The Facts About Drug Abuse
The Drug Abuse Council, 1980
Final Report Of The Drug Abuse Council
IN 1972 Dealing with Drug Abuse: A Report to the Ford Foundation concluded that the national drug policies at that time were not effective and were not likely to eliminate or even greatly affect "drug abuse." That report, describing the complex nature of psychoactive drug use and misuse, identified flaws in programs and laws which had been designed to reduce the harm to individuals and society of the indiscriminate, nonmedical use of psychoactive drugs. Public policy was found to be unrealistic and unresponsive to cultural, social, psychological, and economic factors underlying the widespread use of drugs.
The report to the Ford Foundation was issued at the end of a decade of increasing drug use and increasing concern about such use. Drugs seemed to be everywhere; a generation of young Americans had been urged to "turn on, tune in, and drop out" with a wide variety of mood-altering drugs. The United States was described as a nation of "pill poppers. " Deeply held public fears were heightened as city after city reported heroin addiction of epidemic proportions. From suburban neighborhoods, long considered secure and stable, came reports of heroin experimentation by high school students from middle- and upper-income families. Thousands of American soldiers in Vietnam were said to be addicted to heroin. New words and phrases-"pot," "downers," "uppers," drug "trips"-became part of the popular vocabulary.
In 1972 it was estimated that between three- and six-hundred thousand Americans-the vast majority of whom were said to be inner-city blacks and Hispanics-were addicted to heroin. Nearly 25 million Americans were reported to have tried marijuana and 10 million were said to use it regularly. Millions of others regularly used stimulants, depressants, hallucinogens, and tranquilizers for non-medical purposes. However, alcohol and nicotine continued to be the most widely used and misused drugs illicit drugs-marijuana, heroin, and cocaine in particular-were singled out for attention, yet the misuse of legally available drugs was often ignored. While various methods or approaches for "solving the drug problem" were presented, confusion prevailed. Drug issues, particularly that of the relationship between drug use and crime, were constantly publicized and politicized. Many Americans thought the increase in street crime during the late 1960s resulted largely from illicit drug use and therefore responded enthusiastically to calls for a war on drugs to keep illicit drugs and their users apart. Heroin was labelled "Public Enemy Number One." New "get tough" laws were proposed, and many were enacted. Hundreds of millions of dollars were appropriated for programs to stiffen law enforcement, improve public education, and expand treatment efforts.
At the height of public concern in 1972, Dealing with Drug Abuse urged caution and restraint. It called for a climate of reason which would permit identification of the real risks of drug misuse and rejection of policies and programs based on misinformation and sensationalism. It pointed out that drug use and drug problems were not new but have persisted throughout history, not only in the United States but in many other countries, cultures, and societies as well. It noted that knowledge about the causes of drug misuse was inadequate, as was knowledge about its -grevention and treatment. Moreover, the report revealed much of what was then accepted as fact to be erroneous, out of date, or misleading.
The authors of Dealing with Drug Abuse, the sponsoring private organizations which funded the Drug Abuse Council, and, subsequently, the council's board of directors perceived a pressing need for independent analyses of public drug policies and programs. They felt that lawmakers and public officials, particularly in the federal government, were reacting to drug-related problems from a limited, crisis-oriented perspective when a longer-range view was necessary, and that the effectiveness of law enforcement and treatment strategies was often overstated by public officials, which led to unrealistic expectations of rapid and sweeping solutions. Thus these individuals and groups agreed to sponsor an independent organization capable of providing the public with a less emotional, more apolitical perspective. As a result the Drug Abuse Council was established in early 1972.
As of this writing, the Drug Abuse Council has been in existence for nearly seven years. During this time the council has, through staff-directed projects, research grants, and contracts, assessed many aspects of the use and misuse of psychoactive drugs.2 This work has been undertaken with the unhampered view and resources of a national, independent, nonprofit, nongovernmental organization.
The council has had resources sufficient to examine drug-related issues in depth and over time. It began by analyzing the assumptions underlying public perceptions and policies. It examined the accepted knowledge of the interaction of chemical substances with the human body and mind. It studied various aspects of contemporary society to identify socioeconomic and cultural factors relating to drug use and misuse. The council has reviewed and assessed laws, programs, and projects-federal, state, and local; governmental and private-which have been adopted in response to psychoactive drug use and misuse.
In pursuit of its efforts to learn more about drug use and misuse, the council gathered information from public officials, scientists, historians, and law enforcement and treatment program personnel. It canvassed widely and deeply the experiences and views of current and former drug users, of minority groups and individuals, and of other informed or concerned persons.
The council has periodically published its findings on many aspects of drugs and has sought to bring about changes in policies and programs it considers unsound. Through these activities, it has sought to provide leadership in the private sector.
When operations began in 1972, a five-year period of activity was planned. In the fifth year, the board of directors decided to continue some of the council's functions for an additional two years. Now, as this seven year period comes to an end, we feel a responsibility to share our major observations, findings, and suggestions for the future in the form of a final report.
