Chemical Reactions

Legalize It?: Debating American Drug Policy, by Arnold S. Trebach and James A. Inciardi, Washington D.C.: The American University Press, 230 pages, $57.00/$12.95 paper

Marihuana: The Forbidden Medicine, by Lester Grinspoon and James B. Bakalar, New Haven, Conn.: Yale University Press, 184 pages, $22.50

America's Longest War: Rethinking Our Tragic Crusade Against Drugs, by Steven B. Duke and Albert C. Gross, 368 pages, $25.95

In 1986 Len Bias, a promising young basketball player, died suddenly in his room at the University of Maryland. He had recently consumed huge amounts of both alcohol and powdered cocaine. Coming at a time when the news media were hyping the dangers of smokable cocaine, which was said to be instantly addicting and frequently deadly, the event helped push the war on drugs to unprecedented levels of hysteria and ferocity.

In 1993 River Phoenix, a promising young actor, collapsed outside a Los Angeles nightclub and died shortly thereafter. Toxicological tests found that Phoenix, a strict vegetarian known for his "clean living," had consumed a lethal mix of drugs, including cocaine and (probably) heroin. Phoenix's death received prominent coverage for a while. There were a few stories lamenting the loss, a few more about drug use among twenty-somethings in L.A.'s fashionable hangouts. But not many people were prepared to conclude from the actor's recklessness that "it could happen to anybody," that the nation was at risk, or that desperate measures were necessary.

The contrast between the reaction to Len Bias's death and the reaction to River Phoenix's death is one of many signs that Americans are less obsessed with illegal drugs than they were in the late 1980s. Largely as a result of the change in public opinion, we haven't heard much lately on this topic from bombastic drug warriors such as William Bennett (almost always referred to now as the "former secretary of education") or Charles Rangel (whose Select Committee on Narcotics Abuse and Control no longer exists). This does not mean the prohibitionists are silent. But now that the shouting has died down, we have a better opportunity to hear the calm, rational voices of serious scholars who support prohibition.

One such scholar is sociologist James A. Inciardi, director of the Center for Drug and Alcohol Studies at the University of Delaware. He strongly opposes legalization, but he has shown a willingness to take the idea seriously. He edited the 1991 book The Drug Legalization Debate, and now he appears in Legalize It?: Debating American Drug Policy. At one point, criticizing a misleading historical summary, Inciardi says, "I just hate gross misstatements and overgeneralizations," a sentiment that distinguishes him from most of the drug warriors who have managed to grab public attention in recent years.

The intellectual rigor of prohibitionists like Inciardi is both an opportunity and a challenge for reformers. On the one hand, it allows them to cut through the nonsense and get down to the real issues. On the other hand, they'd better be ready, because they can't dismiss Inciardi as easily as Ed Meese or Joe Biden.

Arnold S. Trebach, a professor at The American University and president of the Drug Policy Foundation, is certainly up to the task. He ably makes the case for legalization in about 125 pages, touching on all the major arguments. Inciardi is familiar with these arguments, and he addresses some of them in his section of the book. But the exchange suffers from the fact that Trebach and Inciardi chose not to read each other's manuscripts and respond to them, which probably would have yielded a more focused debate. One reason they didn't go this route may be that there is a certain amount of acrimony between them. Trebach complains that Inciardi has misrepresented his views and treated other advocates of reform unfairly.

The first point Inciardi concedes, and the second point can be verified by reading his contribution to this book. Summarizing the views of Thomas Szasz, he writes: "What Szasz seems to be suggesting is that heroin, cocaine, and other 'dangerous drugs' be legalized; hence, the problems associated with their use would disappear." Szasz says no such thing. It's undeniable that a certain number of people will hurt themselves, even ruin their lives, by misusing drugs, whatever their legal status. But Szasz argues that such problems are properly beyond the purview of government, and he notes that "the drug problem," as a public-policy issue, exists only because of state intervention.

