Rethinking Drug Policy Assumptions

The so-called war on drugs has lasted more than four decades and increasing numbers of people are convinced that it is not only unwinnable but also misguided. From foreign policy to domestic policy to drug treatment, U.S. drug policy has been based on inaccurate assumptions and incorrect causal models that have led to an ever-escalating failure. The attempt here is to identify some of the principal errors, point out their shortcomings, and offer more plausible assumptions and models in their stead. These alternatives point not simply to downsizing the war and decriminalizing marijuana, as voters in Colorado and Washington State recently did, but to ending the war on drugs altogether by considering a range of legalization options.

Attacking Drugs vs. the Black Market

Current U.S. policy is based on the assumption that drugs cause crime, corruption, and disease. Hence, we label and ban some substances as “dangerous drugs.” It follows that bad people supply these drugs, so we lock them up, but the supply keeps getting through. Engagement between police and criminal suppliers ramps up, leading only to more crime, corruption, and disease at home, while the battle spreads around the world.

It looks as if the more we clamp down, the worse the problem gets. Up until now the response has been not to question the underlying assumption, but to further escalate the war, hoping the right side will eventually achieve victory. There seems to be no consideration of the possibility that it’s the policy itself that’s making matters worse.

Here’s an alternative causal model, one that actually explains the failure of our longstanding policy: drug prohibition—that is, the war on drugs—causes an illegal, or black market, which in turn causes crime, corruption, and disease. With this model, the goal of drug policy should be to attack the black market instead of attacking drugs because the market undermines the stability of friendly countries (witness Colombia and Mexico) and finances our enemies (al-Qaeda and the Taliban, for example). Attempts to suppress the black market by force merely spread it, from one country to another or, in response to local police crackdowns, from one neighborhood to another.

The way to attack an illegal market is to create a legal one. As we learned when Prohibition ended and it became possible to buy alcohol legally, crime, corruption, and disease (such as blindness or even death from contaminated or substitute products sold as alcohol) fell dramatically.

Decriminalization won’t work—even though not locking people up for using a substance is a more humane policy—because it does nothing about the black market. Most people are unaware that Prohibition, with its rampant crime and gang violence, was actually a decriminalization regime for alcohol. The Eighteenth Amendment criminalized “the manufacture, sale, or transportation of intoxicating liquors” but not possession for personal use.

Degrees and Types of Legalization

The question of how to legalize drugs (as opposed to whether to legalize) is a complex one that I have dealt with in three separate works offering a wide range of policy alternatives. While the question is too broad to be settled here, let me at least call attention to two of the most important issues that need to be addressed. First, for each substance, one has to consider whether it should be as legal as tomatoes, or if it should be regulated akin to aspirin, or as alcohol and tobacco, or as antibiotics. That is, there are many forms of “legalization,” and the term has different meanings for agricultural products, over-the-counter medications, legal psychoactive substances, and prescription medications.

Second, there are two basic approaches to legalization. The first, a rights-based, civil liberties, or libertarian approach, argues that individuals should be free, in private, to have control over their own bodies as long as they don’t directly harm other people. This approach tends to be favored by lawyers, judges, police, and others in the criminal justice system because it makes the rules of the game clear to all. The second approach, considered a public health or harm reduction, cost-benefit approach, emphasizes preventing the spread of disease and protecting the health of users. It attempts to devise a different strategy for each substance based on the best scientific knowledge available, and tends to be favored by physicians, psychologists, and those in the biomedical and social sciences. There are many varieties of each kind of approach, and many instances where they agree—but there are also points at which they propose quite different policies; and these differences would need to be addressed in any debate over legalization legislation.

Another key assumption underlying drug prohibition is that drugs “hook” victims, so that making drugs illegal will prevent addiction and the spread of associated diseases. There are many problems with this assumption, but I will only discuss a few. First of all, to simply focus on “drugs” while ignoring dosage level and mode of administration is a mistake. (Other relevant variables include the situation in which the substance is used and the effects users expect it to have.) Higher dosage levels are associated with an increased risk of more serious problems, from dependency to death. Similarly, administering a substance by injecting it is a very efficient means of getting it into your system, but also a dangerous one because of the increased risk of transmitting diseases like HIV and hepatitis through shared needles.

Contrary to the above assumption, the “Iron Law of Prohibition” states that prohibition leads to higher dosage levels and more dangerous modes of administration. These consequences follow naturally from the illegal market. Black marketeers want to pack as much of an outlawed substance as possible into the minimum volume, which is the definition of a high-dosage level; and purchasers, because of the inflated black market price, want the biggest bang for their buck. Similarly, because injecting is so efficient a way of using an expensive substance, there is an economic motivation to use this more dangerous means of administration.

