The War on Drugs or the War on Drug Users? Doing More Harm than Good – Tom Fitzgerald

The “War on Drugs” was officially declared by President Nixon in 1971. In a statement to Congress, Nixon stated that “We must rehabilitate the drug user if we are to eliminate drug abuse and all the antisocial activities that flow from drug abuse (1).” Additionally, he acknowledged that “we must also deal with demand (1).” In the 40 years since this declaration, at one time an effort to rehabilitate drug users and re-integrate them into society and reduce the antisocial activities associated with drug use, the War on Drugs has shifted from this original premise into one of enforcement and incarceration, making the US into the most incarcerating nation on Earth. The War on Drugs has not only failed to improve public health, but in many ways has been detrimental to the health of the US population. The war against the invisible drug enemy has proven unsuccessful in decreasing drug use, but massively successful in increasing HIV among the drug using population. From 1998 to 2008, the use of opiates, cocaine, and cannabis worldwide has all increased by 34.5%, 27%, and 8.5%, respectively (19). Namely, by criminalizing drug users, the War on Drugs has stigmatized a large group of individuals and prevented them from being able to seek appropriate care, resulting in a “social war on those who can be classified as drug users (2).” The focus of public health efforts at this time should NOT be to decrease drug use, but the harms associated with it, namely HIV infection and crime.

This paradigm shift can be attributed to numerous factors. To begin with, “Nixon’s statement to Congress was delivered before the rejection of rehabilitation as legitimate and effective correctional tools. By the end of [the 1970s], rehabilitation was dead, determinate sentencing was the norm and incarceration was the preferred response to all types of crime (3).” America’s response to the global drug market was not originally a public health response, but rather, an economic one. Concerned about America’s place in international trade (such as Britain’s massive profits selling opium from India to China), Nixon allied his CIA with the Hmong General Van Pao during the Laotian Civil War. Van Pao, a Laotian warlord, was able to gain control of the Laotian opium trade with the help of the CIA, and US troops in Vietnam became his most valuable customers (2). “In short, Nixon’s war on drugs…followed a long tradition of contradictory motivations and actions that undercut the expressed goal of fighting illegal drug use…[which] characterize America’s continually renewed War on Drugs since the Nixon presidency (2).” Prohibitionist policies implemented to decrease drug supply and consumption have actually strengthened the drug trade. The end result of this is more prevalent use and abuse of drugs, which are available more widely at higher purity and lower prices than ever.

Between 1981 and 1996, the US drug law enforcement budget increased from $1 billion to $9 billion, and to $12 billion in 2004 (4). For perspective, federal funding for AIDS research was only $200,000 in 1981 and $3.85 billion in 1999 (5). According to the Office of National Drug Control Policy, the economic cost of drug abuse in 2002 in the US, representing “both the use of resources to address health and crime consequences as well as the loss of potential productivity, death, and withdrawal from the legitimate workforce (4)” was $180.9 billion (4).

Critique 1: Labeling and Stigmatization of Drug Users

Although the term “War on Drugs” did not emerge until 1971, the US has been fighting a war on drug users since long before the Nixon presidency with the passing of the Harrison Act in 1914. Before the 20^th Century, drug use was largely considered legal and normal behavior: 15% of the 10,200 prescriptions filled in Boston in 1888 contained opiates (2). Opiate use was not a “drug problem” among mainstream Americans; it was only a drug problem when it was linked with prejudicial ideas and beliefs about race and society. Opiate use was only a problem when the Chinese smoked it in opium dens, and some whites, especially in southern states, feared that “if Blacks had access to cocaine, they ‘might become oblivious of their prescribed bounds and attack white society (2).’” Opium and cocaine were “associated in the popular imagination with the seduction and rape of White American women (6).” In 1914, the Harrison Act, by condemning drug use as an immoral and criminal activity, officially classified the drug user as a criminal. “In the aftermath of this labeling, drug use came to be synonymous with deviance, lack-of-control, violence, and moral decay…by the 1920s the public image of the addict had become that of a criminal, a willful degenerate, a hedonistic thrill-seeker in need of imprisonment and stiff punishment (2).”