For the most part, however, Inciardi understands the arguments of his opponents and tries to rebut them with evidence. Responding to the claim that legalization would reduce theft by making drugs more affordable, he cites research indicating that criminal behavior tends to predate drug use. "It would appear that the inference of causality, that the high price of drugs on the black market per se causes crime, is simply not supported," he writes. But Inciardi concedes that "these same data also suggest that drugs drive crime in that careers in drugs tend to intensify and perpetuate criminal careers." If "drugs drive crime" partly because they cost so much, legalization could reduce the number of crimes even without reducing the number of criminals. This hypothesis is consistent with the finding that addicts commit fewer property crimes once they have access to methadone or legal heroin.

Although Inciardi wants to see the war on drugs continue, he joins Trebach in supporting several reforms aimed at "harm reduction," including needle-exchange programs and greater emphasis on treatment and education rather than enforcement. He also supports the reclassification of marijuana to make it available as a medicine. "It is simply the humanitarian thing to do," he says.

Outside of the Drug Enforcement Administration, there is remarkably wide agreement on this point. Polls repeatedly find that most Americans think marijuana should be available to patients who can benefit from it. In 1988 the DEA's chief administrative law judge agreed. The surgeon general supports medical access, as do many, perhaps most, oncologists. Thirty-five states have approved legislation that allows the medical use of marijuana (only in theory, since it's still illegal under federal law). Nevertheless, in 1992 the U.S. Department of Health and Human Services canceled the only program under which patients were permitted to get the drug legally, and the Clinton administration has yet to make a move on the issue.

So the publication of Marihuana: The Forbidden Medicine is well timed. Harvard psychiatrist Lester Grinspoon, author of the classic Marihuana Reconsidered, and James B. Bakalar, associate editor of the Harvard Mental Health Letter, begin with a brief review of marijuana's history as a medicine, which goes back at least 5,000 years. In the United States, the drug came into wide use for a variety of ailments during the 19th century. Although marijuana eventually lost ground to opiates and aspirin, which were more convenient to administer, physicians still wanted to keep it available as a medicine. Four years after Congress passed the Marihuana Tax Act of 1937, which was aimed at stamping out recreational use but also made medical use very difficult, the drug was removed from the U.S. Pharmacopoeia and National Formulary.

The rest of the book discusses the rediscovery of marijuana as a medicine. Grinspoon and Bakalar describe numerous uses for the drug, drawing on both systematic research and patients' experiences (much of the book is devoted to first-person accounts). It's well established that pot can reduce the excessive intraocular pressure caused by glaucoma and relieve the nausea, vomiting, and appetite loss associated with cancer chemotherapy, AIDS, and AZT treatment. People suffering from migraine headaches, epilepsy, multiple sclerosis, paralysis, skin diseases, asthma, and insomnia have also found that marijuana alleviates one or more of their symptoms, including pain, spasms, and itching.

Much of the evidence about marijuana's medical value is anecdotal. This is hardly surprising, since making a drug illegal tends to discourage research aimed at confirming its useful properties. Grinspoon and Bakalar acknowledge the limitations of case studies, but they note that a number of widely used drugs–including aspirin, insulin, barbiturates, and penicillin–were never tested in controlled experiments. Furthermore, the effects of marijuana are often so dramatic, with symptoms disappearing immediately after smoking and reappearing when the patient stops using the drug, that its usefulness is hard to deny. Even if these reactions are atypical, they suggest that marijuana can help at least some patients. And given the drug's unusual safety and low production cost, there's little to be lost by trying it.

Grinspoon and Bakalar are skeptical that either a renewed federal program or a prescription system, operating alongside continued prohibition of recreational use, could provide marijuana to every patient who would benefit from it. "Opponents of medical marihuana sometimes say that its advocates are insincere and are only using medicine as a wedge to open the way for recreational use," they write. "Anyone who has studied the history of desperate efforts to obtain legal marihuana for suffering people knows that this is false. The attitude falsely ascribed to advocates of medical marijuana is actually a mirror image of the government's attitude. The government is unwilling to admit that marihuana can be a safe and effective medicine because of a stubborn commitment to wild exaggeration of its dangers when used for other purposes. Far from believing that medical availability of marijuana would open the way to other uses, we take the view that free availability of cannabis may be the only way to make its judicious medical use possible."

