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.
But as Thomas Szasz and other critics of contemporary psychiatry have long argued, the ostensibly liberal policy of treating behavior like a disease can have profoundly illiberal consequences. A disease is something inherently undesirable that happens to people against their will. No one in his right mind wants to be sick. Furthermore, drug addiction is said to be a disease that impairs the patient's judgment. Where's the harm, then, in forcing him to be well? Under the circumstances, it would seem to be the compassionate thing to do. Presumably, that is the rationale behind Initiative 685's "court-supervised drug treatment." When the disease model is combined with the public health imperative to minimize morbidity and mortality, and to enlist the state's assistance in that endeavor, the logical result is never-ending intervention in personal decisions. (See "What the Doctor Orders," January 1996.)
Some reformers who are privately skeptical of the disease model push it because they think that's what the public is prepared to accept. From their polling and their focus groups, the supporters of the Arizona and Washington initiatives knew that voters were not ready for outright decriminalization. They needed to be assured that somebody would be in charge--if not cops, then doctors. Given the fate of Washington's initiative, the wisdom of this strategy is open to question. But even if the measure had passed, it might have made further reform more difficult by reinforcing the disease model. If voters believe that people cannot reasonably be expected to control their drug use, how likely are they to support the repeal of prohibition?
On the other hand, the war on drugs is not going to end overnight. Certain piecemeal reforms can mitigate injustice now and help prepare the public for more radical change later. Reducing the penalties for marijuana possession in the 1970s was, I think, such a reform. Making marijuana legally available as a medicine may be another. By the same token, surely drug users would be better off if they were never sent to prison, even if they sometimes had to endure court-ordered "treatment."
Judging from my conversations with reformers, I'm not the only one who is ambivalent about these issues. To help bring the debate into focus, REASON invited several prominent critics of the war on drugs to discuss the pros and cons of medicalization.
Senior Editor Jacob Sullum is the author of For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health, forthcoming this spring from The Free Press.
The Political Legitimation of Quackery
By Thomas Szasz
The Washington State "Drug Medicalization and Prevention Act of 1997" asserts that "we need to...recognize that drug abuse and addiction are public health problems that should be treated as diseases." The merits of this claim cannot be intelligently debated without agreeing on the use of the terms drug abuse, addiction, treatment, and disease, and on the kinds of personal conduct that justify coercive state control by means of public health measures.
From ancient times until recent years, the term public health, as distinguished from private health, was used to denote activities undertaken by a government to protect individuals from disease-causing agents or conditions in the environment, both physical and human. The principal public health measures have been sanitation and the control of infectious diseases, aimed at protecting the community from microbial diseases such as cholera and typhoid. In this connection, the control of venereal diseases illustrates an important consideration: The prostitute's behavior, exposing her client to the risk of venereal disease, was and is viewed as a public health problem, justifying the coercive control of her conduct, whereas the behavior of her client, exposing himself to the risk of venereal infection, was and is viewed as a private health problem, not justifying the coercive control of his conduct. By defining the behavior of the individual who exposes himself to the risk of "addiction" as a public health problem, we radically expand the range of legitimate state coercion in the name of health.
Public health measures play a crucial, but neglected, role in modern political philosophy. Interventions justified in the name of health--defined as therapeutic, not punitive--fall outside the scope of the criminal law and are therefore exempt from constitutional restraints on state coercion. On the contrary, such measures--promoted as protecting the best interests of "sick patients"--are viewed as valuable "services" provided by the Therapeutic State (the polity uniting medicine and state, much as church and state formerly were united). Presciently, John Stuart Mill anticipated this insidious tactic: "The preventive function of government," he warned, "is far more liable to be abused, to the prejudice of liberty, than the punitory function; for there is hardly any part of the legitimate freedom of action of a human being which would not admit of being represented, and fairly too, as increasing the facilities for some form or other of delinquency."
Mill could not have put it better had he been addressing present-day American drug policy. It is self-evident that free access to a particular drug, like free access to any object, increases our opportunities for using and abusing it: Freedom of action means the opportunity to act wisely or unwisely, to help or harm ourselves. It is also self-evident that, since "no man is an island," any private act may be viewed as affecting the economic, existential, or medical well-being of others, and hence be deemed to pose a "public health problem"; and that if protecting people from themselves falls within the sphere of public health, then no private behavior is exempt from being categorized as a public health problem, subject to control by means of medical sanctions.