Stigma is one of the largest implications of the war on drugs for public health, as it prevents or delays progress on many different levels, including the initiation of treatment and re-integration of drug addicts into society. The negative effects of labeling on drug users are interpersonal, internal, and institutionalized. The Centre [sic] for Addiction and Mental Health (CAMH) defines stigma as “an attitude that is deeply discrediting (7)” and inherently associated with something which “deviates from what society has deemed ‘normal (7).’” This deviance involves the adoption of “roles” which become the lens through which the stigmatized individual, as well as society, views him or herself. As a result, the stigmatized person becomes isolated from other non-stigmatized groups in society (7).

The enforcement of drug laws is highly discriminatory, and the inmate population in the US does not at all accurately reflect the prevalence of drug use in the states. Since 1980, the number of people incarcerated for drug-related offenses has increased tenfold, mostly consisting of low-level dealers and users. There is, however, “strikingly little evidence that increase punishment has, or will significantly decrease drug use (8).” Racial disparity is evident in the drug enforcement system: African-Americans, while only accounting for 15% of cocaine use in America, comprise 40% of those charged with powder cocaine violations and 90% of crack cocaine convictions (which carries a much harsher punishment, even for a first offense) (4). Every one in every fifteen African American males in the US is incarcerated, making up 55% of the US prison population, convicted for illegal drug possession. As previously mentioned, however, the availability of drugs such as heroin and cocaine are increasing, while prices are decreasing.

People often attribute behavior to character, rather than to the context in which they occur. This is called the Fundamental Attribution Error, and it fuels the stigmatization of drug users. According to a 2010 Survey on Attitudes to Drug Dependence, approximately 58% of people feel that “One of the main causes of drug dependence (DD) is a lack of self-discipline and will-power (10),” while only 15% agree with the same statement made of those with a mental illness (MI). About 37% agreed that “there is something about people with DD that makes it easy to tell them apart from normal people” (vs. 19% for MI), and 48% agreed that “People with DD are a burden on society” (vs. 8% for MI) (10). Analyses of agreement with other statements show similar results: people do not recognize drug addiction as a disease that deserves treatment like mental illness, and feel less responsible for ensuring that they are provided care and re-integrate into society (10).

Because of the fear of being stigmatized as a “junkie” or “hopeless addict,” many drug users are reluctant to initiate therapy, as this would require admitting to themselves and others that they are social deviants, succumbing to a label they will never be able to rid themselves of. Often, addicts feel that they are undeserving of treatment, that they are “not worth bothering with” by society (10). Family members and friends often felt similarly, as they themselves felt ashamed and embarrassed to confront the issue, believing that the afflicted individuals should be able to “sort things out themselves (10).

Stigma of drug users is present at all levels of society, including those in health care who are supposed to be helping people to recover from their addiction. Examples include healthcare workers refusing to treat addicts or forcing them to wait for much longer than normal or in separate areas, speaking to them in a condescending manner or announcing phrases such as “here is your methadone” loudly enough for others to hear. All of these examples strengthen the stigma of drug users and prevent them from initiating or continuing treatment (10).

Critique 2: Use of the Health Belief Model

The main model underscoring almost all public health efforts, including the War on Drugs, is the Health Belief Model. According to this model, behavior is a “function of the subjective value of an outcome and the subjective probability, or expectation, that a particular action will achieve that outcome (11).” It asserts that individuals will perform some type of behavior in order to prevent or treat some kind of health condition. The main components of whether or not a person will take action are his/her perceived susceptibility, perceived severity, perceived benefits, and perceived barriers (11). The Health Belief Model (HBM) is an individual level model, and does not take into account external social forces acting on an individual that cause him or her to act in a certain way that may not be in accordance with how the HBM would predict.

The HBM was the driving ideology behind programs such as Drug Abuse Resistance Education, or D.A.R.E. Started in Los Angeles in 1983, D.A.R.E is a school-based intervention designed to teach children about drugs and violence. It is run by specially trained police officers, and currently exists in over 75% of American school districts (12). Its efficacy has recently come into question as budget cuts have forced many school districts to discontinue their D.A.R.E programs. The surgeon general has categorized the D.A.R.E program as one that “Does Not Work (13)”. Evidence suggests that D.A.R.E programs have little to no effect on deterring drug use or violent behavior. The surgeon general cites the lack of the utilization of social skills in its curriculum as a factor for this failure (13). A similar drug education program in California schools showed similar results: less than 15% of students self-reported that the program affected their decision regarding personal drug use and 70% reported that it was “negative” or “neutral” in impact. Additionally, many students claimed that the program often singled out students who did use drugs, and that these students were sometimes suspended or expelled from school, further contributing to the marginalization effect from labeling individuals as drug users (14).

