As expected, they found that illicit dealers were most often victimized and in response mobilized the law least often and retaliated most often. But unexpectedly, the fully licit cafe´ operators reported roughly double the instances of victimization as semi-licit coffee shop operators, and neither mobilized the law nor retaliated often. In the following discussion, I add a few points to the overview of these findings to suggest possible future research.That caf´es selling alcohol experienced more crime than coffee shops selling cannabis would not shock American police. Pharmacology matters, as Jacques et al. suggest, albeit always mediated by culture. At the macro level, there is a well-known correlation between drinking and crime, although it varies significantly across cultures , and different cultures have specific repertoires of intoxication .Culture matters, too, in the micro sense; the normative architecture of the settings of drinking or drug use interact with user expectation sets to affect behavior under the influence.Dutch caf´es, like American bars, tend to be spaces of spirited disinhibition; Dutch coffee shops tend to aspire to a more contemplative ethos, disinhibition in a mellow tone. Future research might usefully extend Jacques et al.’s work by varying pharmacology , type of setting , and culture .The flip side of prohibition creating “zones of statelessness” where law is unavailable is that decriminalization can expand the regulatory capacity of the state. This happened in the Netherlands as its cannabis policy evolved from informal toleration of “house dealers” inside some clubs into formally licensed coffee shops and into subsequent refinements that gave officials greater control, for example, tightening license requirements, raising the minimum age for purchase, and banning advertising . As more U.S. states and other nations legalize cannabis, some are concerned that greater availability could cause greater abuse . The Dutch experience does not support this hypothesis, but instead it supports the counterintuitive argument that legalization can provide more, rather than less, social control. Street dealers generally do not check IDs,cannabis drying racks but as Jacques et al. suggest, Dutch coffee shop operators do because their licenses and incomes are contingent on following the rules. In the United States, by contrast, criminalized cannabis is easier for many high-school students to obtain than tobacco, alcohol, or prescription drugs, which are legal but regulated .
Criminologists well understand that criminalization can amplify inequality. In describing their interviewees, Jacques et al. report that although two thirds of their coffee shop and caf´e operators are White, three fourths of their street dealers are Black, the latter also more often immigrants who reported lower levels of education and a higher frequency of criminal records. Rational choice theory suggests that if criminalization laws are designed to make illicit drug selling as dangerous as possible to deter would-be dealers, we should not be surprised when those who enter that line of work are more desperate. Choices are always made under the constraints of context. Although the Netherlands has substantially less inequality than the United States , immigrants and ethnic minorities there still have fewer licit opportunities. The hypothesis would follow that the marginalized are more likely to find their way into the illicit crevices created by prohibition, where there is often lower cost of entry, higher income, and greater autonomy and dignity than in the legal economy. Moreover, in the United States, well-documented patterns of racially discriminatory drug law enforcement have made minor drug arrests a key gateway to mass incarceration, with all the negative consequences that flow from that. More research is needed to see whether this is the case in other comparable democracies. Future studies would perform a great service if they investigated the degree to which prohibition laws function as an adjunct mechanism of marginalization in other societies. If they do not, it would be even more important to learn how this tendency was avoided.Jacques et al. observe that Dutch decriminalization of cannabis does “not appear to have increased cannabis use by natives.” Indeed, in 2009, the latest year for which national data are available, 25.7% of the Dutch population reported lifetime prevalence of cannabis use, whereas 7% reported last-year prevalence . In the United States, by contrast, where roughly 700,000 citizens are arrested for marijuana possession each year, the latest data available show that 44.2% of the population reported lifetime prevalence of cannabis use, whereas 13.2% reported last-year prevalence . It is worth noting, too, that despite hundreds of coffee shops and decades of claims about cannabis serving as a “gateway” to harder drugs, the Netherlands has lower prevalence of other illicit drug use than the United States and many other European societies.
The Dutch evidence runs counter to the foundational claim of cannabis criminalization; prevalence data indicate that availability is not destiny after all. Although governments committed to criminalization are unlikely to fund such studies, much more research is needed on the relationship between drug policy and drug use prevalence and problems .Jacques et al. rightly argue that the “best way to adjudicate competing claims about the consequences of drug law reform is to conduct research in the settings where the reforms have taken hold.” Their argument centers on the effects of decriminalization on crime and violence in illicit markets. Their findings can be read as mixed. Future researchers will likely generate new findings that support, complicate, and qualify those reported here, showing variation across time, space, cultures, and the complex conjunctures of conditions that shape drug use patterns. But in one sense, the key policy significance of Jacques et al.’s study is simply that it was conducted at all because its core question rests on a consequentialist conceptualization of drug policy: that drug policies must be evaluated on the basis of their actual consequences, not on their intent. Dutch drug policy has opened to empirical examination what has until recently too often remained unquestioned drug war orthodoxy. The Dutch case is complicated, and there is no guarantee that their model could simply be exported to other nations with the same relatively benign results. But the Netherlands provides as good a window as we have on what an alternative drug policy future may look like. As cannabis becomes legalized in more places, its commercialization may yet cause the sky to fall. But the evidence to date, both from the Netherlands and U.S. states, suggests no need to duck for cover just yet. Jacques et al. note that reducing crime and violence in illicit drug markets is not the only objective of Dutch drug policy nor, I would add, the most important. The “other objectives” their study does not directly address include avoiding or reducing the harms of stigma, marginalization, and other negative consequences of criminal punishment . Two odd metaphors catch at the difference between Dutch and U.S. drug policy in this regard. President Lyndon Johnson once famously said of FBI Director J. Edgar Hoover, “better to have him inside the tent pissing out than outside the tent pissing in.” For a century, the United States has pursued drug policies designed to deter use by stigmatizing, punishing,hydroponic cannabis system and ostracizing users. In effect we push them out of the societal tent and then are perplexed when they cause problems, so we pass tougher laws, and so on . Since 1976, drug policy in the Netherlands has been designed to keep illicit drug users inside the societal tent. Compared with the United States, the Netherlands has a stronger welfare state, more social housing, national health care, and greater accessibility of treatment, which result in less poverty, homelessness, addiction, and crime .
