Book Review

Drug Policy and Substance Abuse

Confronting Drug Policy: Illicit Drugs in a Free Society

N Engl J Med 1994; 331:748-749September 15, 1994

Article

Confronting Drug Policy: Illicit Drugs in a Free Society
Edited by Ronald Bayer and Gerald M. Oppenheimer. 369 pp. New York, Cambridge University Press, 1993. $59.95. ISBN: 0-521-44115-3

A few months ago in the Journal, Lester Grinspoon and James Bakalar argued that our drug policies “require a war of annihilation against a wrongly chosen enemy” (“The War on Drugs -- A Peace Proposal.” 1994;330:357-60). Confronting Drug Policy, a collection of essays most of which were first published in the Milbank Quarterly, attempts to address this proposition and asks whether our drug policies themselves are the problem. This book critically examines the data on the use and regulation of psychoactive substances, including the history of regulation in international law and its roots in alcohol prohibition; the social, demographic, and epidemiologic features of drug use in the United States; linkages between drug abuse and violence; and most recently, the central place drugs have assumed in public health because of the AIDS epidemic. Specific chapters tell us that moral judgments and laws about drugs differ widely from country to country and change over time. For example, from 1920 through 1933, alcohol was prohibited in the United States but marijuana was legal. Other legal drugs, such as tobacco and alcohol, command huge global markets and cause enormous harm.

The book's subtitle, “Illicit Drugs in a Free Society,” reflects the political tensions that infuse the debate. A growing chorus in favor of decriminalization now includes a former secretary of state, elected politicians, Nobel prize-winning economists, federal judges, and police chiefs -- as well as a new class of drug-policy academics, some of whom argue that the illicit status of a drug may actually increase its risks and accelerate its spread.

A chapter by Harry Levine and Craig Reinarman (both sociologists) examines the lessons of the prohibition of alcohol, our earlier “great experiment” in drug policy. It was claimed at the time that Prohibition was needed because alcohol was “so addicting and dangerous . . . that it could never be regulated.” But 60 years later, we do regulate alcohol (and tobacco), and more effectively each year, judging from declining rates of death in alcohol-related auto accidents. Levine and Reinarman suggest that “most if not all psychoactive substances could be similarly regulated.” Twelve major scientific commissions on drug-policy reform (in the United States, Great Britain, and Canada) have recommended regulatory alternatives to drug prohibition, but all have been ignored.

For Ronald Bayer, a health policy analyst, the “irreducible level of uncertainty about the potential consequences of legalization” may explain some of the stasis. The current policy debate, Bayer believes, “has shattered . . . the dead weight of tradition that for more than a decade served to close off the possibility of critical inquiry.” But U.S. Surgeon General M. Joycelyn Elders might disagree. Having suggested earlier this year that we should discuss “drug legalization,” she was pilloried in the press and reprimanded by the White House.

The Harrison Act of 1914, historian Gerald Oppenheimer points out, restricted the use of opiates and cocaine to “legitimate medical purposes.” This was interpreted to preclude their use by physicians for treating those already dependent on these substances. Abstinence was considered the only legitimate goal of treatment. By contrast, the British Rolleston Committee in 1926 recognized that patients seldom achieved abstinence and upheld the right (and humane responsibility) of physicians to prescribe drugs -- a cornerstone of what would come to be known as the British system. But in the America of the 1920s, the few courageous physicians who followed this approach were hounded from practice. Only with methadone maintenance, almost 50 years later, did American medicine once again consider substitution treatment.

Treatment, of course, is only part of the picture. The sociologist Charles Winick presents evidence that “some people can regularly use [illicit] drugs without harming themselves or inflicting losses on others.” Most who try them soon stop, and among those who continue, recent studies suggest, “controlled use” may be the norm, even for cocaine and heroin.

As other countries deal with the same sort of drug problem we have faced for decades, new approaches are emerging. Harm reduction (the most prominent of these) is a largely European invention that neither legalizes drugs nor denies people's basic rights just because they use drugs; for example, the Dutch Ministry of Health speaks of “Dutch citizens who use drugs.” Harm reduction involves public health strategies that seek to limit the damage done by drugs by means of more accessible user-friendly services, needle exchanges, and new drug-maintenance approaches. The Swiss authorities, for example, have initiated several pilot programs in which injectable opiates are dispensed, and many Dutch and English physicians prescribe maintenance drugs in their general practices. Perhaps it is time, therefore, not only to “confront” our drug policies, as this book suggests, but also to reconsider our public health practices.

Ernest Drucker, Ph.D.
Montefiore Medical Center, Bronx, NY 10467