Even putting aside the questionable pharmacological and moral aspects of this differential policy, there is no evidence whatsoever for its effectiveness in controlling crime. Caulkins and colleagues show that conventional sentencing is significantly more cost effective. Although the crack mandatory sentences were trimmed somewhat in 2007, and the Supreme Court recently acted to restore some judicial discretion in these cases . Whether these changes will translate into a closing of the large racial differential remains to be seen. The optimal level of drug law enforcement is surely well above zero, but just as surely, well below current levels . Caulkins and Reuter argue that we could reduce the drug prisoner population by half without harmful consequences; they note that this would still leave us with system “a lot tougher than the Reagan administration ever was.” Kleiman suggests tactics for getting more mileage out of less punishment through the use of small, quick sanctions, strategically deployed. In 2005, there were about 1.8 million people in substance abuse treatment in the US, about 40 percent for alcohol, 17 percent for the opiates, 14 percent for cocaine, and 16 percent for marijuana . There are certainly many thousands of people who need treatment and are not receiving it. Whether expanding the available treatment capacity would bring them in is an open question. We should be wary of assuming that a purely “public health” approach to drugs can work; the police and courts play a crucial role in bringing people into treatment – increasingly so with the expansion of drug courts and initiatives like California’s Proposition 36, the 2001 law which permits treatment in lieu of incarceration for those convicted for the first or second time for nonviolent drug possession . For most primary drugs of abuse, criminal justice referrals are a major basis for treatment: in 2005, 57 percent of marijuana treatment, 49 percent of methamphetamine,indoor hydroponics cannabis and 27 percent of smoked cocaine. But 36 percent of clients in alcohol treatment were referred by the criminal justice system, so legal status may not be the crucial lever.
In a sophisticated cost-effectiveness analysis, Rydell and Everingham estimate that the U.S. could reduce cocaine consumption by 1 percent by investing $34 million in additional treatment funds, considerably cheaper than achieving the same outcome with domestic drug law enforcement , interdiction , or source country controls . But because treatment effects are usually estimated using pre-post change scores that are vulnerable to two potential biases . First, the post treatment reduction could reflect a simple “regression to the mean” in which an unusually extreme period of binge use would be followed by a return to the user’s more typical levels, even in the absence of treatment. Second, treatment pre- and post tests are vulnerable to selection biases because clients who enter and remain in treatment until post-treatment measurement are a non-random and perhaps very unrepresentative sample of all users. Regression artifacts would inflate treatment estimates; selection biases could either inflate or deflate the estimates. We believe that the full weight of the evidence makes it clear that treatment is both effective and cost-effective, but until these problems are better addressed, we cannot be sure that the benefits of expanded treatment would be as large as Rydell and Everingham implied. Even its most passionate advocates recognize that treatment’s benefits are often fleeting. About three quarters of heroin clients and half of cocaine clients have had one or more prior treatment episodes . Forty to sixty percent of all clients will eventually relapse, though relapse rates are at least as high for hypertension and asthma treatment . Importantly, Rydell and Everingham recognized that treatment can provide considerable health and public safety benefits even if it only reduces drug use while the client is enrolled. Held up to a standard of pure prevalence reduction , treatment is unimpressive. But by the standards of quantity reduction and harm reduction, treatment looks pretty good. American providers – steeped in the Twelve Step tradition – recoil at the phrase “harm reduction” – but it is a service that they can and often do perform quite well. Perhaps the most socially beneficial treatment modality is one that some are reluctant to view as treatment at all – methadone maintenance for heroin addicts. In 2006, there were 254,049 people receiving methadone, only about 20 to 25 percent of all opiate addicts in the US .
The gap is partly due to spotty service provision outside major cities, but in even urban centers, many addicts won’t voluntarily seek out methadone, preferring heroin even with its attendant risks. But Switzerland, the Netherlands, and Germany have amassed an impressive body of evidence that hard-core addicts significantly improve their health and reduce their criminality when they are able to obtain heroin directly from government clinics . Similar ideas were rejected in the US several decades ago, but perhaps it is time for a second look . In the US, the dominant form of prevention takes place in the classroom, generally administered by teachers . Ironically, prevention is the least well funded but most thoroughly tested drug intervention. Drug prevention has very modest effects on drug and alcohol use; e.g., the mean effect size in the most recent comprehensive meta-analysis was about 1/20th of a standard deviation . Considering that 1/5th of a standard deviation is usually considered the benchmark “small” effect size, this is not very encouraging. Making matters worse, the single most popular program, Drug Abuse Resistance Education , accounts for nearly a third of all school prevention programs , but numerous studies show it has little or no detectable effect on drug use . It is not clear whether its ineffectiveness stems from its curriculum or from its reliance on classroom visits by police officers. But classroom based prevention is quite inexpensive, so it doesn’t have to be very effective to be cost-effective. Caulkins and colleagues estimate over $800 in social benefits from an average student’s participation, for a cost of only $150. Most of the benefits involve tobacco prevention, then cocaine, and only minimally marijuana. Classroom-based prevention materials can’t be effective if the messages aren’t salient in real-world settings where drug taking opportunities occur. But a well-funded campaign of magazine, radio, and television ads by the Office of National Drug Control Policyc appears to have had no positive impact on levels of use . We should be wary of thinking we have evaluated “the impact of mass media”; it may just be that the messages we’ve been using aren’t very helpful. Note that our prevention messages are almost exclusively aimed at prevalence reduction rather than quantity reduction or harm reduction .
