Correspondence
The War on Drugs
N Engl J Med 1994; 331:126-129July 14, 1994
- Article
To the Editor:
Kleber (Feb. 3 issue)1 refers to an explosion of use by young people of “crack” cocaine in the 1980s and implies that it was due to a dramatic drop in price and to increased availability. Clearly, any use of crack among younger people is reason for grave concern. Nonetheless, it would be difficult to find epidemiologic evidence that the use of crack “exploded” among the young after its price dropped and its availability increased. Fortunately, the prevalence of crack use has remained low among children and adolescents, relative to that of other drugs. According to the National Household Survey on Drug Abuse,2 the lifetime prevalence of crack use among 12-to-17-year-olds has remained close to 1 percent since crack use was first assessed by this survey in 1988. Only one third of all cocaine users and 1/25 of all illicit-drug users in this age group have ever used crack2. Ethnographic studies of urban black youth have found that crack use is rare in this group3. Furthermore, contrary to early fears that crack might even precede the use of marijuana and legal drugs in the pathway to problematic use, crack use among high-school students is limited to a few who have already used a number of other drugs: in a representative sample of 12th-graders in New York State, Kandel and Yamaguchi found that only 7.9 percent of male and 4.9 percent of female crack users began using crack before they experimented with legal drugs and marijuana4. Finally, people in their late 20s and early 30s are much more likely to be crack users than are adolescents2.
In the light of this evidence, crack may not be the example that Kleber intends, of a drug whose use proliferates among the young after its price drops and its availability increases. Instead, it may be useful to investigate the relatively rare use of crack in this age group as a possible source of clues to the prevention of other drug epidemics. The low prevalence of crack use among the young in the face of increased availability represents an unanswered research question. Perhaps, as Kleber argues, stringent prohibitions and increased penalties are responsible. However, this is only one of many competing theories, and for the time being, the available evidence does not allow us to select one position over another.
4 ReferencesHoward D. Chilcoat, Sc.D.
National Institutes of Health, Baltimore, MD 212241
Kleber HD . Our current approach to drug abuse -- progress, problems, proposals. N Engl J Med 1994;330:361-365
Full Text | Web of Science | Medline2
Department of Health and Human Services. Preliminary estimates from the 1992 National Household Survey on Drug Abuse. SAMHSA Office of Applied Studies. Advance report no. 3. Washington, D.C.: Department of Health and Human Services, June 1993.
3
Hamid A . The developmental cycle of a drug epidemic: the cocaine smoking epidemic of 1981-1991. J Psychoactive Drugs 1992;24:337-348
Web of Science | Medline4
Kandel D ,Yamaguchi K . From beer to crack: developmental patterns of drug involvement. Am J Public Health 1993;83:851-855
CrossRef | Web of Science | Medline
To the Editor:
Grinspoon and Bakalar (Feb. 3 issue)1 cite Oregon and the Netherlands as paragons of peace in the war on drugs. But in the 1980s, after the decriminalization of marijuana, the rate of drug abuse among teenagers in Oregon was nearly twice the national average2. The rate of use of cannabis among teenagers in the Netherlands is currently more than 20 times higher than the decade-old figure cited by Grinspoon and Bakalar3.
The authors' support of the use of marijuana for medical purposes is scientifically unfounded. There is no evidence that marijuana is superior to ondansetron (Zofran), dexamethasone, or synthetic tetrahydrocannabinol (Marinol) as an antiemetic in patients undergoing chemotherapy. Nor is there scientific evidence to support the use of marijuana for AIDS-associated anorexia, depression, epilepsy, narrow-angle glaucoma, or spasticity associated with multiple sclerosis. As a crude drug, moreover, marijuana has been shown to produce undesirable mental changes, disturbances in coordination, giddiness, and hypotension in at least 25 percent of novice users, especially elderly persons4.
