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This Article Was Originally Published in the Respected Scientific Journal "New Scientist" Date noted below:

Magazine section: Features

The highs & lows of prohibition: As drug-related crime soars, so calls to legalise drugs become more vociferous. But what would that do to the cost of healthcare?

New Scientist vol 143 issue 1945 - 01 October 94, page 38

ONCE upon a time it was possible to caricature opponents of drug laws as reformed acidheads from the generation that went to Woodstock. No longer. These days their ranks include free-marketeers with power haircuts and (in Europe at least) a handful of senior police officers. It's an unlikely alliance that has yet to produce anything like a consensus on the degree to which prohibition should be relaxed. But that's not surprising, given the complexity of the questions that must be asked.

Here's a sample. Should drugs of abuse be sold on the high street, or made available only to registered "addicts" at clinics? If legal trading of some recreational drugs is sanctioned, who should police it? Where would you draw the line, between cannabis and amphetamines, between amphetamines and heroin, between heroin and crack cocaine? Would legalising only "soft" drugs intensify the black market and crime related to illegal harder drugs? Or would legalisation of any of these drugs inevitably lead to a free-for-all attitude and a sharp rise in consumption? If so, would the medical costs of treating more addicts be a price worth paying for reducing crime?

There are almost as many opinions as there are researchers and policy makers. But through the fog of debate shines one glaringly obvious fact: pumping money into law enforcement hasn't made the social problem of drug addiction go away - and it probably never will.

Policy makers know this. War-on-drugs slogans might still rain down from political soapboxes, but in government think-tanks the battle is slowly turning into an exercise in damage limitation. The slogan that really matters these days is decidedly prosaic: "harm reduction through treatment and prevention". Reducing the health hazards (and costs) of drug abuse and cutting the umbilical cord that ties it to crime are the priorities now.

"We need to emphasise that treatment and prevention are much more effective than interdiction," says Richard Clayton, director of the Center for Prevention Research at the University of Kentucky. In August came encouraging news from a Californian study of the economic effectiveness of treating addictions. The report estimated that for every $1 invested in a range of treatment programmes, $7 were saved in the long run from reduced health bills and crime rates.

But couldn't such savings be multiplied and added to by decriminalising drug abuse? Researchers and policy makers find themselves caught between a rock and a hard place. Clayton sums up the dilemma: "From a public health perspective, I am opposed to legalisation. From a law-enforcement perspective, I am deeply concerned that we are putting people in gaol and that we have the highest incarceration rate in the world."

Opponents of decriminalisation would like to think that current approaches to harm reduction will in the end produce the desired control over drug abuse. But will they?

The supposed jewel in the harm-reduction crown is methadone maintenance. For heroin junkies, shooting up three time a day and searching for illicit supplies - as well as the means of paying for them - is undeniably time- consuming and dangerous. On paper, the option of clean, free, state- administered methadone looks far more attractive. But in reality, methadone programmes may only ever scratch the surface. For every registered heroin user in Britain, there are between five and ten others who prefer the high prices and danger associated with the black market to any of the treatments offered by the state.

"Anne" is one of them. A heroin addict in her early 40s, she is married with a four-year-old daughter and manages to hold down a demanding professional job - but only because for the past ten years she has disciplined herself never to take more than a quarter of a gram of heroin a day (a modest dose). And even then her lifestyle hangs in the balance. Twenty-four hours is as long as she can function without a fix. Not wanting to jeopardise her career, she has not registered her addiction.

Nor will thousands of other heroin addicts as long as drug abuse remains, in effect, a criminal activity, argue pro-legalisers. Policy makers, they say, have allowed themselves to be caught like frightened rabbits between two incompatible approaches. Medicine dreams of controlling drug abuse like a chronic disease, while the law criminalises it. Both are desperate attempts to keep the "menace" of drug abuse at arm's length.

Or so say advocates for change. Their opponents, of course, equate legalisation with more consumption, more addicts and runaway health bills. It costs about £900 a year to treat an opiate addict in Britain. And the cheaper and more available a drug is, the more people use it, right?

Monkey model

With monkeys and lab rats this simple equation usually holds true. Consumption of a drug rises or falls in proportion to how easy or difficult the drug is to obtain (see Diagram). But with humans things are a little more complex. Legalisation would certainly make drugs much more affordable. "The street price of an expensive drug is of the order of 35 times the price that the NHS pays," says Richard Stevenson, an economist at the University of Liverpool and an outspoken advocate of legalisation. And, yes, if the history of alcohol prohibition in the US is anything to go by, that could mean more consumption.