This final report consists of two major sections: first, the report of the directors of the Drug Abuse Council; and second, six chapters on various drug policy topics prepared by the council's staff and consultants. While not every judgment or suggestion advanced in these staff report chapters is specifically endorsed by the council's board of directors, they do form the analytic base from which the board drew its observations, conclusions, and recommendations.
The Report of the Directors
As this report developed, it became increasingly clear that the most valuable document we could provide would be one addressed to the concerned citizen, not just to the professional in the drug field. We stepped back from the day-to-day concerns of those who work in research, treatment, prevention, and law enforcement to begin to address the broader philosophical, social, moral, legal, and pragmatic issues influencing national drug policies and the expenditure of public funds. Thus readers of this report will find few recommendations about the particulars of program efforts in treatment, prevention, or enforcement. We do not mean by this to suggest that there are no improvements that can be made in program operations; there are in fact many. We have, however, chosen to focus our discussion instead on the public policies and attitudes from which these program efforts stem. We believe that substantial benefits can come only as a result of a significant rethinking of our approach to drugs, not from tinkering with the mechanisms of our public program response.
This report is a conscious effort to stimulate public interest in drug policy issues and to promote greater public understanding of them. By indicating the costs and benefits of past and present efforts, we can begin to formulate and accept principles with which more reasonable and effective alternative approaches to drug misuse can be constructed. We have no blueprint for a step-by-step solution to the nation's -problems with drugs; in our opinion it would be a mistake for anyone to think such a plan could be devised, given present knowledge. It would, however, be equally erroneous to think that nothing can be done to improve the current situation.
Since the creation of the Drug Abuse Council in 1972, what is often termed "the American drug scene" has changed in several ways. As a general observation, more Americans appear to be using more psychoactive substances. Drug use and misuse have become among the most compelling realities of contemporary existence. Among legally available drugs, alcohol has increased in the number of its users, particularly among younger people. Among illicit drugs, marijuana has steadily increased in use, as has cocaine more recently. Although recent research has provided evidence of substantial numbers of occasional, nonaddicted heroin users, federal officials report that heroin addiction has declined over the past two to three years.
Greater changes can be observed in the nation's response to drug use and misuse in terms of changes in laws and publicly supported programs. In some respects, the situation has improved. Given the magnitude of federal expenditures on drug treatment programs and law enforcement efforts-estimated to be nearly $6 billion since 1971-some improvements should be demonstrable. For example, the passage of the Drug Abuse Office and Treatment Act of 1972 has led to the creation of a nationwide network of drug treatment programs, chiefly for heroin dependence. As a result, treatment for those dependent on heroin is now more readily available. The federal National Institute on Drug Abuse reports that between 1971 and 1978 hundreds of thousands of individuals have received treatment in about two thousand federally funded clinics throughout the country. However, many more have not voluntarily sought treatment.
Another area of improvement over the past few years is in basic research, work which has broadened understanding of the addictive process and the biochemistry of the brain and central nervous system. More questions remain unanswered than have been answered, but recent progress is encouraging.
Perhaps the most significant change may be the decline in the emotional fervor that once dominated public discussion of drugs. Public concern is still intense; nonetheless, there is wider public acknowledgment that simple, quick solutions to our drug problems will not be forthcoming. As a result, public expectations are more moderated development that may encourage more realistic law enforcement and control objectives.
While we consider these to be changes for the better, the basic situation remains: Despite progress in a number of areas, more Americans use and misuse more psychoactive drugs than ever. Since in our considered judgment this situation will prevail at least through the next few years, it is necessary for us as a nation to plan carefully and thoughtfully how to handle it most responsibly. This planning requires a basic rethinking of national goals, policies, and strategies regarding the use and misuse of psychoactive drugs. The underlying social dynamics and problems that lead to drug misuse are so exceedingly complex as to as yet elude totally satisfactory solutions; the rational course, then, is to begin with what has been learned from history, particularly from the experience of the past several years.
The council has several general observations that we regard as of central importance to this process of rethinking, but before submitting them, we emphasize again that we have no step-by-step blueprint for solving the nation's drug problems. We can, however, indicate where past experience and current analysis should direct us, and we can begin to strive toward more consistent, coherent, and responsible approaches to drug use and misuse in the future. The following observations are, in our view, central to this process.
1. Psychoactive substances have been available for use since the beginning of recorded time and will predictably remain so. Man will undoubtedly continue to use such substances for a variety of reasons: to relax, to escape, to enjoy, to worship, to delude, to destroy. At given times in history certain drugs have had greater appeal or easier availability and have consequently been used more widely, but the essential point is that some psychoactive drugs are almost always readily available to enable people to achieve what they wish or need for alteration of mood or mind. As we search for more effective policies and programs, this certainty of drug availability should be at the forefront of our thinking.
2. While the use of psychoactive drugs is pervasive, misuse is much less frequent. A failure to distinguish between the misuse and the use of drugs creates the impression that all use is misuse or "drug abuse." This is particularly true in the case of illicit drugs. For example, while millions of Americans of high-school and college age have experimented with various drugs and many use some of them regularly, clearly the majority exercises personal restraint or obeys social controls in drug-taking behavior. To state this in another way, the number of young Americans who are in serious personal difficulty because of the misuse of drugs is relatively small. However, the frequent depiction of the minority who do misuse drugs, especially illicit ones, as typical conveys the mistaken impression that misuse is pervasive if not inevitable.