Grinspoon and Bakalar also overlook the relation between drug abuse and other forms of substance abuse. The use of illicit drugs is universally associated with tobacco use, alcohol abuse, and binge drinking. Equally important, this “peace proposal” fails to acknowledge the relations among drug abuse, conditions such as human immunodeficiency virus (HIV) infection, and myriad social problems, ranging from child abuse to homicide. If the authors advocate the decriminalization of drugs, would they also oppose stricter controls on handguns? The two positions are not inconsistent.
4 ReferencesRichard H. Schwartz, M.D.
Fairfax Hospital for Children, Falls Church, VA 220461
Grinspoon L ,Bakalar JB . The war on drugs -- a peace proposal. N Engl J Med 1994;330:357-360
Full Text | Web of Science | Medline2
Office of Alcohol and Drug Programs. Oregon public school survey. Salem: Oregon Department of Human Resources, 1993.
3
Gunning KF. Crime rate and drug use in Holland. Rotterdam, the Netherlands: Dutch National Committee on Drug Prevention, September 22, 1993.
4
Schwartz RH, Beveridge RA. Marijuana as an antiemetic drug: how useful is it today? J Addict Dis (in press).
To the Editor:
Dr. Kleber argues that we must continue to rely on the criminal-justice system to deal with the public health problem of drug use. He does not speculate on how many more million people we will have to imprison, or why other countries such as the Netherlands and England have managed their drug problems better, without relying on massive imprisonment. He fears that millions of people who do not now use drugs that are already widely available would suddenly become powerless addicts if drugs were more readily available, and thus he espouses a cynical view of human beings as needing police to protect them from their urge to use drugs with almost magical powers to corrupt “anyone.” This is a philosophical bias, however, not a scientific fact.
Not only have guns and threats of punishment failed to deter millions of drug users, but they may also be a powerful incentive to continued use. Although the public health message about drugs emphasizes concern for the health and safety of the user, the criminal-justice emphasis stresses submission to a punitive authority. Is it any wonder, then, that our war on drugs has failed most miserably among minorities for whom submission to an often hostile authority is unacceptable? The sheer brutality of the drug war on addicts, the paramilitary and occasionally murderous assaults on the homes of (often innocent) citizens, the terrorizing of young children exposed to such assaults on their homes and parents, and these children's loss of their parents as a result of our policies of incarceration are all apparently to be tolerated for years to come as somehow being in someone's best interest.
The drug war has caused a massive shift of resources from local public health programs to criminal-justice efforts at a time when the public health system has been under extraordinary pressure to deal with the HIV, hepatitis, and tuberculosis epidemics and when millions have lost insurance and must rely on public health resources. The goals of fighting the drug war and protecting the public health are increasingly coming into conflict.
John J. McCarthy, M.D.
Bi-Valley Medical Clinic, Sacramento, CA 95816To the Editor:
Marijuana cannot be characterized as “a remarkably safe substance.”1 Its active ingredient, tetrahydrocannabinol, may have some therapeutic value as an antiemetic but has not been generally accepted thus far, because there are other, more useful, such drugs and because its other applications are far from established.
Because my special concern is the use of marijuana by children and adolescents, I must point out that the effects of this drug make it especially hazardous to the young. First, it has a measurable effect on visual perception and motor coordination, thus impairing driving ability2. Second, it produces other perceptual distortions that impair the user's sense of reality3,4. This effect is very seductive to the adolescent who is struggling to come to terms with some of the more difficult aspects of growing up. Third, and most dangerous, precisely because of its antiemetic properties, when used together with alcohol (a not uncommon indulgence), marijuana can render users immune from the nauseating effects of alcohol, thereby enabling them to consume a potentially lethal amount of that life-threatening drug.
There are no convincing data to support the claim that marijuana users are abjuring alcohol or the reverse. The experimenters and the confirmed users are patrons of both drugs. Unfortunately, the experimenters are often the youngest, the most naive, and the least self-observant, hence the most at risk for untoward reactions5.