It is ironic that, in 1997, Americans should recommend "drug medicalization" as a cure for America's drug problem: It was the "drug medicalization" act of 1914--better known as the Harrison Narcotic Act--that transformed widely used analgesics and sedatives into dangerous "narcotics," specially monitored by the federal government, available only by a physician's prescription. Horribile dictu, isn't it possible that defiance of such controls is not a disease, and that coercive state interference with the free market in drugs--like similar interference with the availability of other goods--may be the root cause of the problem we now try to solve by still further "medicalization"? Aren't we fools if we fail to ask, cui bono?: Who benefited from drug medicalization in the past and who benefits from it today?
The die is now cast: Misbehaviors of all sorts are (defined as) medical problems. Unwanted behavior, exemplified by the use of illegal drugs, is, by fiat, a disease. The concepts of disease and treatment have thus become politicized. The World Health Organization's definition of drug abuse as the "use of a drug that is not approved by a society or a group within that society" is illustrative. Thus, doctors, judges, journalists, civil libertarians, everyone accepts--or pretends to accept--that self-administering heroin is a disease and that a state agent administering methadone to an "addict" is a treatment.
Some see the Therapeutic State as an instrument of compassion and science in the service of "moral progress" and accordingly support "medicalization" in all its many guises. Others see the Therapeutic State as an instrument of cruelty and pseudoscience in the service of a new form of statism and accordingly oppose "medicalization."
Contributing Editor Thomas Szasz, professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse, is author of many books, including Our Right to Drugs: The Case for a Free Market (Praeger).
A New Metaphor for Autonomy
By Jeffrey Singer
In November 1996, Californians voted to allow possession and use of marijuana for medical purposes with a physician's recommendation. Arizonans went further. They permitted patients to possess and use any illicit drug, provided they receive a written prescription from a physician, who, in turn, obtains a concurring second opinion. In addition, the Arizona ballot measure gave drug users probation and rehabilitation rather than prison time for the first two convictions. It prohibited incarceration of nonviolent drug offenders until the third conviction. Finally, the measure made eligible for release all inmates serving time for simple drug possession with no other offenses.
Vice President Al Gore, Attorney General Janet Reno, drug czar Barry McCaffrey, and former Presidents Bush, Carter, and Ford participated in media events warning voters of the dangers posed by these initiatives. Despite those efforts, the ballot measures passed easily, with 56 percent support in California and 65 percent in Arizona.
From the perspective of some libertarians, most notably Thomas Szasz, the public health model embodied in these initiatives can be seen only as a pernicious extension of the meddlesome Therapeutic State. But when applied to drug policy, medicalization actually represents a radical rupture with the federal government's oppressive drug war.
I served as medical spokesman for the group that developed and promoted the Arizona initiative. Our mission was to seek alternatives to current drug policy. Accordingly, we commissioned focus group research to explore how citizens felt about the drug issue.
Two dispositions were immediately apparent: 1) People overwhelmingly felt the drug war was a failure, and 2) people strongly opposed the alternatives of decriminalization and legalization. But this did not mean they opposed significant reform. For example, focus group participants firmly rejected the policy of "do drugs, do time." They believed treatment was much more appropriate than imprisonment for drug users. This belief was so strong that they were willing to parole offenders already in prison. Furthermore, they believed that when it came to prescribing drugs--even marijuana, heroin, and LSD--the patient/doctor relationship should supersede government control. Arizona voters probably did not realize how widely such beliefs were shared: Tracking polls showed that 60 percent supported the initiative but only 25 percent thought it would pass.
The focus group and tracking poll results illustrate what postmodern philosopher Michel Foucault calls "subjugated knowledge"--an implicit belief that people cannot communicate unless given the language to do so. The Arizona focus group research revealed a radical resistance to the drug war that lacked a narrative with which to express itself. The common "metaphors" of resistance--legalization and decriminalization--were unsatisfactory. A new vocabulary took shape as a result of the focus group experience. Group members repeatedly said drug abuse is really a "medical" issue. They said drug treatment, even if it doesn't work, is a more just form of punishment. Thus, a new discourse on drugs emerged, representing a halfway position between prohibition and repeal. Years of prohibitionist propaganda made it impossible to generate popular support for anything more ambitious.