The standard line on Prohibition is that it was a miserable failure that sent respect for the law plummeting and crime rates soaring. Yet in the narrowest of medical terms it could, just about, be described as a success: between 1916 and 1932 in the US the incidence of cirrhosis of the liverdropped dramatically (see Diagram) (This is not to say that some individuals didn't suffer or die as a result of imbibing "bathtub gin" and other bootleg concoctions.) Most historians of substance abuse estimate that per capita consumption of alcohol fell by between 30 and 50 per cent during Prohibition.

But the links between alcohol availability, consumption and liver disease are not always so straightforward. Take the case of Britain in the 1980s. While overall consumption of alcohol in the population as a whole changed very little, affordability and deaths from liver disease increased quite substantially (see Diagram) It doesn't seem to make much sense. Surely you'd expect the number of deaths to follow the same trend as consumption? That's true, but only if the drinking habits of hard-core alcoholics most at risk of liver disease followed the same pattern as those of the rest of the population. Perhaps they simply drank more and more as alcohol became more affordable.

The truth is unclear, but the example at least highlights a key question. Can we ever predict the health costs of legalising drugs without making a distinction between casual users and the seriously addicted, between "users" and "abusers"? At the moment, the distinction is largely ignored by policy makers. "This is partly because of political pressures, and partly because in our surveys we cannot get agreement on what use and abuse really mean," says Clayton. Few policy makers would be keen to run with the notion that some people can use heroin or cocaine casually, without being on a slippery slope to hell.

Outwardly, of course, the difference between a casual user and an addict is often blurred. Addicts may cling to the idea that they are still in control. In the words of one 50-year-old woman who drank a couple of bottles of whisky a day for years before seeking help: "I could take it or leave it - I just preferred to take it."

Yet some believe it is possible to draw a crude line. Clayton, for example, estimates that in the US about 10 per cent of alcohol users consume about 70 per cent of traded alcohol, while some 15 per cent of cocaine users consume about 65 per cent of traded cocaine and about 11 per cent of marijuana users consume about 70 per cent of traded marijuana. "These small percentages I would regard as abusers," he says - the people most likely to be selling drugs and the ones most likely to end up in emergency rooms. "Most drug users are not of much danger to themselves, or to anybody else."

But this is controversial territory. "Talking about use and abuse is conceptually unsound," says Griffith Edwards, of the National Addiction Centre at the Institute of Psychiatry in London. "One is dealing with continuities." He says it is a mistake to assume that the heaviest consumers of drugs are responsible for the bulk of the health and social costs. In the case of alcohol, cirrhosis is only one problem: what about heart disease, violence and traffic accidents?

Calculating the heaith costs of legalising drugs is difficult for another reason: making one drug more freely available may influence consumption of other drugs. One fear about legalising marijuana is that it would increase demand for harder drugs. But this doesn't seem to have happened in the Netherlands, where cannabis has been decriminalised, or tolerated, in Amsterdam's coffee shops since 1980. Reliable figures are hard to come by, but no studies have yet reported an increase in overall consumption of marijuana. Nor has there been a marked increase in heroin addiction. Indeed, at 0.14 per cent, the proportion of the population that uses drugs in the Netherlands is lower than in Britain, Germany, Denmark and Italy.

Pro-legalisers say that legalising soft drugs could even help to reduce consumption of hard drugs. In Britain at the moment, says Russell Newcombe, who studies trends in drug abuse for local governments, "we have the worst possible situation - teenagers buying cannabis from people who also sell heroin and crack". It might also help in other ways. Tell a 14-year-old that the joint he's smoking makes him a criminal, and what does that do to his respect for other aspects of the law? Especially when his parents can drink and smoke cigarettes, arguably causing more damage to their health, with impunity.

But this doesn't tell us where we should draw the line. Should we stop at soft drugs? Should we legalise possession, trade, or both? Stevenson, for one, believes it would be counterproductive to legalise some drugs and not other, because "criminals would concentrate their marketing efforts on the others and their price would go up". He is also convinced that unless both the supply and the possession of drugs are legalised, the black market will continue to flourish. Others see complications in legalising even soft drugs. How would we regulate trade in marijuana, asks Clayton? "The government in the US has not been able, at the federal, state or local level, to even regulate effectively alcohol or cigarettes."

