversing misguided drug policy in the United States today. A marketing plan for better drug policies should hit the following notes:
- Traditional civil liberties. The readiness of proponents of the disease/law enforcement model to intervene in citizens' lives--whether claiming the benign need to overcome denial or protect Americans from their appetites or the punitive goal of punishing people--is directly opposed to fundamental American civil liberties. Some of the images that can be marketed to show the incompatibility of current drug policy with traditional civil liberties include: (a) raids on purchasers of gardening paraphernalia; (b) drug testing, which seemingly violates in the most basic way the Constitutional prohibition of unreasonable searches; (c) forfeiture of property not only by drug users but by those who own property on which drugs are found; (d) police raids gone wrong, like the one in Boston during which an African-American minister suffered a heart attack and died (Greenhouse, 1994); (e) the 1984ish "Big Brother/government image, which seemingly arouses so much suspicion and resentment in America today.
- Humaneness. Americans pride themselves on their humanity and their willingness to help the needy. The inhumanity of American drug policy thus has strong marketing possibilities. These include: (a) the denial of marijuana as a popular anti-nausea chemotherapy adjunct (see Treaster, 1991), (b) the medical benefits of marijuana (or THC) in glaucoma treatment, (c) the willingness of antidrug advocates and public officials to in effect sentence many drug users to death through the increased likelihood of AIDS in the absence of needle-exchange programs, to which America is singularly opposed among Western nations (Lurie et al., 1993).
- Effectiveness/cost. Beginning in the late 1980s, insurers largely decided that substance abuse treatment was not cost-effective (Peele, 1991a; Peele & Brodsky, 1994). Although in most cases this resulted simply in providing less intensive versions of the same therapies previously practiced in hospitals, many people continue to doubt the efficacy of standard disease- and hospital-based drug and alcohol treatment. Images of this ineffectiveness include: (a) prominent failures of treatment in cases such as that of Kitty Dukakis, (b) the revolving door for most of those in public treatment programs and many in private treatment, (c) the costly implications of filling American jails with drug law offenders, (d) the gargantuan overall costs of the disease/law enforcement system at a time when governmental and health costs are overwhelming U.S. public policy.
- Justice. Americans are offended by unfairness in our legal and social system. Examples of these drug injustices include: (a) murderers in some prominent cases have received less time than some drug users, (b) the imprisoning of drug users who lead otherwise lawful and unexceptional existences, (c) the violation of the right to self-determination, which has become a popular conservative theme--even though in most cases the most virulent anti-drug voices are from the Conservative Right.
Useless and wildly expensive drug policies could continue unabated for years. But the possibility for epochal change in other areas of American life offers real opportunity for change in drug policy. Nonetheless, even as our healthcare, political, and economic systems evolve around us, such change can only occur if it is presented in terms of traditional American precepts.
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