3. While not enough is known about why certain individuals misuse drugs, it is known that there is a definite correlation between pervasive societal ills-such as poverty, unemployment, and racial discrimination-and drug misuse. When such conditions predominate-as they do in the inner-city areas of many large American cities-the manifestations of widespread drug misuse and trafficking in illicit drugs can be seen in their most pernicious forms. So long as these adverse social conditions persist, -widespread -drug misuse care be, expected. Drug misuse resulting from such societal conditions aggravates other urban problems, and makes restoring the vitality of our inner cities more difficult to achieve.
4. Attempts to control the availability of drugs often present a conflict between the desires of individuals and the aspirations of society. When harm to both the individual and society is clearly demonstrable, the conflict may be resolved. When harm to either is less clearly demonstrable, it is less easily resolved. This may lead to dissension of considerable magnitude, involving sensitive questions of individual rights and the limits of governmental powers. To state it plainly, the price of an effective strategy for eliminating drug misuse would be perceived by many Americans as too high in terms of the invasion of privacy and the abrogation of individual freedoms. National drug policies must reflect careful balancing of these concerns in order to enjoy substantial public support.
5. Drug-related laws and policies center too often on the drugs themselves and not often enough on the problems of the people misusing them. This leads to preoccupation with and elaboration of the adverse aspects of certain drugs, as if they themselves were somehow culpable. Such thinking can reinforce a focus on eliminating or legalizing the availability of certain drugs as "solutions" to related problems. Drug policies should instead be primarily focused on people and their problems.
6. Too many Americans have unrealistic expectations about what drug laws and programs can accomplish. All too often, these laws and programs are expected to eliminate drug problems. More disturbing, drug laws and programs have been expected to contribute substantially to other social objectives as well, such as reducing crime, increasing employment, or restoring family cohesion. Such expectations place overwhelming and unfair burdens on laws, programs, and those administering them, and make failure and public frustration commonplace. Our drug policies and laws need to be more realistically stated to command public support.
7. Finally, we Americans should resist the temptation to blame our drug problems on others. We have done this too often in the past. Our drug problems are peculiar to our own national experience. They derive from our history and cultural traditions, our mistakes and prejudices, our societal ills and flaws-not those of Turks, Mexicans, Burmese, or Colombians. Certainly, many aspects of drug problems are international in scope, and much can be gained by multinational research and education efforts. At times we must seek the cooperation of other peoples and other countries in order to try to curtail the flow of illicit drugs into this country. However, the chances for success in these cooperative efforts would be enhanced, in our view, if they were undertaken with an acceptance that the most fundamental aspect of American drug problems is the magnitude of demand for drugs and that the problems leading people to misusedrugs will not vanish even if the supply of one or two drugs is eliminated.
It is against the backdrop of these general observations that the council submits its conclusions and recommendations. We repeat, they will not dispose of our drug problems. However, if applied they would, in our view, mitigate much of the harm that comes from present policies and approaches-harm that in the minds of many is damaging in a free society.
As we observed above, Americans tend to overlook the capacity for misuse of licit drugs and overestimate the misuse of illicit drugs. As a consequence, we pursue widely divergent courses, depending upon the legal status of a particular psychoactive substance.
For example, some drugs, such as caffeine, are freely available in a wide variety of forms. Use is frequently promoted and misuse largely unacknowledged. Other drugs, such as nicotine and alcohol, are considered potentially more harmful, but their use is largely controlled by social attitudes and their misuse, though discouraged, is not prohibited. Actions taken under the influence of such drugs that have a potential for injury to others-drunken driving, for instance-are subject to criminal sanctions, although misuse itself is not.
Still other drugs, such as barbiturates, amphetamines, and tranquilizers, have generally recognized legitimate medical uses, yet they also have significant potential for harm if misused. There is growing public awareness of this potential harm, and the availability of these drugs is more carefully controlled, as, for example, by prescription of licensed physicians. Criminal sanctions are employed to discourage diversion from legitimate channels.
Then there are some drugs, such as heroin and marijuana, which are considered to be harmful to individuals and society and without legitimate medical uses. National policy toward these drugs over the past seven years has been a two-pronged effort to control the supply or availability and reduce the demand. Thus, laws are designed to eliminate the availability of these drugs by prohibiting their use, production, or distribution, and criminal sanctions are employed to enforce them. On the demand side, assistance-primarily treatment for heroin addiction through publicly funded clinics-is offered and sometimes mandated for those using these drugs.
Public drug policies are in essence a reflection of prevailing attitudes about psychoactive drugs, and current attitudes are, conversely, strongly influenced by past and present policy. In this manner current policies reflect assumptions and events more than a half century old, despite the fact that many of those assumptions were erroneous or founded in demogoguery. Unfortunately, in the view of the council, drug policies and prevailing public attitudes continue to represent misunderstanding and wishful thinking more than sober analysis. For example, it is still widely believed that by prohibiting the use of a particular drug through the criminal law, that drug can be eliminated from society. Despite sobering experiences to the contrary, it is still hoped that more resources for law enforcement and treatment or more stringent laws will end problems with drugs.