By criminalizing drug users, the philosophy of the War on Drugs is that they are then entered into a corrections system where they are rehabilitated and can then re-enter society. As previously mentioned, 55% of American inmates have been incarcerated for a drug-related offense; often these are minor crimes. The idea is that “incarceration might deter offenders from returning to criminal behaviour [sic] upon their release and that it scares off others from committing drug-related crimes in the first place (15).” Evidence indicates, however, that increased incarceration does not result in decreased rates of crime, nor does it deter others from committing crimes (15). “In fact, the opposite is true. Re-offending is a major problem among individuals who commit drug-related offences [sic], with evidence suggesting that incarceration increases the chances of repeat offending (15).” According to the HBM, we would expect liberated inmates to experience firsthand what using drugs was putting them at risk for (further incarceration), and realize that they are, in fact, susceptible. This should lead to a change in behavior towards rehabilitation, when, in reality, it does not.

Incarceration does not necessarily prevent inmates from using drugs. In many cases, being incarcerated can increase one’s drug use, as drug use is seen as socially acceptable, or as a social norm in prison (15). This can lead to exacerbated drug dependency and problems among inmates who are then released in worse conditions than they entered the corrections system, making them more likely to re-offend on account of drugs (or related crimes such as violence). Even if they do not re-offend, ex-convicts encounter significant difficulty finding and maintaining steady employment. There are different kinds of people arrested for drug violations, and the criminal justice system does not distinguish them from each other when it should. There are those who use drugs recreationally but do not commit violent acts, those who use drugs and are involved in criminal activity to finance their habit, those who are involved in drug dealing and trafficking, and those who use drugs and commit unrelated violent acts. Perhaps the first two categories should be dealt with separately from others in order to treat the drug problem, rather than exacerbate it in prison and then release an even more dependant person into society, where he or she is more likely to commit a violent crime than before incarceration (15).

Critique 3: Abstinence as a Social Expectation

With the criminalization of drugs and those who use them in the early 20^th Century, the United States sent the message that drug use was no longer to be considered acceptable. By changing the law to prohibit certain harmful behaviors, the US hoped to change behavior and beliefs about what was acceptable and what was not, rather than by changing attitudes in the hope of changing behavior. As we have seen, though, the war on drugs has become a war on drug users, and by criminalizing minor criminals and releasing them after they have served their time, we can actually increase the amount of crime and drug use thereafter. The American hard line stance on drugs has been unyielding, and those who criticize it or adopt less prohibitive policies (such as harm reduction strategies including needle exchange) are dubbed “soft on drugs,” a label no public figure wants to have if they wish to remain in good standing with their constituents (19).

Recognizing that drug-related harms are a greater threat to public health than drug use itself, other countries throughout the world have embraced some of the values of harm reduction, a loose set of principles intended to decrease the “adverse health, social, and economic consequences of drug abuse without requiring abstinence from such use (4).” Harm reductionists accept drug use as an inevitable social norm that has existed for millennia, and realize that many campaigns to eliminate it have proven ineffective and in many cases can exacerbate the problems. Abstinence is not the social norm, but the use of drugs is. It is often argued that harm reduction and abstinence are mutually exclusive when they are not. Reduction in the levels of use may be the most effective way to decrease harms in certain scenarios. However, harm reduction emphasizes pragmatism to identify and prioritize goals to truly improve public health; one of the first concessions that must be made is that complete abstinence is an impossible goal, at least for the time being (9).

The War on Drugs does not embrace this mentality, but maintains that the problem is drug users, and that the only way to mitigate the drug problem is by enforcing criminal laws and incarcerating those who break them. These laws ignore the truth that drug abuse is an addiction, and simply outlawing it does not solve the problem, but in many cases can aggravate it. Needle Exchange Programs (NEPs) have encountered much resistance due to this mindset, as opponents falsely claim that their mere presence encourages drug use when there are no data indicating such. In fact, health outcomes often improve in areas where NEPs are implemented as a result of addicts coming into contact with the health care system (16). NEPs do not operate in a vacuum, but in a “continuum of care” and often provide the first opportunity for drug users to seek treatment. Because of this contact, harm done to users (such as new HIV infection from sharing needles) decreases, as does harm done to sexual partners, children, and other members of society. Unfortunately, drug paraphernalia laws often prohibit or limit the extent to which these services can be provided in different communities. Some laws force NEP workers to operate underground, at risk for arrest; this actually helped to promote NEPs to target populations. Both were using illegal products and putting themselves at risk of arrest, which carries “tremendous social meaning” in the drug-using community (16).