In thinking about U.S. drug policy, my Dutch colleagues often use “a stopped-up sink” metaphor: “Americans keep feverishly mopping the floor, but the faucet is still running.” The day I was finishing this article, two stories appeared simultaneously in the New York Times . The first was about an extraordinary letter to UN Secretary General Ban Ki-moon on the eve of the UN General Assembly Special Session on Drugs. The letter urged an end to the war on drugs as a failed public health policy and a human rights disaster. It attracted more than 1,000 signatures, including those of former UN Secretary General Kofifi Anan; former President Jimmy Carter; Hillary Clinton; senators Bernie Sanders, Elizabeth Warren, and Cory Booker; legendary business leaders like Warren Buffett, George Soros, and Richard Branson; former presidents of Switzerland, Brazil, Ireland, and ten other former heads of state; former Federal Reserve Chair Paul Volcker; hundreds of legislators and cabinet ministers from around the world; Nobel Prize winners; university professors; and numerous celebrities. All attendees at the Special Session were given copies of the letter. The UN ordered all copies confiscated . The second article provided vivid testimony as to why such a letter was necessary: The U.S. Supreme Court refused to hear the appeal of a 75-year-old disabled veteran serving a mandatory sentence of life without parole for growing two pounds of cannabis for his own medical use, a fact uncontested by the prosecutor . Such grave injustices have allowed the Drug Policy Alliance and a growing number of other nongovernmental organizations to mount a drug policy reform movement of unprecedented scale. Stopping the drug war and the mass incarceration it helped spawn has become a top priority for the civil rights movement, from the NAACP to Black Lives Matter. Voters in the United States and elsewhere are slowly taking matters into their own hands. Medical marijuana laws have been passed in 24 states, and cannabis has been legalized under state law in Colorado, Washington, Alaska, Oregon, and Washington, DC. Voters in California, Arizona, Massachusetts, and perhaps other states are set to vote on cannabis legalization initiatives in November 2016. Most European countries have embraced at least some harm reduction policies. Portugal, Uruguay, Australia, the Czech Republic, Italy, Germany, and Switzerland have moved toward decriminalization of cannabis in one form or another. Former drug war allies across Latin America are in revolt against U.S.-style prohibition. These are the sounds of the American drug war consensus collapsing. Global drug policy is at an historic inflection point, and it is trending Dutch.ICU patients frequently receive opioid and benzodiazepine medications to treat the pain, anxiety, and agitation experienced during a critical illness. Trauma ICU patients may require high and/or prolonged doses of opioids to manage pain associated with multiple open wounds, fractures, painful procedures, and/or surgery. They may also require benzodiazepines to prevent or manage anxiety and agitation and to facilitate effective mechanical ventilation . Although the effect of different pain and sedative medication regimens on TICU patients is unclear, prior evidence suggests that administration of opioid and benzodiazepine medications in the ICU setting is associated with the development of many complications including delirium and poor patient outcomes . Exposure to high or prolonged use of opioids and benzodiazepines may also contribute to both drug tolerance and drugphysical dependence . Once drug dependence has developed, patients are then at risk for withdrawal syndrome , a group of serious physical and psychologic symptoms that occur upon the abrupt discontinuation of these medications .Unlike in the PICU patient population, physical dependence during drug weaning of adult ICU patients exposed to prolonged doses of opioids and benzodiazepines has received little study. Indeed, there is a large discrepancy in the amount of literature regarding WS in the adult versus PICU populations. There are two descriptive studies with retrospective chart review designs and small samples in adult ICU surgical-trauma patients and burn ICU MV patients . Cammarano et al found that 32% of their sample developed WS after prolonged exposure to high doses of analgesics and sedatives. Brown et al found that all burn MV patients who received opioids and benzodiazepines for more than 7 days developed WS. In a prospective experimental study of major abdominal and cardiothoracic postsurgical ICU patients, 35% who received a combination of opioids and benzodiazepines developed marked withdrawal compared with 28% who received a combination of opioids and propofol . These three studies were reported more than 1 decade ago, prior to the current recommended change in sedative management . A recent prospective study of 54 TICU patients showed a lower occurrence of iatrogenic opioid WS than in previous studies .