Individuals use and misuse all kinds of licit and illicit drugs for a wide variety of reasons, some with greater potential for harm to themselves and society than others. For example, some drug use is clearly experimental or inquisitive; individuals want to know what a drug will do to them, how it will make them feel and act. Other drug use is recreational; individuals use drugs to relax, to enhance enjoyment of a social situation. Still other drug use is demonstrably harmful and antisocial; individuals use drugs in ways harmful to themselves or society.
As it is now constituted, however, national drug policy does not reflect an adequate appreciation of these very real differences in drug-using behavior-yet at the same time most Americans in their day-to-day experience are at least generally aware of such differences. For example, most are aware of the difference between social drinking and alcoholism. They perceive the difference between taking an occasional tranquilizer and taking tranquilizers compulsively, between taking prescribed narcotics to relieve pain and being addicted to them. Many Americans have begun to recognize the difference between smoking an occasional marijuana cigarette and being constantly "high" on marijuana. To command informed public support, public policies must recognize these differences in the patterns and circumstances of drug use.
Public policy regarding heroin can probably never be the same as policy respecting marijuana or alcohol. These drugs differ pharmacologically, and people generally use them for different reasons and in different situations. However, the principles upon which the control mechanisms of public drug policies are based can and should be consistent. As the public begins to appreciate the differences in drug use patterns and behavior, some changes in attitudes and policy approaches are occurring.
For example, many states have lessened the severity of their laws regarding marijuana possession. The use and misuse of sedatives and tranquilizers are under scrutiny. Responsible national organizations such as the National League of Cities and the U.S. Conference of Mayors have publicly called for new approaches to heroin addition. Others have urged caution in our response to the observed increase in cocaine use, lest an illadvised response make matters worse.
The federal government's attitude about drugs also has been affected. The Ford administration's 1975 White Paper on Drug Abuse, which expressed the federal strategy, differed dramatically in tone from the "war on drugs" approach of the early 1970s. Although the White Paper had little immediate impact, it opened the door for substantial future changes. The Carter administration's appeal for the "decriminalization" of marijuana has provided additional evidence that change is possible.
Because the country does appear to be in a relatively calm mood regarding drugs and a process of rethinking is evident, it is a good time to look to the future. Given the council's belief that in the future there will in all probability be more, not less, use and misuse of psychoactive drugs, it is essential to consider ways in which society may face this situation.
Suggestions for the Future. To state it plainly, the challenge facing America regarding drugs is to determine how best to live with the inevitable availability of psychoactive drugs while mitigating the harmful aspects of their misuse. A case can be made that we are, in fact, learning to do just that.
For example, the latest national survey indicates that two-thirds of American adults regularly use alcohol and some 13 million adult and youthful drinkers are said to be problem drinkers. Currently, federal efforts are increasingly focused on determining the underlying causes of alcohol misuse in the hope of developing more effective preventive and treatment measures. However, despite very deep concerns, there are no serious proposals for a return to Prohibition. The lessons of that experience were well learned-the criminal justice system could not and should not be society's chief agent for controlling alcohol abuse. Instead, attention is now directed at more effective public education and health measures. The public seems to wish to reduce the dangers and risks associated with the misuse of alcohol and yet continue to enjoy the perceived benefits derived from responsible use. While no one argues that we have been successful in eliminating the enormous social costs of alcoholism and alcohol related problems, current policies are largely regarded as both reasonable and responsible.
Similarly, a case can be made that, with nearly 50 million Americans having tried marijuana and 16 million of these reporting current use, the public (on the basis of opinion polls) believes that marijuana use will not decrease markedly over the next few years and that society must adapt to this use in a more reasonable, responsible manner. While this usage, too, is seen by many as a disturbing development, appreciable numbers think that responsible adaptation is possible. To date, eleven state legislatures have removed the threat of criminal arrest and imprisonment for the possession or use of small amounts of marijuana. This development reflects an understanding that severe criminal sanctions against the use of small amounts of marijuana are neither appropriate nor effective. The harm to society associated with the use of small amounts of marijuana is not seen as sufficient to justify the use of criminal sanctions in attempts to control it.
Another case in point is the great increase in public awareness during the past ten to fifteen years of the potential harm of excessive cigarette smoking. Increased awareness has led to new approaches in education and to ordinances and laws imposing civil fines for smoking in designated "no smoking" areas. Yet there have been no serious proposals to jail those who smoke. Since smoking is perceived as at worst a public health problem, not a criminal activity, more effective public education and health measures are seen as the most appropriate policy response.
These changes are encouraging. Perhaps they offer directions for changes in public policy regarding the use of other psychoactive drugs. In developing such new approaches to the use and misuse of these drugs, the nation must first set realistic, consistent goals. In this regard, the primary goal the council urges is that society seek to minimize the harm and dysfunction that can accompany the misuse of any psychoactive substance, whether that drug is currently classified as licit or illicit,
To accept this goal entails accepting factors which up to now have not enjoyed wide acceptance-e.g., the continued use of illicit drugs by many Americans. It also entails accepting that not all illicit drug use is necessarily harmful. Further, it indicates that seeking to minimize harm from drug misuse is not synonymous with seeking to eliminate drug use.