A greater emphasis on secondary prevention and harm reduction might have real payoffs with respect to social costs,pots for cannabis plants but we won’t know unless we try . Evidence from classroom sex education is instructive in this regard; programs that teach safe sex are reliably more effective at reducing risky behavior than are abstinence-based programs . We can hazard some guesses about where American drug policy might head in the future. The medical marijuana movement is likely to diminish in visibility as sprays like Sativex reduce the role of marijuana buyers’ clubs, yet adult support for marijuana legalization will continue to increase as the tumultuous “generation gap” of the 1960s becomes a distant memory. Methamphetamine will soon peak, if it hasn’t already , leaving us to deal with a costly aging cohort of addicts, much like our earlier heroin epidemic. And vaccines against nicotine and cocaine addiction may soon hit the market, with both desirable and unintended consequences . But rather than developing the case supporting these speculations, we close with two trends that are already well underway, each of which has the potential to seriously subvert current cultural assumptions about drugs and drug control. The conventional wisdom is that ecstasy is a “love drug” or “empathogen,” and that it is the drug of choice for European and Asian American college students and young professionals. But there are many reports of increased ecstasy use by minorities living in several cities . Many observers have noted its prevalence in the “hyphy” movement and the associated rap music . There is evidence of an increase in the number of references to ecstasy use in hip-hop music starting in 1996 . The reported rise in ecstasy use in the hip-hop scene has ignited alarming claims that ecstasy is “the new crack” ; a CBS television story asked whether Ecstasy was a “hug drug or thug drug” . In fact, researchers have only begun to examine the diffusion of ecstasy into inner-city neighborhoods . There is laboratory evidence of heightened aggression in the week following MDMA ingestion , but in a 2001 study of arrestees, ecstasy use was not associated with race, and negatively associated with arrest for violent crimes . It is also unclear whether self reported “ecstasy” use always involves MDMA, as opposed to closely related drugs like methamphetamine . Thus the emerging “thizzle” scene does raise intriguing questions about psychopharmacology, culture, and their intersection, but whether there is any meaningful causal connection between Ecstasy, race, and crime is far from certain. Earlier, we offered a thought experiment about a hypothetical drug called Rhapsadol. We now ask the reader to consider a newly created synthetic stimulant, “Quikaine.” Quikaine targets the neural system by increasing the speed of ion transfer between synaptic gaps. Thus, it reduces reaction time and increases the speed with which physical tasks can be accomplished.Neither does it affect intellectual functioning. Second, consider “Intellimine.” Its sole impact on the human body is to improve cognitive capacity; it has no other emotional or physical impact, and no lingering effect on mental functioning once the drug leaves the system. In addition, because variants of this drug have been used for decades to help with ADHD/ADD and Alzheimer’s it has a long and empirically sound safety record. In fact, children and the elderly receive maximum benefit of the drug. How should we regulate these drugs? Should they be legally available for purchase by adults? If not, are there more limited circumstances in which their use might acceptable? For example, would Quikane’s use be warranted by those charged with protecting others from danger, such as certain military operatives or police officers? What about for completing tasks faster and more safely, such as on an assembly line? How about for simply reducing the amount of time spent on household chores? Should we allow surgeons, crisis managers, and other high-stakes problem solvers to take Intellimine? These drugs are hypothetical, but new synthetics already have some of their properties, and there is every reason to expect rapid advances in the development of performance enhancers in the near future . They will raise vexing questions about personhood, agency, freedom, and virtue. For centuries, we have associated psychoactive substances with the pursuit of purely personal goals: fun, seduction, escape, transcendence, ecstasy. New drugs like Intellimine and Quikane will force us to come to grips with a radically new framing: Drug use as a tool for enhanced economic competitiveness. Parents who now worry about how marijuana might jeopardize their children’s Ivy League prospects may soon worry about whether abstinence lowers SAT scores. Employers who now screen urine for marijuana may come to view abstainers as slackers. It will be fascinating to see how we learn to reconcile these new pressures with our traditional attitudes toward drugs. We close with a brief list of topics that are sorely in need of research attention. Rather than a long wish list, we confine our attention to priorities that are implied by our analytical framework; specifically, the argument that quantity reduction and harm reduction deserve a more equal footing with prevalence reduction. The first priority is to give far greater attention to the development of quantity and harm indicators in epidemiological research. Our national drug surveys devote far more attention to prevalence than to dosage, settings of use, or consequences of use, and the reliance on household and classroom populations over represents casual users and under represents the heaviest users .