By utilizing social expectation theory in the attempt to alter behavior, lawmakers have created laws that prohibit and penalize behavior that actually lead to better health, forcing those who work to improve public health to operate outside of the law. Though this criminal activity created a bond between public health workers and their target population, drug use needs to be accepted as a social norm if real progress is to be made against the harms it causes. Simply altering the law to criminalize drugs and users (and public health workers) is not an efficient strategy, as it ignores the fact that drug use is inherent in society and the data that show that criminalizing it does not solve the problem (16).

Alternative Approach to Harms Caused by Drugs

Defense 1: Drug Use as a Social Norm

The main issue of the war on drugs, from which most others stem, is the criminalization of drugs and drug users. One possible alternative to mitigate some of the harm engendered by this ideology is to experiment with the idea of legalization or decriminalization of “softer” drugs. We have seen that jail time is not a deterrent to crime and drug use, and as America incarcerates more people than any other nation on earth, legal expenses and supporting corrections facilities costs massive amounts of public money. Additionally, it has been shown that many drug users, once released, are likely to re-offend, and often the degree of crime escalates after imprisonment (15). The US should embrace scientific evidence in formulating policy and follow the lead of Canada and European nations by ending the so-called “War on Drugs” and its prohibitionist drug policies and experimenting with legalization and decriminalization of certain drugs, as well as implementing harm reduction strategies more widely. If we are serious about impeding the harms associated with drug use, namely HIV acquired through the sharing of needles, we must introduce public policy based on achievable objectives and stop worrying about “sending the wrong message,” as data suggest such interventions do not do so. Despite “clear evidence that the war on drugs is ineffective, costly, inhumane, and harmful to the user and society, the choice to stay the course as a societal response is ultimately a moral choice with drastic consequences (17.)”

Instead, the US should follow the example of many European nations and Canada in accepting that drug use is an inherent social norm and take pragmatic steps towards reducing the harms associated with drug use. The main harm, especially among intravenous drug users, is the risk of HIV infection among users, as well as their sexual partners and children. Other countries have recognized HIV infection among intravenous drug users as a much greater threat to public health than drug use itself, as it constitutes a growing proportion of new and existing HIV infections, and as those with HIV are living longer, they are capable of infecting more people (18).

The Global Commission on Drug Policy’s report from June 2011 also supports these interventions, as they deemed that “the War on Drugs has failed (19).” Regarding sound drug policy, the commission states that policies must “take into consideration diverse political, social, and cultural realities. Policies should respect the rights and needs of people affected by production, trafficking, and consumption (19).” By accepting drug use as a social norm, countries are better able to meet the needs of their people and develop policies that produce better health outcomes.

Defense 2: Maslow’s Hierarchy of Needs and Addiction Maintenance

As the Global Commission’s report noted, countries must respect the needs of people affected by drugs before they can begin to even think about rehabilitation (19). According to the National Institutes of Health, drug dependence is defined as “a person need[ing] a drug to function normally…Drug addiction is the compulsive use of a substance, despite its negative or dangerous effects. A person may have a physical dependence on a substance (20).” Abraham Maslow, in his hierarchy of needs, groups human necessities into different levels. Each lower, or more basic need must be satisfied before a person can seek to fulfill needs in the next level up (21). At the very base of the pyramidal hierarchy rest physiological needs. Included in the category of physical needs are food, water, and bodily comfort. The next step up is safety, or concern for danger, followed by belongingness and love needs, and then esteem needs (21). The Health Belief Model operates under the assumption that those basic, or deficiency needs have been met. However, in most cases of addiction, they have not been. Addiction causes a physical dependence on a substance, and without that substance, a person’s most basic physiological needs are unmet, as he or she is unable to function normally. It is clear that the concern for safety is unmet as well, considering the extreme measures that addicts will take in order to satisfy the primal physiological needs, even knowing the health consequences of doing so. Public health interventions must consider this in approaching the issue of drug addiction and harm reduction, as efforts above the primary level will prove fruitless unless the individual’s most basic needs are met. Even after the physiological needs are met, those of belongingness, love, and esteem are still lacking due to the stigma associated with being labeled a drug user.