If our goal is to minimize harm and dysfunction, then the target of national efforts should logically be the harm and dysfunction which come from indiscriminate drug use. Such a target calls primarily for education, public health, treatment, and rehabilitation measures. Such measures could be more effective in reducing the misuse of drugs if other drug policies themselves were more reasonable, consistent, and realistic. The experience of decades makes it clear that only in reducing the misuse of drugs is there real hope for effectively reducing drug problems. This is not to say that society should sanction the unbridled use of psychoactive drugs. To the contrary, public policy should make clear society's strong disapproval of the misuse of such drugs. This disapproval will be more persuasive if it is expressed in terms of concern for individual health and well-being.
This is also not to say that the nation should immediately abandon all domestic and international law enforcement efforts aimed at reducing the availability of illicit drugs. Though by no means are all drug law enforcement and control efforts effective, it would be highly inaccurate to say that they have produced no benefits. While many of these benefits (e.g., reduction in the availability of particular drugs) have proved temporary in the past, even such temporary gains are welcome developments. To the extent that law enforcement efforts curtail the supply of illicit drugs in a responsible manner, they should be continued.
The problems with drug law enforcement are complicated. Americans have historically overemphasized drug law enforcement and control measures and, at least until recently, underemphasized policies aimed at reducing the misuse of drugs. In so doing we have paid enormous costs in both dollars and other, less quantifiable ways, such as increased burdens on the criminal justice system, corruption, and decreased respect for law and those enforcing it. All too often these law enforcement efforts have continued blindly and repetitiously without a careful assessment and balancing of their costs and benefits.
Perhaps the greatest costs have been those attendant to criminalizing users of illicit drugs. For example, to brand as criminals hundreds of thousands of American youths otherwise leading normal lives, by virtue of their experimental or recreational marijuana use, presents a fundamental problem in a society founded on principles of justice and respect for law. It leads directly to suspicion of and disrespect for the law. Similarly, to -persist in depicting addiction to opiate drugs as leading inexorably to violent criminal behavior fosters further disrespect for law. As is well documented, many opiate addicts do engage in certain kinds of criminal behavior, particularly "crimes against property" in order to raise funds to support their drug habits; but addiction itself, whether to narcotics, alcohol, or nicotine, is essentially a psychological and physiological phenomenon. There are social, cultural, and economic factors which demonstrably influence this phenomenon or are intimately related to it, but addiction is a "crime" only because we have traditionally labeled it as such.
At this stage in our history, there is a clear need to redress the longstanding imbalance between publicly funded efforts to reduce misuse and efforts to reduce supply. The primary focus of public policy should be on the former. We submit that such a redressing would encourage more realistic expectations-even public acceptance-of what law enforcement strategies and agencies can accomplish in reducing drug availability.
The most important aspect of such a change in emphasis would be that public policy would reflect contemporary and foreseeable realities in a straightforward manner.
By placing the major emphasis on reducing the misuse of drugs, society will be confronted with the necessity of improving program effectiveness in that regard; the record of the past is not exemplary. There is an urgent need to expand the base of knowledge concerning educational, preventive, and treatment methodologies and techniques. This means a far greater investment in basic and applied research and evaluation. In addition to increasing the research investment, it will be necessary to develop a national research strategy which can provide direction and coordination to these efforts. Since it is unlikely that answers will be instantly forthcoming, this strategy should be applied for the next several years and assure continuity of the research effort. Public officials must also be more willing to change policies if necessary in response to expanded knowledge. Only by taking these steps can there be a realistic expectation of attracting the calibre of research scientists that could make a difference.
While we think such an expanded research effort will produce more understanding and better guidance for educational, preventive, and treatment approaches, certain steps can be taken now, based on available knowledge and experience, to make the publicly funded response to drugs more reasonable and more effective.
At the federal administrative level, for instance, there should be much closer coordination between domestic and international drug law enforcement efforts and agencies on the one hand and prevention and treatment strategies and agencies on the other. Effective coordination can occur only at the highest levels of the executive branch of government, whether by a special-purpose, cabinet-level committee or by a special staff in the executive office, because the important drug program functions are lodged in several departments and agencies throughout the executive branch.
Such a high-level coordinating body or staff could meet two essential criteria for greater effectiveness in national drug policy development and implementation: First, it could develop a cohesive policy, and, second, it could advise the President and provide accountability to Congress, and thereby to the public.
This concept is, of course, not new. The 1972 Drug Abuse Office and Treatment Act created the White House Special Action Office on Drug Abuse Prevention which was succeeded in 1976 by the Office for Drug Abuse Prevention. This latter office ceased to function in 1978, to be succeeded-at least in some of its functions-by a Special Assistant to the President for drug issues, a small staff within the White House's Domestic Policy Staff, and a Federal Strategy Council composed of public officials and private citizens. However, while it thus appears that a coordinating mechanism does now exist at the highest level of the executive branch, it is our impression that this mechanism is not currently achieving its major objectives, namely, the development and implementation of a cohesive national drug policy and closer coordination of law enforcement and treatment agencies.