This new discourse of medicalization is not a top-down narrative of control written by the government. Instead, the people have generated a language of resistance to oppressive and ineffective policies. This discourse is percolating up from citizens who believe medical authorities can address the drug issue more effectively than government bureaucrats.
Libertarian critics mistakenly take the term medicalization to mean the transfer of power from a political dictator to a medical dictator. To be sure, the postmodernist would agree that medicalization is a metaphor of control. But as Foucault argues, there is no way "outside of" power; all human interactions involve power relations. Therefore, the only way of conceiving issues of autonomy is through empowerment. In the context of drug policy, "medicalization" is a metaphor of empowerment.
In practical terms, the Arizona and California ballot measures have eased statist drug controls. The federal government responded by threatening to punish doctors who prescribe illicit drugs to their patients. This policy prompted federal lawsuits (including one in which I am a plaintiff) that fundamentally challenge the way drugs and medical practice are regulated. A recent national poll found that 69 percent of Americans oppose the federal response to the medicalization initiatives.
During the Arizona campaign, I had many arguments with libertarian friends who shared Dr. Szasz's suspicions of medicalization. But the reaction of the federal government and the law enforcement community to the measure's approval, coupled with strong public opposition to that reaction, has led many of them to re-examine their positions. Any drug policy reform that engenders so much outrage from the political establishment and incites such widespread dissent can't be all bad.
Jeffrey Singer is a Phoenix surgeon who served as medical spokesman for Arizonans for Drug Policy Reform, which ran the Proposition 200 campaign.
The Medical Marijuana Menace
By Dave Fratello
California and Arizona voters changed the politics of the drug war when they approved "medicalization" ballot initiatives in 1996. Both reformers and prohibitionists have had to deal with the consequences.
On the reform side, as the movement begins to mature and achieve a tangible success here and there, we are seeing internal debate and factionalization. For years the movement has functioned amorphously, with a "big tent" mentality and a lot of preaching to one another. Nowadays, those of us working on medical marijuana initiatives for the 1998 ballot seem to catch flak from every angle. Repeal advocates tell us that medical marijuana does not go far enough. We are also criticized for how we would permit medical marijuana--with regulation rather than declarations of complete freedom for doctors and patients--and for limiting it to certain medical conditions.
At the same time, the 1996 votes have helped remind reformers of our common enemies. When an issue like allowing some patients to use marijuana, seemingly so peripheral to the broader drug policy debate, causes a panic among the drug war's partisans, it is worth asking why. One way of addressing that question is to speculate what might happen if voters approve every state initiative on medical marijuana (a total of four to six) this November. Could we expect anything like the over-the-top, multi-agency roar federal officials let out in 1996? If so, perhaps the drug warriors will further erode their credibility by fighting public wishes and denying patients a useful medicine.
Alternatively, the federal drug warriors might give in on medical marijuana, moving it to Schedule II or III so doctors could prescribe it, and thereby put a "friendly face" on prohibition, exactly as Thomas Szasz fears. The multi-state initiative strategy is designed, in part, to force or facilitate the rescheduling of marijuana, with the underlying risk of relieving pressure for reform. If federal officials choose to build a firewall behind medical marijuana, but in front of legalization, hopes for repeal of prohibition would dim.
But is it really plausible that the guardians of prohibition would make that move? The ban on medical use of marijuana is rooted in the restrictions established by the 1937 law that banned recreational use, a mistake Congress failed to fix when it rewrote the drug laws in 1970. Compelling studies of marijuana's therapeutic potential in the late 1970s and early '80s did not affect federal policy, so it is difficult to believe today's proclamations that science will resolve this issue. The evidence suggests that the drug warriors believe prohibiting medical use is crucial to the overall policy of intolerance toward marijuana.
If the problem is ideological, it may be impossible to get a concession. The never-ending frustration of medical marijuana advocates is that the drug war can't seem to accommodate a modest reform like making cannabis available by prescription. By the same token, such a reform could be devastating to the war on the drugs. That, at least, seems to be the understanding of hard-core drug warriors.
Whatever the federal reaction, the fight for medical marijuana offers benefits that abolitionist critics often overlook. In addition to being a compassionate step in itself, changing state laws on medical marijuana tends to put the right issues into play and the right people on the defensive. It raises questions about the nature of drug prohibition and the rationality of its enforcers. It enhances the credibility of reformers and attracts allies who may ultimately be persuaded to support more radical change.
