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Article - A General Theory of Drug Abuse

Summary/Abstract

Americans' notions about drug abuse policy have coalesced around three distinctly different strategies. The three strategies-grossly simplified can be summarized thus: Social Welfare Strategy, War on Drugs Strategy, Legalize/Regulate/Tax Strategy

Content

For a generation or more, Americans' notions about drug abuse policy have coalesced around three distinctly different strategies. The three strategies-grossly simplified- can be summarized thus: The Social Welfare Strategy derives from the belief that people abuse drugs because of deprivation. People want an escape from lives empty of job opportunities, or meaningful education, or decent housing, or proper healthcare, or rewarding personal relationships. Substance use can alleviate this emptiness for a time, but use often leads to abuse, and underprivileged people have few resources to overcome that abuse. But just remove the deprivations, say the Social Welfare strategists, and most of the reason to abuse drugs and alcohol will disappear. Of course, this strategy is expensive: it means creating a minimum standard of living and expanded opportunities for education and employment. That, in turn, means higher taxes on "those who can afford it". The War on Drugs Strategy views America as a decent, law-abiding, sober majority in conflict with a recalcitrant, rebellious drug-abusing minority. If people would just obey the law, everything would be OK. But force is required to encourage obedience: harsher and harsher penalties must be levied on drug traffickers, and more and more firepower brought against the producers, until the evil is finally eliminated. The deviant drug abuser or trafficker must be punished not only to "correct" his behavior but to salve the morale of the law-abiding majority. Adherents of the Legalize/Regulate/Tax Strategy view substance use as a private matter. They are willing to let people use alcohol, tobacco, heroin, cocaine, or whatever, providing there isn't a clear intrusion on the welfare of others. If they get addicted, tough luck- they made a free choice and must take responsibility for the consequences. Under this strategy, all psychoactive substances are legal; but there are regulations to assure minimum standards of purity and quality, to prevent sales to minors, and to favor milder over stronger forms of each drug (e.g., beer over gin, coca tea over crack, laudanum over heroin.) Each drug is taxed to cover the costs of regulation and of the "downstream" healthcare costs, and also to pay for public education campaigns to discourage people (especially adolescents) from using in the first place. The regulating and taxing, in effect, is a payoff to the non-using public to gain their consent. My hypothesis is that the advocates of these strategies fight a three-way struggle in which, in America, no one of them is ever strong enough to overcome the other two. Whereas there can be at-least-temporary winners in a two-way struggle, a three-way conflict may be perpetually stalemated if (as I believe is the case here) the three are fairly evenly matched. Whenever one strategy begins to gain the upper hand, the other two mercilessly badger it from two sides and weaken it. So: of course the War on Drugs could prevail, given the unlimited police power of the Gestapo or the K.G.B.; but in the America of the 1990s, social welfare advocates tirelessly defend the rights of the accused, and the humdrum realities of policing the inner cities leads to a kind of de facto legalization: the War becomes a velvet fist in an iron glove. Of course Social Welfare could raise everyone out of poverty, as it has in Sweden, but somehow in the America of the 1960s we lost the will to keep funding all of the splendid programs of the War on Poverty and to run them effectively. And of course Legalize/Regulate/Tax could transform a nasty problem into a relatively benign one, as it has in the Netherlands, but somehow in the America of the 1970s when we started that way with marijuana, we only went halfway with Legalize and never secured the Regulate and Tax payoff. From the user's point of view, society is persistently giving a muddled triple message: "You're a troubled human being in need of help"--"You're a drug fiend who ought to be in prison"--"You're a citizen who should be left to mind his own business". As a result the moral authority of society is weak, leaving the user's relationship to The Drug as the central organizing principle and source of meaningfulness in life. Three-Way Conflict and Perpetual Stalemate I postulate that there are two overriding realities about American politics that will constrain policymaking in the substance abuse arena throughout the foreseeable future: Ӣ The anti-tax climate is so strong that no major new initiatives for public expenditure can be funded. The best that advocates in any arena can hope for is incremental increases. Ӣ Policymakers, Democrat and