In addition to the more effective coordination mechanism that we recommend, other improvements in the performances of drug agencies are possible. This is as true for treatment and prevention programs as it is for law enforcement agencies, particularly as they relate to heroin addiction. Again, however, we stress that for such improvements to make a lasting impact they must be preceded by substantial changes in public policy.
In drug treatment activities at present, improvements are both possible and needed. Some improvements can come by applying the new knowledge gained in recent years; others can come by seeking more aggressively to increase that knowledge. At the same time there is a need to acknowledge the limitations of drug, treatment, imposed by social and economic conditions well beyond the influence of drug treatment programs.
One development that has begun to affect drug treatment during recent years is change in the concept of heroin addiction. There is convincing evidence that more individuals use heroin than are addicted to it. Since most heroin treatment has been founded on the principle that to use heroin is to be addicted to it, the existence of large numbers of nonaddicted heroin users has substantial implications. It is also known that the typical heroin addict, once thought to use heroin to the exclusion of all other drugs, is more likely to use many drugs, some in concert with heroin, others when heroin is unavailable. One implication of this is that when heroin is unavailable today's heroin addicts are as likely to turn to other drugs as they are to treatment.
The past eight to ten years have seen substantial progress in the treatment of heroin addiction. Various treatment approaches have evolved, the most widely publicized of which has been the use of the synthetic opiate methadone as a "maintenance" drug for individuals addicted to heroin. There are currently seventy-eight thousand individuals enrolled in methadone maintenance programs throughout the country, the majority of which are publicly funded.
During this same period there has been a corresponding increase in the number of individuals enrolled in what are most often termed "drug free" treatment programs, i.e., those based on the principle of abstinence from drug use and using psychological and behavior modification techniques to achieve this goal. There are currently an estimated 132,000 individuals receiving treatment in this type of program.
There now exists a nationwide network of treatment programs and facilities none of which existed prior to 1972. This network was initiated primarily by federal grants and contracts through state drug abuse coordinating agencies to local governmental or nonprofit programs. As a result, federal officials are frequently quoted as saying that any heroin addict who wants treatment can receive it. While this statement may be theoretically accurate, there are two major caveats. First, the accomplishments of treatment efforts are limited by lack of funding, societal conditions (e.g., the general employment picture), and the difficulties of providing "successful" treatment under any circumstances. Second, for every heroin addict who is in treatment on any given day, there are an estimated three who are not. They have neither volunteered nor been referred by the criminal justice system.
While there has been dramatic progress in making treatment more available, serious problems remain. Perhaps the most frustrating of these problems is the fact that no one-including the council-appears able at this time to provide definitive, persuasive answers about the comparative effectiveness of the various treatment approaches. The basic problem with ascertaining treatment effectiveness is that there is no public or professional consensus about what treatment should accomplish or what constitutes "successful" treatment. Different approaches-e.g. abstinence, methadone maintenance, and detoxification-are needed to respond to the broad diversity of people in trouble from the misuse of drugs. Treatment success should be gauged by the improved function of the individual in society as measured by personal stability, employment, and related criteria. Treatment for drug dependence need not have as its primary goal abstinence from all drug use for its own sake. To the extent that abstinence is attainable for certain individuals, it should be a goal; for others, such a goal may be unrealistic, premature, or even self-defeating. Treatment goals should reflect the complex nature of drug dependence, which varies from person to person.
Successful treatment for drug dependence may-foster-such a degreeof stability in an individual that he or she is able to be gainfully employed; employment may in turn become a major reinforcing factor in the success of treatment. It is, however, unrealistic to expect too much regarding employment from treatment and rehabilitation efforts since the individuals in treatment often have little or no work experience and few skills to offer in a job market characterized by fluctuating economic conditions. Successful treatment may also result in such stability that the individual no longer engages in criminal activities to support a costly drug habit. In each case, the goal of drug treatment should be the degree of stability necessary to lead to later developments, not those developments themselves. While some may brand such differences as only matters of semantics, we believe they are of crucial importance to the search for realistic goals in the treatment of drug dependence.
Further problems with treatment become evident when attention is focused on the quality of different programs. There are not enough programs which offer the wide range of assistance needed by those dependent on drugs who seek rehabilitation. Numerous factors have contributed to this situation, not the least of which is the rapid proliferation of programs which occurred in the early 1970s. Many weak programs were funded then and are still in existence. The nature and quality of the clinical process in many programs have also been adversely affected by the increased number of treatment clients coming to them by referral from the criminal justice system. This development has led some drug treatment programs away from a properly therapeutic function into an increasingly custodial role with their patients.
Health and drug treatment providers should not have to become society's agents for the control of social deviance or criminal activity. The primary responsibility of treatment systems should be treatment. If modification of drug-taking behavior, even of life styles, is a component of treatment then it should be presented as such. Treatment for drug dependence should be available chiefly because people need help, not as a behavior or crime control measure. Conversely, efforts to curtail drug-related crime should be presented as such and not mislabeled as therapeutic approaches to drug dependency.