With those benefits in mind, medical marijuana initiatives should neither stoke nor calm fears about the medicalization of drug policy. Permitting the medical use of marijuana does not, as Thomas Szasz has written in Liberty, endorse the "fiction that self-medication is a disease" or declare "punishing it a treatment." The mechanism for allowing medical use is to carve exemptions into existing criminal laws. That seems to reduce the power of the state, especially since it forces those charged with implementation to change their tactics, sometimes fundamentally. Police in California, for example, are learning that marijuana they seize may be someone's medicine, in which case they have to give it back.
If opponents of the drug war want to have an impact, rather than focusing on the perfect policy or waiting for revolutions in the public's thinking, we have to reach out to new people, find working compromises, and advance concrete proposals. Proposals rooted in medicalization concepts currently have the greatest public appeal, notwithstanding the recent vote in Washington state. The more moderate and sensible our proposals seem, the better our chances of success. At the same time, if it is true that any successful challenge to the drug war, even on a relatively narrow issue, threatens an overly rigid paradigm, so much the better. We can't count on overthrowing the generals with modest peace offerings. But in the very strange world of U.S. drug policy, it just might happen.
Dave Fratello, previously with the Drug Policy Foundation, is communications director for Americans for Medical Rights, a Los Angeles-based group that ran California's Proposition 215 campaign and is sponsoring medical marijuana initiatives in several states.
Medicalization and Scientism
By John P. Morgan
Medicalization--the idea that drug consumption can be understood by a scientific assessment of what drugs do in the body and brain--is not new. Many physicians in the late 19th century tried to explain heroin or morphine addiction as a kind of allergic reaction: The repeated injection of opiates permanently changed the user's physiology, creating an illness requiring lifelong use of the drug.
Today, medicalization relies on apparently scientific explanations of the neurobiological mechanisms underlying addiction. Research in this area is increasingly complex, if not abstruse, and journalists look to the investigators themselves to explain how important and revealing it is. These scientists take a pharmacocentric approach, focusing on the drug as the cause of behavior and ignoring other factors. Their reports are scientistic, using the neutral language of neurobiology to disguise value judgments. Investigators usually assert that results from animal or cell-culture experiments are clearly relevant to humans. Indeed, they often claim that a given study "proves" the existence of a human drug reaction that cannot be found among humans.
Two highly publicized studies reported in the June 27, 1997, issue of Science illustrate these tendencies. In one, Fernando Rodriguez de Fonseca and other investigators at the Scripps Research Institute in La Jolla gave rats daily injections of a synthetic drug resembling delta-9 tetrahydrocannabinol (THC), the main active ingredient in marijuana, for two weeks. Then they gave the rats a cannabinoid antagonist, which stripped the THC-like drug from its receptor sites. This provoked a withdrawal syndrome lasting an hour or so, featuring tremors, hyperactivity, and defensive posturing. The researchers also measured increases in brain concentrations of corticotropin-releasing factor (CRF), a neural hormone. Such increases have been seen in rodents undergoing alcohol and heroin withdrawal.
The study and an accompanying editorial said these findings confirmed cannabinoid withdrawal in humans and provided evidence that increases in CRF create anxiety that drives marijuana users to ingest other drugs. De Fonseca et al. claimed their study therefore offered support for the "gateway" theory, which says smoking marijuana leads to the use of cocaine and heroin.
In the second study, Gianluigi Tanda and other researchers at the University of Cagliari in Italy measured the release of dopamine in the mesolimbic area of the rodent brain following injection of THC, a THC-like synthetic, and heroin. Neurobiologists have long wondered if cannabinoids raise extracellular dopamine in this brain area because such increases are triggered by many drugs that humans use for pleasure, including heroin, alcohol, amphetamine, nicotine, and cocaine. Prior to the Tanda study, evidence of dopamine release caused by injection of cannabinoids was equivocal.
In their report, Tanda and his colleagues unhesitatingly compared marijuana to heroin and, like de Fonseca et al., invoked their rodent findings as evidence for the much-discussed gateway theory. They speculated that marijuana use, by increasing dopamine, "primes" the brain, so the dissatisfied cannabis smoker will be drawn to heroin for the familiar dopamine rush.