Dark conclusion

One answer would be for the police to turn a blind eye to all possession of drugs. But that could create its own problems. As William Vodra, a lawyer who worked for the US Drug Enforcement Administration in the early 1970s, explains: "If you tolerate hypocrisy, then it's not inappropriate to have a law on the books and turn a blind eye to those who break it, but that cannot be good for public policy." Besides, law enforcers are simply much better at prosecuting users than dealers. Of the 47 616 drug offences recorded by Britain's Home Office in 1991, less than 3000 were for drug trafficking. The most common offence, accounting for more than 38 000 cases, was the unlawful possession of cannabis.

In the end, the legalisation debate is about much more than cold economics. It is about deciding whether it is morally right to take steps that would probably expose more people to drugs of abuse. The fact that cheaper drugs could mean more addicts leads some to a dark conclusion - namely, that legalisation would result in a minority of people being consigned, with the blessing of the state, to addictive misery so that the majority can reap the benefits of a less crime ridden society.

But what if a good part of the misery stems from the very illegality of illicit drugs? The main problem faced by heroin addicts like Anne, who cannot or will not quit, is the exhorbitantly high cost of their illicit drugs. For them, legalisation could be seen as compassionate. Moreover, it's plain to everyone that the harm caused by exposure to drugs depends on the social and economic circumstances of the user. Job opportunities, housing and education all help us to handle drugs better. Improving these is probably the best form of harm reduction there is.

Losing the battle

OVER the past decade, the US government has spent $53 billion enforcing drugs laws, locking up 260 000 people in federal prisons in the process. And for what? In inner cities, crack and heroin use stubbornly refuses to shrink from what experts describe as "saturation levels", while in some American prisons, drugs offenders account for more than half the inmates.

In 1984, 42 per cent of people arrested in Manhattan also tested positive for cocaine. By 1986, the figure was more than 80 per cent. Prostitution rates among female drug users in the US have been put at between 30 and 70 per cent.

Meanwhile, health costs continue to spiral as emergency rooms in American hospitals attempt to deal with an increasing number of overdose cases. The number of cocaine-related emergencies rose from 5000 in 1981 to 120 000 in 1992. "The purity of those drugs is up, and the price is down," says Richard Clayton, director of the Center for Prevention Research at the University of Kentucky. "That would suggest that there is a larger supply."

Bad news, too, from classroom surveys in the US - LSD, speed and cannabis are all marching back into American teen culture. After more than a decade of apparent decline, the number of student users of these drugs began to climb again in 1992 (see Diagram)

The story is similar in Britain. In inner city areas more kids than ever before are speeding, tripping and getting stoned, and the proverbial cigarette behind the bike shed is fast becoming a line of coke. One in three children aged 14 and 60 per cent of 17-year-olds have taken an illegal drug at least once, says Russell Newcombe, a sociologist who studies drug abuse in British towns and cities, drawing on classroom surveys, police and medical records and long nights questioning kids at raves and clubs.

Newcombe also reports an upward trend in "polysubstance abuse". In the 1960s and 1970s, heads might have stuck to acid, junkies to heroin and adrenalin surfers to speed. But not any more. These days a teenager might kick off the evening with a joint at home, sink a couple of pints at the local pub, then show up at a rave for a tab of ecstasy. Winding down in the early hours might involve smoking heroin.

True, the crack epidemic which many feared would sweep through Europe like a hurricane in the early 1990s has yet to fully materialise. But there is little room for complacency. Judging from the growing numbers of police seizures, cautions and convictions, consumption is slowly rising. "Many drug users who five years ago said they would never touch crack are now addicted," says Newcombe.

And heroin consumption is also on the increase. For most of the 1980s, the number of new addicts notified to the Home Office each year stood at about 5000. Now the figure is 9000, and the heroin being sold on the streets is purer - and more potent - than it has been for years (see Diagram)

Law enforcers, by contrast, are barely holding their own. "In cities like Liverpool and Manchester, the police can't deal with the problem," says Newcombe. "At best, they're managing to arrest 2 per cent of pushers on the streets."

The costs are plain to see. In 1993, almost £2 billion worth of drug- related theft - about £114 per household - was committed in Britain, according to a survey carried out for the Labour Party. Britain spends twice as much on enforcement - about £340 million annually - as on prevention and treatment. As many as 1 in 14 prisoners in England and Wales last year were in for drugs offences.