One method that has proven effective in meeting the physiological needs of opiate abusers is methadone maintenance treatment. Methadone is a synthetic opiate that binds to the same receptors in the brain as heroin, satisfying the physical dependency. Unlike heroin, however, methadone does not provide the user with a euphoric “high.” Therefore, methadone can be used to allow addicts to retain normal functioning and re-integrate into society, as it can be administered orally and can last up to 36 hours (22). By satisfying the physiological needs of an addicted individual, further public health interventions such as counseling and employment assistance, can be more effective. Unfortunately, since methadone is classified as an opioid, it is still illegal in many jurisdictions (22).

While there is no “cure” for addiction, methadone maintenance treatment allows users to abstain from illicit drug use; because of the high doses of methadone used for maintenance, it requires a much higher dose of heroin to achieve the same euphoric effects. Drucker argues that “getting off methadone is not a goal of methadone treatment, any more than getting a successfully managed diabetic off a regime of insulin is the correct treatment for that condition (22).” The way addiction is portrayed and thought of, or framed, needs to change in order for public health interventions to be effective. A “medical model” most accurately identifies addiction as a medical condition, rather than a criminal one that places the user at fault.

Defense 3: Community Organization and Empowerment for Advocacy

Another model that can be used to influence behavior change among the drug using population is community empowerment, a group-level model of behavior change. Community empowerment, or organization, is defined as a model where “people “define their own goals, mobilize resources, and develop action plans (23).” A group of affected individuals organize and act in order to enact social change. This is important for groups such as drug users, as they have been stigmatized by their affliction and marginalized so much that they often do not seek treatment, believing that they are not worth the effort to help (19). There are three levels of community organization, though the one most relevant to the adoption of harm reduction is social action, whereby a community is empowered to solve its own problems and to implement change by eliminating unjust policies in major institutions (23). Since intravenous drug users had been stigmatized long before the advent of HIV/AIDS, the identification of intravenous drug use as a risk factor for HIV transmission exponentially worsened the stigma (7). Drug users were unable to resist the stigma, as the drug war ideology had labeled them as deviant and untrustworthy. They also lacked the political clout that many gay male communities had accumulated which enabled them to better advocate for themselves. In effect, drug users found it impossible to advocate for themselves (7).

Since the 1980s, though, different groups of drug users and public health professionals have advocated for drug users and harm reduction. The first example of this occurred in Amsterdam in 1984, where the city’s Junkie Union created its first needle exchange program to slow the spread of Hepatitis B. As one of the first harm reductionist movements, the Junkie Union posited that since addiction was classified as a medical condition, efforts should be made to minimize the harm that intravenous drug users cause themselves and others by providing access to treatment, since total abstinence was viewed as unattainable (16).

While beneficial, traditional needle exchanges tend to be geared only towards a subset of the drug using population, leaving others without access to services. Sarah Kershnar, director of the Harm Reduction Coalition, has stressed that “unless policy makers and educators interact with youth in the development of programs designed to deal with the problems of drugs, AIDS, and violence, young people will continue to see them as condescending and patronizing in their approach (14). Heather Edney, director of the Santa Cruz Needle Exchange Program in California, advocates that not only “recovered” addicts should be included in outreach and harm reduction programs, but also current drug users in order to be better able to “reach” the target population. Edney points out that “the purpose of the Santa Cruz program is not to ‘help’ young people – rather, young people want to learn how to do it for themselves; the program tries to provide the, with the services and tools to do just that (14).” This community organization and empowerment provides for a “bottom-up” rather than “top-down” condescending approach to resolving problems associated with drug use. With this empowerment, groups can begin to take steps towards reducing stigma and changing policies that aggravate, rather than mitigate public health. Ending prohibitionist drug policies may allow drug users who would not seek treatment or self-advocate under older laws to do so. By beginning to eliminate the stigma we force upon drug-addicted members of society, it may be possible for them to organize and advocate in order to provide their own communities with the skills and resources needed to improve health outcomes.

REFERENCES

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