5 ReferencesDoris H. Milman, M.D.
Children's Medical Center of Brooklyn, Brooklyn, NY 11203-20981
Grinspoon L ,Bakalar JB . The war on drugs -- a peace proposal. N Engl J Med 1994;330:357-360
Full Text | Web of Science | Medline2
Braff DL ,Silverton MA ,Saccuzzo DP ,Janowsky DS . Impaired speed of visual information processing in marijuana intoxication. Am J Psychiatry 1981;138:613-617
Web of Science | Medline3
Klonoff H ,Low M ,Marcus A . Neuropsychological effects of marijuana. Can Med Assoc J 1973;108:150-156
Web of Science | Medline4
Mellinger GD ,Somers RH ,Davidson ST ,Manheimer DI . The amotivational syndrome and the college student. Ann N Y Acad Sci 1976;282:37-55
CrossRef | Web of Science | Medline5
Milman DH . Marijuana -- twenty years later. Am Acad Pediatr Adolesc Newsl 1983;3:16-19
To the Editor:
Sweeping statements such as “As everyone knows, prohibition of drugs . . . enriches gangsters, while promoting burglary, theft, and violence in the streets”1 ignore the fact that these activities are largely a result of drug use rather than of efforts to enforce laws against drugs2. Recent evidence that violent crime has risen steadily in the Netherlands since decriminalization is a further indication of the link between crime and drugs3. Grinspoon and Bakalar further assert, “Drug testing is . . . dangerously unreliable.”1 In fact, drug testing and safeguarding of individual rights have vastly improved over the past 5 to 10 years4. We also understand better the pitfalls of testing and the most appropriate applications.
How can any well-informed physician or attorney suggest, as these authors do, that a switch in high-school drug use from alcohol to marijuana is a “desirable trade”? Both drugs are responsible for serious health problems, especially in young people5.
The fact that a recent poll focusing on national drug use demonstrated a startling increase, from 21.9 percent to 26 percent, in the number of high-school seniors using marijuana in the past year6 further suggests that lobbying by adherents of the drug culture is succeeding. This also proves that our national medical and social leadership against drugs must be strengthened.
An effective national strategy against drugs should combine strong law enforcement, broad treatment on demand, and efforts at prevention on all levels. It is time for the public to reject the lobbying efforts of the drug culture and its attempts to provide misinformation and mixed messages.
6 ReferencesEric A. Voth, M.D.
International Drug Strategy Institute, Topeka, KS 666061
Grinspoon L ,Bakalar JB . The war on drugs -- a peace proposal. N Engl J Med 1994;330:357-360
Full Text | Web of Science | Medline2
Drugs, crime, and the justice system: a national report from the Bureau of Justice Statistics. Washington, D.C.: Department of Justice, 1992:5.
3
Scripps-Howard News Service. Tolerant drug laws changing in the Netherlands. December 11, 1993.
4
Evans DG. Drug testing: law, technology, and practice. Deerfield, Ill.: C.B.C. Press, October 1993.
5
Committee on Drug Abuse 6
Johnston LT. Annual household survey of drug use. Ann Arbor: University of Michigan, February 1993.
To the Editor:
The practical alternative to the legalization of drugs is a consistent policy of discouraging the use of both legal and illegal drugs -- not only marijuana, cocaine, and heroin but also alcohol and tobacco. Such a policy is not compatible with the proposals of Grinspoon and Bakalar, who would encourage the wider use of currently illicit drugs by removing social pressures against their use and removing law-enforcement efforts to curb their supply, among other permissive steps.