Both studies were widely covered in American newspapers, framed in just the way suggested by the researchers. Their extrapolations to humans were reported without qualification, and their results were described as "new evidence" of marijuana addiction and a gateway effect.
This unscientific interpretation ignored the findings of prior research involving both animals and humans. Rodents and primates will not self-administer THC or other cannabinoids even when they have been primed with repeated injections and abrupt withdrawal. Simply put, these animals do not like pot; they find small doses unappealing and large doses aversive. Hence the de Fonseca study, in which the researchers went to great lengths to precipitate a short-lived cannabinoid withdrawal reaction in rats, has no obvious relevance to animal behavior, let alone human use, which typically involves smoking small amounts of cannabis episodically, with THC declining slowly after each session.
De Fonseca et al.'s most egregious extrapolation was their speculation that cannabis smokers move to other drugs because of the "anxiety" seen in withdrawal. It is difficult to show any marijuana withdrawal phenomenon in humans, and I know of no study that links cessation of cannabis use with the use of other drugs. Yet somehow the release of a neural hormone in rats signaled to the researchers that human cannabis users suffer abstinence anxiety that they try to alleviate with cocaine or heroin.
Similarly, it's hard to know what to make of the dopamine increases found in the Tanda study, since rats do not actually like cannabinoids. Earlier research in this area was based on the theory that reinforcing drugs raise dopamine levels. Now we have an experiment linking increased extracellular dopamine with a compound that is not reinforcing in rodents and has not been shown to be an important drug of dependence in humans. There are many drugs that increase extracellular dopamine which humans do not find attractive, including levodopa, tricyclic antidepressants (Elavil, Tofranil), and anticholinergics (atropine, Artane).
These attempts to scare people about marijuana through animal studies, because actual human experience with the drug is not alarming enough, suggest the pitfalls of the biological reductionism on which medicalization depends. Where medicalization is the practice, scientism is the theory.
Show Me the Data
By George D. Lundberg
My personal activities in the field of substance abuse go back about 30 years to my time as a faculty member at the University of Southern California in Los Angeles. I am, by training and experience, a forensic pathologist and a toxicologist. The 1960s in Los Angeles were the early heyday of our modern drug abuse epidemic and provided a natural laboratory for studying voluntary human street drug experimentation, informing the academic and clinical fields, albeit with great pain and sadness.
I define drug as any chemical which, when administered to a living thing, produces an effect. I define drug abuse as the use of a drug in a manner that is likely to cause harm. This definition deliberately ignores law and medical practice because most drug abuse is legal (alcohol and tobacco) or within the bounds of medical practice (e.g., prescription sedatives). For practical purposes, drug abuse is confined to psychoactive drugs, which are chemicals that affect the way a person thinks, feels, or behaves. Drug use is not necessarily a problem; harm from drug use is the problem. Of course, you cannot have drug harm without drug use, but you can have drug use without drug harm.
We in the new group called Physician Leadership on National Drug Policy (PLNDP) believe that scientific evidence should drive American drug policy and that up to this point it has not. The PLNDP is a group of leading physician activists and pragmatists who intend to work with the public and with policy makers to improve the lives of our patients and our communities by reducing drug harm.
Chronic psychoactive drug use can lead to addiction, which is a chronic illness. Addiction does not go away. Physicians don't always strive for cures. We generally don't cure hypertension, arthritis, diabetes, or asthma, for example, but we can medically manage them quite well. The same is true with chronic chemical addiction. We cannot cure it, but we can manage it, often successfully, at a reasonable cost to society.
We in the PLNDP believe that when one considers the tens of billions that our federal and state governments spend each year on drug control, we should be getting better results. We should be applying principles of scientific evidence to the various methods available to intervene in the drug field--for primary prevention, secondary prevention, treatment, and rehabilitation. Available evidence strongly suggests that emphasizing source control, interdiction, and domestic enforcement--methods that account for 75 percent of drug control spending--is a very inefficient strategy. It is clear that the government is throwing large amounts of taxpayer money away each year. We don't have all the answers yet, but we do know that proven treatment methods offer a more cost-effective alternative.
Drug law enforcement has a place, but not necessarily the premier place, because the evidence does not support that approach. Now that the U.S. military (of which I was a loyal full-time member for 11 years) has run out of real wars to fight, it is getting involved in phony wars on marijuana fields in Mexico and coca fields in Bolivia. Let's stop playing drug war games. They are no longer entertaining, and they don't work.