For now, pending the outcome of further study and evaluation as well as research developments, there is a clear need to integrate the treatment of heroin addiction more closely with the general health care system. Drug treatment is now too isolated; the cross-fertilization of new ideas and trends from other disciplines which should be occurring is not observable. For drug treatment to retain its vitality in the immediate future, it cannot remain entirely apart from the mainstream of traditional physical and mental health care, nor on the other hand can it be totally absorbed by that system.
Our final suggestion on treatment is that we should immediately enter into a more active phase of research and experimentation with heroin, particularly regarding the potential of using the drug itself in the treatment of heroin addiction. We do not know enough about the treatment of heroin addiction or about what types of treatment are effective to be able to close our minds to alternative approaches. Through experience we have learned much about the use of methadone in treatment; we need to learn more about the potential of similar use of heroin. Several highly qualified research scientists have designed a variety of research protocols which call for the use of heroin at some stage in the addiction treatment process. Under present law, these projects could be funded; we are convinced that the most promising of them should be.
This research should emphasize local and state options and flexibility. What may prove efficacious in one setting may not in others, and what may prove effective for one individual may be inappropriate for another. While we have much to learn from the experience of other countries, particularly England, heroin addiction in America presents unique problems requiring creative approaches. Thus, our call for research and experimentation into the use of heroin in treatment should not be misconstrued as an endorsement of the concept of heroin maintenance (i.e., the provision of heroin to registered addicts). We have serious reservations as to whether such an approach would prove beneficial in this country. On the other hand, we submit that we do need direct experience with the use of heroin in treatment settings; otherwise, we will not be able to learn what we should know before making decisions regarding fundamental policy changes.
just as we think treatment program efforts and policies can be improved, we feel that drug law enforcement can also be improved. The basic problem with law enforcement efforts lies with the drug laws themselves. As long as these laws separate drugs into licit and illicit categories, there will be a necessity for such agencies as the Drug Enforcement Administration, with its primary mission of controlling the availability of illicit drugs. The elimination of the availability of these drugs is in our view unachievable; still, as long as the laws remain in effect, they should be responsibly enforced.
Earlier we indicated our belief that national drug policy ought to be based on the way in which a drug is used rather than on the properties of specific drugs. This enlightened approach is generally characteristic of our public policies with respect to alcohol, tranquilizers, and a host of other potentially abusable drugs. Society accepts responsible use of these drugs, while seeking to prevent their misuse and, if necessary, punishing both those who jeopardize the safety of others by irresponsible usage behavior and those who illegally manufacture or sell such drugs. However, our laws regarding illicit drugs such as marijuana, cocaine, and heroin do not distinguish responsible from irresponsible use; thus, under the law, any use of these drugs constitutes misuse or "drug abuse." Drug law enforcement is consequently directed, at least theoretically, against all users and suppliers of illicit drugs. This is where problems with drug law enforcement begin. It is not, however, where they end.
Many proponents of a national policy of total prohibition of illicit drug use are beginning to acknowledge the impossibility of achieving such a goal. Revised goals, such as containment rather than elimination of availability, are now being advanced. Infrequently acknowledged, however, even with the more cautious goals, are the attendant costs of attempted prohibition, such as criminalizing and stigmatizing hundreds of thousands of users and using questionable practices in developing cases against them.
Nor are we convinced of the supposed benefits of many current drug law enforcement efforts. It is commonplace to assume that laws and law enforcement efforts decrease the number of people who would otherwise use these contraband substances. However, there are reasons to doubt this assumption. Exhaustive study has revealed little deterrent impact from the so-called "get tough" drug laws of New York State. This study showed little change in the incidence and prevalence of heroin or other illicit drug use as a result of the new law. Similarly, in Oregon, where annual surveys have been conducted to assess the impact of that state's enactment of marijuana "decriminalization," no appreciable increase in use has been observed over time or in comparison to other jurisdictions where marijuana penalties have remained stringent. In fact, other surveys indicate that the primary reason people have chosen either not to begin use or to discontinue it is simple lack of interest; -the existence of criminal sanctions against use ranks quite low as a reason given for not using marijuana. While such examples do not offer sufficient evidence from which to draw firm conclusions, they do raise important questions requiring careful examination.
The most important recommendation the Drug Abuse Council can make in the area of drug law enforcement has little to do with specific law enforcement approaches. We propose a major research effort to analyze the actual effects of drug laws and drug law enforcement on personal decisions to use or not use illicit drugs. A well-designed national study, similar to that of New York drug laws undertaken in 1974 by the Bar Association of the City of New York, could furnish much useful guidance in this sensitive area.
