Drug Trial

Is "medicalization" the first step in ending the drug war? Or just the next step in continuing it? Jacob Sullum lays out the "public health" issues and a panel of experts responds.

Washington state's Initiative 685, the "Drug Medical-ization and Prevention Act of 1997," failed by a big margin last November. But "medicalization" is here to stay. In one form or another, it is the most frequently endorsed alternative to the war on drugs--far more popular among reformers than the free market favored by libertarians. That fact is a source of hope to some, dismay to others.

In 1988, when Baltimore Mayor Kurt Schmoke helped generate a surge of interest in drug policy reform by calling for "a national debate on the merits of decriminalizing drugs," it was medicalization he had in mind. "Making drugs illegal has not diminished the American appetite for these substances," he later explained. "That is because drug abuse is a disease. And like any other disease, it responds to medical treatment, not criminal sanctions....De-criminalization is in effect `medicalization,' a broad public health strategy--led by the Surgeon General, not the Attorney General--designed to reduce the harm caused by drugs by pulling addicts into the public health system. Criminal penalties for drug use would be removed and health professionals would be allowed to use currently illegal drugs, or substitutes, as part of an overall treatment program for addicts....Drugs would not be dispensed to non-users, and it would be up to a health professional to determine whether a person requesting maintenance is an addict."

This general approach--with some important differences in detail--has played a leading role in criticism of the war on drugs during the past decade. One cannot attend the Drug Policy Foundation's annual conference without hearing repeatedly about the merits of a "medical" or "public health" model. The Lindesmith Center, a New York drug policy think tank funded by billionaire philanthropist George Soros, emphasizes "harm reduction," a public health strategy aimed at mitigating the costs of both drug use and drug laws through measures such as needle exchange, heroin maintenance, and the legalization of marijuana for medical use.

Physician Leadership on National Drug Policy, a new group that includes former FDA Commissioner David Kessler and former Secretary of Health and Human Services Louis Sullivan, declares that "addiction to illegal drugs is a chronic illness." Without calling for decriminalization, the group argues that law enforcement has been overemphasized, saying "enhanced medical and public health approaches are the most effective method of reducing harmful use of illegal drugs."

Washington's Initiative 685, which was modeled after Arizona's Proposition 200, echoed this theme. "In addition to actively enforcing our criminal laws against drugs," it said, "we need to medicalize Washington's drug control policy and recognize that drug abuse and addiction are public health problems that should be treated as diseases." Accordingly, it prescribed "treatment" rather than incarceration for "nonviolent persons convicted of personal possession or use of drugs." Such offenders would receive probation, and the sentencing judge could "require participation in an appropriate drug treatment or education program." If already in prison, people in this category would be "eligible for immediate parole and drug treatment, education, and community service," provided they were not covered by a "habitual criminal" statute or serving a concurrent sentence for another crime.

Despite the line about "actively enforcing our criminal laws against drugs," these provisions would have eliminated jail time for simple possession--a dramatic change from current policy. But another aspect of the initiative, authorizing doctors to "recommend" Schedule I drugs for the treatment of "seriously ill" patients, got more attention, since it tied into the national debate over medical marijuana. This section said a physician who recommended a Schedule I substance, such as heroin, LSD, or marijuana, would not be prosecuted or disciplined as long as he cited relevant scientific research, obtained the patient's written consent, and got a second opinion from another doctor.

Washington's voters did not go for it. Although its backers spent 10 times as much as their opponents--with infusions of money from Soros, Phoenix entrepreneur John Sperling, and Peter Lewis, CEO of Cleveland-based Progressive Insurance--the measure lost by 20 percentage points. Some voters may have felt that out-of-state organizers with out-of-state money were trying to pull one over on them. The opposition's ads, funded in part by Microsoft and by presidential hopeful Steve Forbes's Americans for Hope, Growth and Opportunity, sought to reinforce that impression. The conservatives who turned out to oppose the state's highly publicized gun control initiative probably also helped defeat Initiative 685.

The loss in Washington was a mirror image of the victory in Arizona, where 65 percent of voters endorsed essentially the same initiative in November 1996. Since then the Arizona legislature has passed bills overriding key elements of the proposition. In response, the initiative's supporters have gathered signatures to submit those bills to the voters as referendums on the 1998 ballot. They are also backing the Voter Protection Act, a proposition that would amend the state constitution to require a three-fourths majority in each house of the legislature to overturn a voter-approved initiative.

Unlike the Arizona and Washington measures, initiatives that deal exclusively with medical marijuana do not explicitly advocate a "public health" approach to drug policy generally, but they do represent one aspect of the "harm reduction" agenda. After California's Proposition 215 passed by a comfortable margin in 1996, Americans for Medical Rights began pushing similar measures in other states. Activists hope to have medical marijuana initiatives on the 1998 ballots in Alaska, Colorado, the District of Columbia, Maine, Nevada, and Oregon.

However medicalization fares on state ballots, it will continue to shape opposition to the war on drugs for years to come. That is partly because it offers a sharp contrast to the prohibitionist approach that has long dominated U.S. drug policy. The stated aim of the prohibitionists is to eliminate drug use--by which they generally mean the use of certain drugs, set apart from accepted intoxicants by custom, superstition, and historical accident. The stated aim of the public health specialists, by contrast, is to minimize morbidity and mortality--including the harm associated with the use of all drugs, whatever their current legal status.

Thus, the public health specialists are in some ways more realistic than the drug warriors: They acknowledge that any drug, licit or illicit, can be harmful under certain circumstances. And they stress harm rather than drug use per se. This implies that the consumption of psychoactive substances is not necessarily problematic. It also suggests a willingness to consider the undesirable effects of attempts to discourage drug use. This openness to evidence is probably the most important way in which public health specialists differ from prohibitionists.

In terms of policy, both prohibitionists and public health specialists talk a lot about "education." Prohibitionists seem more willing to bend the truth if they think it will help scare people away from drugs, while public health specialists are more likely to insist that drug "education" have a sound scientific basis. They note that scare tactics tend to backfire in the long run, as people recognize that they've been misled and learn to distrust the source. Still, public health messages about drugs, like public health messages in general, are aimed at changing behavior, not simply disseminating facts.

Aside from education, the policy prescriptions offered by public health specialists sound quite different from those offered by drug warriors. Prohibitionists emphasize interdiction, crop eradication, and other attempts to reduce the supply of drugs, along with arrests, fines, property forfeiture, and imprisonment for producers, sellers, and buyers. Public health specialists emphasize treatment, taxes, and regulations.

The prohibitionist orientation is basically punitive: Using certain drugs is a crime; people who do it deserve to be arrested, humiliated, imprisoned, and divested of their property. The public health orientation, by contrast, is therapeutic: Drug abuse is a disease; people afflicted by it need to be treated. From this perspective, current policy is irrational and inhumane. After all, you don't lock people up for cancer or diabetes.

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