George D. Lundberg is editor of The Journal of the American Medical Association.
Defending the Public Health Trademark
By Ernest Drucker
Public health is concerned with the well-being of populations and therefore shares with medicine the goal of reducing suffering due to disease. But its "patient" is the community and its measure of successful "treatment" is the reduction of collective morbidity and mortality, usually measured in terms of prevention. Indeed, clinical medicine exists as a function of public health's failure: It treats the casualties of unhealthy social policy and poor public health practice.
The problem with public health comes from its close historical association with clinical medicine, i.e., an over-reliance on the disease model. While a perfectly appropriate way of understanding the course and characteristics of individual illness, the disease model is only a small part of what is required to appreciate the complex biological and social circumstances that contribute to morbidity and mortality. Many critics of the public health perspective fail to distinguish its perspective from that of medicine. Workplace injuries, highway accidents, and home poisonings are not diseases, but they are well understood (and prevented) using a public health model.
When it comes to drugs, public health data usually focus on the most negative outcomes (disease and death) and the "hard realities" of drug use: addiction, overdose, AIDS, crime, domestic violence. But this is only part of the picture. In the vast majority of cases, the positive aspects of drug use, such as psychological benefits and social involvements, outweigh any harm. Because of the stigma attached to illegal drug use, these "soft realities" are largely ignored in public discourse. But they can be inferred from public health data.
While tens of millions of Americans have used illicit drugs--70 to 80 million marijuana, 40 million cocaine, and 20 million heroin--the number of heavy or problematic users is only 5 percent to 10 percent of those figures, similar to the proportion seen with alcohol. Public health data on moderate alcohol use (one or two drinks per day) suggest it is not only harmless but actually beneficial. I suspect a similar case could be made for other drugs, which are often used (successfully) to "self-medicate" anxiety, depression, and attentional difficulties.
Through public health data we can also see that, despite an overall reduction in the number of drug users during the most vigorous prosecution of the war on drugs, from 1972 on, the consequences of drug use have generally gotten worse: There has been an absolute increase in drug-related health problems such as AIDS and overdose deaths. Meanwhile, the huge economic and social costs of massive incarceration and criminalization associated with drug prohibition generate a cascade of adverse consequences in the targeted communities. These are consequences not of drug use but of drug policy. And it is public health methods that make them visible to the naked eye.
So who could be against public health? Well, for a start, our gracious editorial host, Jacob Sullum. His forthcoming book about America's current "war on tobacco" bears the subtitle The Tyranny of Public Health. The phrase is provocative, suggesting that public health could operate contrary to the public interest, and possibly oxymoronic, since most of us who work in the field are impressed by our relative powerlessness to affect policies. But it does capture something of the battle for the right to use the "trademark" of public health: One can cite many moralistic (and often useless) restrictions imposed on victims of past epidemics in the name of public health, or the contemporary use of imaginary or overblown health risks to exert social control, as in bans on smoking in outdoor spaces.
On the face of it, any public which is fully and accurately informed of a serious risk to its collective well-being may fairly decide that it wishes to protect itself and restrict the freedom of some individuals to achieve that goal. But if the advocates of drug prohibition want to justify their position on public health grounds, why do they consistently overlook public health data suggesting measures that might actually save lives? The continued ban on the use of federal funds for needle-exchange programs, for example, defies a large body of scientific literature demonstrating their efficacy and ignores the recommendations of multiple expert commissions. As a consequence of this failed policy, my colleague Peter Lurie and I estimate, 10,000 to 20,000 preventable AIDS cases have occurred in the United States.
The message of history is that most people are willing to forgo some individual freedom for the larger good if the threat is real, the process is fair, and the response is effective at saving lives--as with confining or isolating carriers of easily infectious diseases such as typhoid or bubonic plague. These examples seem to me the opposite of tyranny. But current attempts to justify our demonstrably unhealthy drug policies in public health or medical terms make a mockery of both professions, whose best efforts are sorely needed to deal with our all-too-real drug problems.
Ernest Drucker is professor of epidemiology and social medicine at Montefiore Medical Center/Albert Einstein College of Medicine, a senior fellow of the Lindesmith Center, and editor-in-chief of the journal Addiction Research.