Under Prohibition, the United States went from a nation of drinkers of safe beer (low-dosage alcohol) to drinkers of higher-dosage and often contaminated whiskey. After Prohibition the country gradually returned to its preference for beer. Similarly, over time users have gone from smoked opium to injected heroin; from low-dosage cocaine in the original Coca-Cola to inhaled powdered cocaine to crack; and from lower THC levels in marijuana to higher levels. In addition, because marijuana is bulky and has a strong odor it has the black market disadvantages of taking up a lot of space and being relatively easy to detect. This drives up the price of marijuana relative to cocaine and heroin, and creates an economic incentive for users to switch from soft to hard drugs.

A major study published in American Psychologist back in 1990 contradicted the assumption that drugs “hook” victims. Its findings, summarized in the study’s Abstract, have long been known, but are startling to many non-experts, and are worth quoting here:

The relation between psychological characteristics and drug use was investigated in subjects studied longitudinally, from preschool through age 18. Adolescents who had engaged in some drug experimentation (primarily with marijuana) were the best-adjusted in the sample. Adolescents who used drugs frequently were maladjusted, showing a distinct personality syndrome marked by interpersonal alienation, poor impulse control, and manifest emotional distress. Adolescents who, by age 18, had never experimented with any drug were relatively anxious, emotionally constricted, and lacking in social skills. Psychological differences between frequent drug users, experimenters, and abstainers could be traced to the earliest years of childhood and related to the quality of parenting received. The findings indicate that (a) problem drug use is a symptom, not a cause, of personal and social maladjustment, and (b) the meaning of drug use can be understood only in the context of an individual’s personality structure and developmental history. It is suggested that current efforts at drug prevention are misguided to the extent that they focus on symptoms, rather than on the psychological syndrome underlying drug abuse.

In other words, instead of saying that drugs hook victims, a better causal model for drug abuse is to say that people with significant problems self-medicate. In addition, this description of drug use fits with what we know about adolescence. That is, in our individualistic culture, adolescence is a time of experimentation with different options during the transition from childhood to adulthood. Teenagers work summer or part-time jobs, and they are exposed to courses in a variety of disciplines so that they can make informed career decisions. Dating is an institution that provides young people with experience in forming, maintaining, and dissolving intimate relationships, so that they have a basis for selecting a life partner. In a similar way, teen experimentation with forbidden psychoactive substances can be seen as a way of learning their effects so that people can decide whether to use them in the future.

Punishment vs. Reintegration and
Mandatory vs. Voluntary Treatment

Another set of mistaken assumptions underlies current policy regarding prevention and treatment. When it comes to illegal substances, current policy argues that (1) all use is abuse; (2) zero tolerance will discourage use and therefore abuse; (3) punishing users will send a powerful message to others and prevent them from going down the wrong path; and (4) mandatory drug treatment, offered by the courts as an alternative to imprisonment, is an effective and enlightened policy.

An alternative set of assumptions is that (1) only some use, when it is out of control and self-destructive, is abuse; (2) for many individuals and many psychoactive substances, both legal and illegal, controlled, non-problematic use is possible; (3) marginalizing problem users is counterproductive—a more effective strategy is to reduce the harm they do to themselves and others and attempt to reintegrate them into society; and (4) mandatory treatment (for example, in drug courts) undermines the institution of psychotherapy, and is less effective than voluntary treatment.

Tolerance is a virtue, so it’s unfortunate that a slogan like “zero tolerance” has become part of the world of prevention and treatment. A better slogan might be “get a life.”

When the Vietnam War ended and the troops came home, there was great anxiety in the law enforcement community. Tens of thousands of drug-addicted, trained killers were about to descend on American society. The fear was that their cravings for illegal substances, such as marijuana and heroin, would lead to an unprecedented crime wave as their addictions forced them to come up with the money to support their habits.

It never happened. Yes, some continued to have drug problems and others sought treatment, but for the great majority of problem users, they simply stopped. On their own. With no professional help.

This non-crime wave makes no sense according to the “drugs hook victims” ideology, but it is easily understandable if you employ the point of view that people with significant problems self-medicate. In Vietnam, soldiers faced constant danger and staying high made them feel better. Back home, staying high interfered with their reintegration into society. Work, family, love, a better future—all of these depended on attending to and living in reality, not blotting it out.