Data collected by the federal government make clear why removing the prohibition against illegal drugs is bad public health policy. Prohibition reduces the use of the two most widely used such drugs, marijuana and cocaine, as compared with the use of alcohol and cigarettes, the two drugs legal for use by adults (Table 1Table 1
Drug Use in the United States during Two Periods Six Years Apart.)1. The overall costs to society for alcohol and cigarettes are $86 billion and $65 billion, respectively, as compared with $58 billion for all the illegal drugs combined (including the costs of law enforcement, prison, and interdiction efforts)2,3.Prohibition reduces both use and the total costs imposed by drugs on society. The primary costs to society result from drug use, not from prohibition. Reducing drug use is the appropriate goal of public health policy. When it comes to reducing harm, a rational policy should focus first on alcohol and cigarettes. The just-released National High School Senior Survey showed that in 1993, 51.0 percent of high-school seniors used alcohol in the 30 days before the study and 29.9 percent smoked cigarettes, whereas 15.5 percent smoked marijuana and 1.3 percent used cocaine4. Only when the rates of use of alcohol and cigarettes fall below the rates of use of marijuana and cocaine in the United States will the claim that prohibition does not curb drug use become credible.
4 ReferencesRobert L. DuPont, M.D.
Institute for Behavior and Health, Rockville, MD 208521
Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. National household survey on drug abuse: main findings 1991. Washington, D.C.: Department of Health and Human Services, 1993. (DHHS publication no. (SMA) 93-1980.)
2
Rice DP, Kelman S, Miller LS, Dunmeyer S. The economic costs of alcohol and drug abuse and mental illness: 1985. Washington, D.C.: Government Printing Office, 1990.
3
Gostin LO ,Brandt AM . Criteria for evaluating a ban on the advertisement of cigarettes: balancing public health benefits with constitutional burdens. JAMA 1993;269:904-909
CrossRef | Web of Science | Medline4
Johnston LD, O'Malley PM, Bachman JG. Monitoring the future study (National High School Senior Survey). Ann Arbor: University of Michigan, 1994.
Author/Editor Response
The authors reply:
To the Editor: Limitations of space force us to comment on just a few points. Contrary to Dr. Schwartz's statement, there is evidence that marijuana is useful for medical purposes; for example, Vinciguerra et al. found that 44 of 56 patients undergoing cancer chemotherapy who had no relief from standard antiemetic drugs became free of symptoms after smoking marijuana1. Sadly, the controlled studies on medical cannabis that should have been completed years ago are not available. In their absence, many physicians have overcome widespread prejudice and misinformation through personal experience.
In response to Dr. Schwartz and Dr. Voth, surveys found no widespread increases in marijuana use among adults2 or high-school students3 in the states that moved toward decriminalization in the 1970s. Recent increases in marijuana use in the Netherlands are paralleled in other European countries that maintain prohibition. A 1992 interview survey of residents of Amsterdam found that only 6 percent had used cannabis even once in the past month4. Few Dutch officials, educators, or physicians can be found who favor the recriminalization of marijuana.
Dr. Voth cites a “startling increase” in marijuana use to justify present policies, and Dr. DuPont cites decreased use for the same purpose. Apparently, advocates of prohibition cannot agree on their reasoning. As we pointed out in discussing the prohibition of alcohol, drug use fluctuates for many reasons unrelated to the laws.
In response to Dr. Voth on the issue of drugs and violence: the 1992 report of the National Institute of Justice specifically identified drug buying and selling as the source of most drug-related violence and stated that “evidence of a pharmacologically based drugs-violence relationship is not strong.”5 The attempt to link crime with cannabis use in the Netherlands is misleading, since crime rates are rising all over Europe. There are more murders in the illegal-drug business in New York each year than in all of the Netherlands.
Dr. Voth refers to the “lobbying efforts of the drug culture” (we might with equal plausibility claim that there are “lobbying efforts of the prohibition culture”), and he seems, oddly, to think we are recommending the use of marijuana by high-school students. It is unfortunately necessary to point out repeatedly that the issue is not whose “culture” deserves approval or whether drug use is desirable. It is whether we want to go on criminalizing the everyday behavior of millions of people.
5 ReferencesLester Grinspoon, M.D.
James B. Bakalar, J.D.