Republican, have so stridently declared themselves against the legalization of drugs that no reversal can be expected for at least a generation. Now, any truly effective manifestation of the Social Welfare or the War on Drugs Strategies would require a massive infusion of tax moneys for anti-poverty programs or for policing of inner cities, borders, and suchlike. But this is not the era of Lyndon Johnson; those massive infusions aren't going to happen, because taxpayers won't permit it. Therefore, both the Social Welfare and the War on Drugs Strategies will remain in their present emasculated state. But there is similarly no hope on the horizon for effective implementation of the Legalize/Regulate/Tax Strategy, because no major politician would dare to be the first to advocate it. My second hypothesis, then, is that there is a fourth drug policy strategy to which America will, for the above reasons, default: the Laissez-Faire Strategy. Adherents to this Strategy believe that substance abuse problems are basically cyclical, and will wax and wane on their own account regardless of our muddled attempts at intervention. Therefore, the essential tactic in each situation is to keep calm and avoid wasting energy. The goal is to maneuver to avoid any new laws, taxes, or policies, but instead perpetuate existing mechanisms for minimizing the harm that drug use does. The inclination is always toward the passive, with occasional forays to delay, dilute, negate, or otherwise frustrate the activist initiatives of the Social Welfare, War on Drugs, or Legalize/Regulate/Tax Strategies. From this hypothesis we may derive a simple prediction: twenty years hence the drug abuse situation in America will be essentially the same as it is now. The familiar gamut of treatment modalities will serve clients and claim successes. There will be lip service to some sort of "war on drugs", with the occasional major media-splashed bust of a drug cartel from Country X and the seizure of many kilos of drug Y. And most illicit drugs will be cheap and easily available, and people will abuse them in their hundreds of thousands. Last month's issue of MidCity Numbers presented clear evidence of a stalemate in the particular case of heroin abuse: the number of heroin users in San Francisco is where it was a generation ago, and the price that Americans pay for heroin is as low as ever. So, I predict that in the year 2017: Ӣ There will be, as now, a million or so Americans using heroin. Ӣ They will pay, as now, a dollar or so for each milligram of heroin. Ӣ Most of them will use the needle and be at risk for parenteral infection, specifically HIV. All Quiet on the Western [Drug] Front If my hypotheses are correct- three substance-abuse Strategies are engaged in an perpetual grand struggle which is stalemated and which will result in an enduring "steady state" condition of the drug scene- we can make some remarkable deductions. Let's use the example of heroin use in San Francisco, whose characteristics I have monitored carefully for 26 years. Here are the basic parameters: Ӣ The period prevalence (number using in a given year) of heroin users in San Francisco has ranged between 6,000 and 14,000, in the years since 1970. The overall mean of period prevalence is c. 11,000. Ӣ There have been four "peaks" (around 1971, 1978, 1987, and 1997) and three "troughs" in the prevalence graph. Ӣ In the early 1970s there were relatively few users over 30 because widespread heroin use only began in 1968. By the late 1980s, though, the heroin scene had "matured" such that the bulk of users were in their 30's and 40's, with substantial numbers in their 20's and 50's. Ӣ HIV disease caused an increase in mortality starting in the early 1990s, but not by much: only about 2% of the City's heroin users die each year. That's much lower than the rate (c. 4%/year) at which San Francisco gay men perished at the peak of the HIV epidemic. With these data in mind, I am emboldened to paint the following picture of the City's heroin using population, in broad brush strokes: San Francisco has, and will continue to have for decades to come, a "heroin-prone population" of 15,000 people. This population is fairly evenly distributed in age from early 20's to early 50's, with about 500 persons in each year-cohort. The proportion of this population that uses in any given year is dependent upon heroin supplies: when the drug is cheap and abundant, nearly all will use, and when it is expensive and hard to get, fewer than half will use. Something like 700 people are initiated into heroin use each year. This gain is exactly balanced by a permanent loss of 700 users: 200 to 300 because they die, and the remainder because they quit permanently. The City's treatment programs are a significant, but not the major, cause of peoples' successful quitting. This "model" postulates stalemate and stasis on the heroin abuse "front", from which I've claimed that I can write the story for 2007 or 2017 right now. How far from the mark will I be? We shall see...