Years ago, I had a conversation with a marijuana activist. He was an intelligent, college-educated young man who could have earned much more in another line of work, but whose revulsion at our drug policy led him to sacrifice income for what he viewed as a worthy cause. “You know,” he said, “I’ve actually been smoking very little these days.” He described his situation—he worked long hours and needed to keep a clear head; he was in a serious relationship with a woman and wanted to focus his attention on her when they were together; and as a single adult he had responsibilities for feeding himself and maintaining his apartment. In essence, he had a life and was involved with highly valued activities, so that marijuana functioned for him the way alcohol functions for occasional users of that substance—now and then providing a few hours of an altered state of consciousness, integrated responsibly as part of a fulfilling life.

By criminalizing all use we marginalize problem users, which diminishes their likelihood of recovery; and we also marginalize non-problem users who’ve had the bad luck to get caught up in the criminal justice system—thereby creating serious problems for them where none existed before.

Supposedly, mandatory drug treatment offers an enlightened option for users who’ve been arrested. To understand why this is not the case, it’s necessary to have a basic understanding of the way therapy works. To begin with, therapy is based on trust. In voluntary therapy, the therapist is working for the client, and what happens in therapy is protected by confidentiality, which allows the client to candidly discuss anything, including illegal drug use. If the client feels that therapy isn’t working, that client is free to leave altogether, or to seek another therapist. In mandatory drug treatment, the therapist is working for the court, and a client seeking to leave therapy can be labeled as uncooperative, which can result in imprisonment.

For non-problem users, therapy turns into a charade. The individual has to pretend he or she has a drug problem to avoid going to jail. The user then has to pretend to cooperate with the therapist, since lack of cooperation could result in jail time. In this situation, therapists get paid for their time, which provides an incentive to maintain the charade. Eventually, the client is deemed cured and has succeeded in avoiding jail by undergoing the lesser punishment of pretend therapy. (Some people may actually benefit from the process by dealing better with various aspects of their lives, but this is hardly a justification for undermining the institution of therapy by making therapist and client co-conspirators in a lie.)

In order to understand the situation for problem users it’s necessary to consider the role of motivation in therapy. (“How many therapists does it take to change a light bulb?” the relevant joke goes. “Only one, but the light bulb has to want to change.”) Why is it that the success rates in therapy are so much better for anxiety and depression than they are for substance abuse? The reason is that anxiety and depression are unpleasant, so clients are motivated to change. They are likely to cooperate with therapists because they want to experience less of those unpleasant feelings, and more positive feelings instead. The situation is the opposite for overeating, risky sexual behavior, gambling, and substance abuse. These are pleasurable activities, so change—even if it is clearly better for the client—entails a loss of an important source of pleasure. Thus, when clients are self-motivated to change, because they see that they are headed in a bad direction, they are more likely to cooperate with a therapist who suggests difficult or unpleasant tasks than they are with a court-ordered therapist who says “Change, or else!” This is one reason for the slogan “drug treatment on demand.” You’ll get better results with people who want to change than with those who are forced to change against their will.

One form of brief therapy, known as solution-focused therapy, describes three kinds of therapeutic relationships. In a customer relationship, the individual wants to change (technically, the individual is “willing to construct a solution”), and the therapist helps that person to change. In a complainant relationship, the client wants to complain but is unwilling to change (one who might say, “I’d be fine if only my spouse would change”). In a visitor relationship, the individual has neither a complaint nor an interest in changing (such as a child who has problems at school, whose mother brings him or her for therapy, and whose father [the visitor] comes because the therapist asked him to, although he isn’t sure what he’s doing there). In general, solution-focused therapists work directly toward change with customers, and try to convert complainants and visitors into customers.

A colleague of mine suggested that mandatory treatment deserved a separate label as a fourth kind of relationship—a hostage relationship.

In short, replacing the inaccurate assumptions and causal models underlying the war on drugs with better alternatives points to a different way of understanding drug use and abuse and to different drug policy options. These alternatives include shifting our primary aim from attacking drugs to shrinking the black market through a targeted policy of legalization for adults, and differentiating between problem users (who should be offered help) and non-problem users (who should be left alone). We must also shift from a policy of punishing and marginalizing problem users to one of harm reduction and reintegration into society, while shifting from a mandatory treatment policy to one of voluntary treatment. Moreover, abstention need not be the only acceptable treatment outcome—we must recognize that many (but not all) problem users can become occasional, non-problematic users. Finally, moving away from a near-exclusive treatment focus on the substance itself to building on positive aspects of people’s lives, such as work, family, friends, and interests, will enable us to forge a more successful, more humanistic approach to drug use.