Stephen B. Duke and Albert C. Geoss, co-authors of America's Longest War, are more optimistic about achieving medical availability without legalization. But like Grinspoon and Bakalar, they recognize the significance of the government's opposition to medical marijuana. "The political cost of permitting marijuana's rescheduling would be an admission that the government has been consistently wrong since 1937," they write. "The claims of medical necessity have been smothered by the intense politicization of the plant."

Duke, a professor at Yale Law School, and Gross, a California attorney, mount a devastating attack on such drug-induced irrationality throughout their book. Thorough, well documented, and readable, America's Longest War is a very helpful summary of the arguments against prohibition. Duke and Gross lay their groundwork carefully, starting with descriptions of the major drugs and a historical review, so this is a good book for someone approaching the issue for the first time. It's also a useful source for journalists and activists who deal with drug policy.

The chapters analyzing prohibition's impact on crime, civil liberties, and individual autonomy are especially effective. Duke and Gross add clarity to the debate by distinguishing seven major ways in which the war on drugs fosters crime. And even if you've heard how privacy, due process, the right to counsel, and property rights have been eroded by the war on drugs, the cumulative effect of the chapter on civil liberties is chilling. (See "Casualties of War," February.)

In their chapter on "autonomy costs," Duke and Gross compare drug use to other risky or damaging activities, including excessive television viewing and overeating. "A better case can arguably be made for the government to coerce citizens to trim down than to prohibit them from choosing which drugs to use," they write. After all, obesity is demonstrably bad for your health, and "almost no one wants to be fat." What's more, "the victims of obesity are easily identified and government coercion could be restricted entirely to them. Persons who have no problem with obesity would be free to eat whatever and whenever they liked. Drug prohibition, in contrast, denies the freedom of all to choose whether to use a drug because a very small minority of users are unable to resist overindulgence."

Although America's Longest War is generally well reasoned, there are a few lapses. Duke and Gross are too quick to accept the findings of research on the effectiveness of drug treatment programs. They insist that "treatment does work," and they say it "should be available, at nominal or no cost, to anyone who needs help with substance abuse." Yet they acknowledge that "there are rarely any control groups in these studies [of treatment programs]. Drug abuse is a self-limiting problem. Most serious drug abusers either die or get their problems under control, with or without treatment. Treatment is not a prerequisite to controlling drug consumption, or even to abstinence. Most drug users who quit, including heroin addicts and tobacco addicts, do so without treatment. Hence the impressive improvements found in treatment studies are somewhat misleading." In fact, without control groups we cannot safely conclude anything about the effect of treatment (as opposed to the passage of time) on people's drug problems. Given the limitations of the research and the significant costs involved (often at public expense), more skepticism is justified.

Duke and Gross also seem to contradict themselves in their discussion of drug advertising. They want a "free and open debate" about the hazards and benefits of drugs, including comparisons between substances and forms. Yet they propose banning drug brands, the main incentive for advertising. Without brands, competition and the innovation it spurs would be crippled. Companies would have little incentive to come up with safer and better drugs if they could not tout the benefits of their products, and much useful communication would be stifled.

Finally, although Duke and Gross discuss the importance of moderation in drug use, their legalization plan would undermine it in two significant ways. First, they do not leave much, if any, room for parents to teach their children responsible drug habits. "We would encourage courts to hold parents and others civilly and even criminally responsible for negligently providing access to such drugs," they write, adding that underage consumption should itself be considered "actionable or punishable harm."

Second, they would confine use of the currently illegal drugs to the home. "There should be no 'drug saloons' or the modern equivalent of opium dens," they write. Yet such establishments could help tame drug use by tying it to safe environments and interaction with other people. In Legalize It?, Trebach cites the old opium dens, which were generally calm and peaceful, and the success of Dutch cafés that sell marijuana as evidence that "drug saloons" would have a positive impact.

Despite these and a few other missteps, Duke and Gross have produced an important book that should help change people's thinking about drug policy. I hope my disagreements with them will seem more significant in a few years, since that will mean we are moving in the right direction.