Harvard Medical School, Boston, MA 021151
Vinciguerra V ,Moore T ,Brennan E . Inhalation marijuana as an antiemetic for cancer chemotherapy. N Y State J Med 1988;88:525-527
Medline2
Single EW. The impact of marijuana decriminalization. In: Israel Y, Glaser FB, Kalant H, Popham RE, Schmidt W, Smart RG, eds. Research advances in alcohol and drug problems. Vol. 6. New York: Plenum Press, 1981:405-24.
3
Johnston LD, O'Malley PM, Bachman JG. Marijuana decriminalization: the impact on youth 1975-1980. Paper 13 of Monitoring the Future Occasional Paper Series. Ann Arbor: University of Michigan, 1981.
4
Sandwijk JP, Cohen PDA, Musterd S. Licit and illicit drug use in Amsterdam: report of a household survey in 1990 on the prevalence of drug use among the population of 12 years and over. Amsterdam: Universiteit Amsterdam, 1991.
5
Drugs, crime, and the justice system: a national report from the Bureau of Justice Statistics. Washington, D.C.: Department of Justice, 1992.
Author/Editor Response
All surveys of drug use are flawed. The National Household Survey on Drug Abuse, cited by Chilcoat, is clearly inadequate for estimating crack use among minority youth. The Office of National Drug Control Policy estimates that there are 2 million cocaine addicts in the United States,1 whereas the Household Survey would yield fewer than 700,000. Addicted heroin and cocaine users are often not found in traditional households. A more accurate, but still flawed measure of drug use in this population is the Drug Use Forecasting program, which conducts tests in 24 cities of urine samples from persons arrested for a variety of offenses. For males 15 to 20 years old, the program shows high rates of cocaine use, the median being 26 percent2. It is noteworthy that more than half the people in this study whose urine tested positive for cocaine reported that they had never used the drug3.
Chilcoat's statement that crack use is rare among urban black youth is both inaccurate and unsupported by the reference he cites. That reference suggests that such use is far from rare. We agree that crack users do not usually begin with crack and that people in their late 20s are more likely to use it than adolescents.
Dr. McCarthy ignores my urging of a substantial shift in resources from supply-side activities to treatment, prevention, and research and presents no evidence on how eliminating the role of law enforcement would improve matters. England -- far from doing better, according to my recent Home Office visit -- has more than 150,000 heroin addicts (with a population one fifth of ours), a major problem of drug-related crime, less than 20 percent of addicts in treatment, and rising cocaine use. The Dutch are increasingly intolerant of their approach to drug use and are proposing, for example, mandatory treatment of addicts4. Illegal drug use is higher among minorities, not because “submission to an often hostile authority is unacceptable,” but for the same reasons that the legal use of alcohol and tobacco is also higher -- namely, the greater prevalence of poverty, racism, and fewer social opportunities. The nexus of AIDS, tuberculosis, and drug abuse suggests that one of the best ways to prevent their spread is adequate treatment and prevention of illicit drug use. If the price of drugs dropped sharply and their availability increased under legalization, the prevalence of these diseases could increase markedly.
Drug policy is never perfect. Legalization, however, is likely to reverse the progress already made, lead to substantial growth in addiction, and make an intolerable social situation harder to turn around. Even the best changes will not solve our problem quickly, but the easy, rapid solution remains a fantasy, unfortunately.
4 ReferencesHerbert D. Kleber, M.D.
Center on Addiction and Substance Abuse, Columbia University, New York, NY 100191
White House. National drug control strategy: reclaiming our communities from drugs and violence. Washington, D.C.: Government Printing Office, 1994:25.
2
National Institute of Justice. Drug use forecasting: 1992 annual report: drugs and crime in America's cities. Washington, D.C.: Department of Justice, 1993.
3
Golub A, Johnson B. A recent decline in cocaine use among youthful arrestees in Manhattan. Presented at the American Society of Criminology's Annual Meeting, October 1993. Am J Public Health (in press).
4
Goldsmith C. Netherlands' soft policy on drugs may harden as public complains about junkie criminals. Wall Street Journal. March 11, 1994.