In addition to encouraging us to recommend such general policy research, our years of examination of the issues involved in the widespread use of marijuana in contemporary society have convinced us, beyond a doubt, that the use of criminal law and criminal procedures to deter marijuana use results in more harm to society than is warranted by present knowledge regarding its potential harm with moderate use. This conviction should not be misconstrued as giving marijuana a clean bill of health. Much about this drug remains unknown. Research should continue, particularly multi-year studies which seek to examine the consequences of marijuana use by humans over long periods of time. Enough is now known to warrant considerable caution with its use, particularly heavy use; use by pregnant women and by adolescents should be avoided. However, we also believe that legislative efforts to decriminalize atfederal and state levels the possession of small amounts of marijuana for personal use should continue. States should be encouraged to try different legislative models, the effects of which could be assessed over time, in an effort to learn which works most effectively to minimize potential harm from the indiscriminate use of marijuana.
The above observations and suggestions about drug treatment and law enforcement lead us to the conclusion that, by adhering to an unrealistic goal of total abstinence from the use of illicit drugs, opportunities to encourage responsible drug-using behavior are missed. Individual decisions about drug use invoke value judgments seldom made in isolation; peer pressure and social, economic, and cultural variables must all be taken into consideration as we seek to minimize harm and prevent misuse.
Public education efforts should attempt to place the use and misuse of psychoactive drugs in accurate perspective for all members of society, not just younger members. In order to be helpful in minimizing the harm of drug misuse, information must be credible, coherent, and verifiable. It must be believable when placed in the context of life experiences. For example, it strikes us as inconsistent to issue calls for total abstinence from some drugs while "happy hours" with two drinks for the price of one are promoted for another. Such inconsistencies are readily apparent to the youth of our country and engender skepticism on their part as to the wisdom of official drug policies-and of the older generation in general.
Many of our suggestions and observations have been directed toward policyrnakers in the public sector, those elected and appointed public officials who make national drug policy through their actions and decisions at federal, state, and local levels. It is no less true today than it was seven years ago when the Drug Abuse Council was created that the views of these officials tend to be crisis-oriented and short-range. While public officials have a duty to lead as well as to administer, there are limitations to their ability to go much beyond prevailing public attitudes in matters as volatile as drug issues. The private sector, on the other hand, can and should play a critical, responsible role in developing longer-range views and policies and improved public attitudes.
The Drug Abuse Council has been one such effort in the private sector. Other alternatives either already exist or could be created. Any such entity will require the exertion of private-sector leadership and the investment of resources sufficient to undertake independent research and legislative, budgetary, and policy analyses. Much basic examination and reexamination has occurred and does not require repeating. With modest annual expenditures, an organization within the private sector could help keep the American public informed and provide leadership for the development of broad public support for sensible drug policies and programs. It is our conviction that the private sector needs to continue to take an active role in both developing and assessing public drug policies and programs.
A Final Thought and Suggestion. The goal of the council was stated in its 1972 Annual Report. The chairman said,
The Directors of the Drug Abuse Council, widely representative in personal and professional exposure and involvement, are determined not to look to exhortations or crash programs for illusory solutions or cures. Instead, because the Council was initiated and is supported as a private independent agency, unencumbered by shibboleths or taboos or political or bureaucratic pressures, the Directors have been free-and have exercised their freedom-to begin to learn, and to publish what they have learned, about drug abuse and treatment in. a drug using society.
Since 1972 the many publications of the council-and of persons and agencies supported by the council-have reported what we have learned about drugs, about their use, misuse, and our response to them. In the concluding paragraphs of one of the last and most significant studies initiated and supported by the council, The Nation's Toughest Drug Law: Evaluating-the New York Experience ' it is stated that,
First, the use of heroin and other opiates is but one element of a larger problem. The misuse of all dangerous drugs-alcohol, cocaine, opiates, and other mood-changing drugs, some prescribed and some sold over the counter-all together constitutes "the drug problem." Problems with so many components do not yield to one-dimensional solutions. As no single drug treatment method is suitable for all users, so there is not likely to be a single legal approach that is suitable for all offenders.
Second, whether or not illicit drug use is for the most part a medical concern as some contend, it is incontrovertibly deeply rooted in broader social "maladies." Narcotics use in particular is intimately associated with, and part of, a wider complex of problems that includes family break-up, unemployment, poor income and education, feeble institutional structures. and loss of hope.
The final observation is a corollary of the second: it is implausible that social problems as basic as these can be effectively solved by the criminal law.
If this statement is accurate-and we are convinced that it is-it reinforces our considered judgment that drug misuse is primarily a social, medical, and public health problem, a problem that will not yield to single or simplistic solutions or approaches. And it reinforces our judgment that solutions or approaches that might be useful in one place or with some individuals would not necessarily be so in another setting or with other people.
Recognizing that deeply felt attitudes and established policies reflect fears and judgments that will yield slowly, if ever, to facts and conditions described in the council's publications, we recommend that serious consideration be given to the use of individual state or local option as a means of attempting solutions appropriate in one place but not in others. Local option could encourage greater flexibility and ingenuity rather than reliance upon an unrealistic, rigid homogeneity in national drug policy. We need to respond to the diversity of people who use and misuse drugs, base all our policies on a consistent set of principles seeking to discourage misuse, and keep our seemingly innate drug-using behavior within reasonable limits through means which do not themselves cause more harm than they prevent.