Framing the issues
Framing the issues
Abstract and Keywords
The use of psychoactive substances is commonplace in many parts of the world, despite the efforts of policymakers, government officials, public health advocates, and concerned citizens to prevent, eliminate, or control it. If previous experience can serve as a guide, in the future many countries will face periodic drug-use epidemics, followed by aggressive policy responses to suppress them. Continued endemic drug use generates a patchwork of policy responses that never quite keep up with the problem. The scientific evidence on the impact of policy constitutes the core interest of this book and consists of three broad approaches: programmes to prevent drug use, treatment and harm-minimization services that help heavy drug users change their behaviour, and supply control programmes to restrict access to illicit substances. This book suggests that public health concepts provide an important vehicle to coordinate supply control and demand reduction.
The use of psychoactive substances is commonplace in many parts of the world, despite the best efforts of policymakers, government officials, public health advocates, and concerned citizens to prevent, eliminate, or control it. If the last century’s experience can serve as a guide, in the future many countries will face periodic drug use epidemics followed by aggressive policy responses to suppress them. In many other countries, continued endemic drug use (i.e. regular and widespread consumption) will generate a patchwork of policy responses that never quite keep up with the problem. These policy responses, or more specifically, the scientific evidence on the impact of policy, constitute the core interest of this book. We set out to determine first whether drug policy can be informed by scientific evidence and, if so, how evidence-informed policy can serve the public good. Having stated our goal, the remainder of this chapter describes why drug policy is important, whether an evidence-informed approach is possible and how this book will inform the policy debate.
1.2 Why drug policy matters
The use of psychoactive substances dates to the dawn of recorded history and may well represent a basic neurobiological process that has contributed to human evolution (Hill and Newlin 2002). The application of public policy to address drug-related problems is a more recent development that reflects how governments and societies struggle with substances that can induce pleasure and aid the work of medicine, yet also cause enormous harm to the individual user and society. Box 1.1 presents examples of the kinds of drug policy issues that have captured the attention of journalists, the public, and government officials, and which will be the subject of this book. Selected from different parts of the world, these vignettes highlight the individual and societal impact of illicit drugs and drug markets, and draw attention to the need for effective policy measures that reduce drug-related violence, disease, and suffering. They also suggest that some policies designed to ameliorate drug-related problems can have unintended consequences that can be as serious as the problems they are designed to solve.
Despite the pessimistic pictures portrayed in these vignettes, glimmers of hope come from several directions. The examples in Box 1.2 show that when drug policies target specific problems and populations, and when they are informed by sound scientific evidence, they can alter the course of drug use and even drug epidemics. Building on the cumulative research base relevant to drug policy and (p.5) the growing capacity to use modern epidemiological methods to monitor drug use trends, this book examines the extent to which drug policy can be informed by scientific research at the local, national, and international levels.
1.3 What we mean by the term drug policy
Drug policy as a field of government activity has a lengthy history. Today governments around the world have developed a variety of laws and programmes (p.6) intended to influence whether or not individuals decide to use psychoactive substances and to affect the consequences of use for both the individual and the community. A subset of such substances, essentially those not in everyday public use in industrialized societies in the first half of the twentieth century, are denominated as ‘drugs’. The laws and programmes governing these substances constitute the drug policy of a given nation (Kleiman 1992; Longshore et al. 1998). The laws typically prohibit or regulate the possession, use, distribution, and production of these substances and set penalties for violations. Programmes include campaigns to persuade children not to try the substances, services to help users either stop drug use or use them in less dangerous ways, and efforts to discourage producers from making and distributing drugs. They also attempt to control the medical prescription of certain drugs, with penalties for breaches of regulations.
Drug control programmes occur in many different government sectors, including schools, communities, health care, policing, and border control. A country’s ministry of education might provide funds for primary school teachers to deliver drug prevention classes, whereas its ministry of health might fund methadone maintenance clinics for heroin-dependent patients. Contemporary drug policy therefore constitutes a broad range of administrative actions and government agencies. These actions comprise three areas, each of which will be covered in this volume: 1) programmes to prevent the initiation of drug use by non-users, 2) treatment, rehabilitation, and social service programmes intended to help heavy drug users change their behaviour or reduce the consequences of their drug use, and 3) laws, regulations, and initiatives to control the supply of illegal drugs, as well as the supply of diverted prescription drugs used for non-medical purposes. The latter category typically differs from the other two by having an international as well as a domestic component.
In most countries the non-medical use of many psychoactive substances is illegal, thereby denying government the ability to use the policy levers such as regulation and taxation of suppliers that are available for legal substances like alcohol and tobacco. Finally, drug policy may include government sponsorship of scientific research, programme evaluations, and monitoring initiatives. These activities have grown substantially in the past 25 years as part of the policy response to drug-related problems in many industrialized countries, and will be considered in this book as a part of a long-term solution.
1.4 The need for a global, evidence-informed approach
There are four reasons why a busy policymaker, the general reader, or the less actively involved student of drug policy should invest precious time in reading this volume.
Drug policy is a complex entity inherently shaped by both national and international trends. The growing globalization of trade, technology, travel, and even criminal activities, creates a need to approach drug policy at both levels. Although many high-quality policy books take a single country as their focus, this book attempts to place local and national perspectives in an international context. The Political Declarations and Plans of Action adopted by the member states of the United Nations in 19981 and in 20092 constitute two important milestones in addressing the world drug problem within an international context. Both declarations sought to enhance international cooperation in countering the world drug problem, which was seen as a shared responsibility. Specific goals and targets to reduce the supply and the demand for illicit drugs were also agreed by member states. At the high-level segment of the fifty-seventh session of the Commission on Narcotic Drugs, held in 2014, member states evaluated the progress made since 2009 towards meeting the goals, concluding in a joint statement that the initial goals had not been met and further action was necessary (United Nations Office on Drugs and Crime 2014). This book represents the view that scientific research can inform that process.
1.4.2 The team of authors
This book is based on a series of integrative reviews of the world literature related to drug policy and the interpretation of that literature to better inform the policymaking process. The authors met three times for plenary sessions to develop themes, critique each other’s chapter drafts, discuss the meaning of newly collected data, and draw conclusions from both the data and the literature they were reviewing. Once a set of chapters had been drafted, a smaller committee of senior editors was asked to synthesize the contributions into a single narrative that describes the dimensions of the global drug problem, and the different policy options designed to address it. Our use of an international team of authors brings to the task a variety of disciplinary orientations and cultural backgrounds, and increases the range of scientific material upon which the book draws. The team includes both individuals who have made careers studying drug policy and those who have worked in the development or execution of governmental drug policy.
1.4.3 The focus on evidence
Public policy often does not take into account the scientific evidence about the nature of the problem being addressed and the likely impact of various interventions. We have reviewed literature from numerous academic fields, including history, epidemiology, psychiatry, psychology, economics, criminology, political (p.8) science, and sociology to draw conclusions for government, policymakers, and the public health community. While we recognize that individual citizens and policymakers will often base drug policy on their moral and cultural values, this book promotes scientific evidence, public health, and the public good as added considerations in the formulation of drug policy.
1.4.4 A ‘public good’ perspective
To speak of policy is implicitly to ask the question: ‘Policy for whom and for what?’ We focus our discussion in this book on the ‘public good’, a concept that comprises public health but is not limited to it. Unlike clinical medicine, which focuses on the cure of diseases in individual cases, one patient at a time, public health is a specialized field of knowledge committed to the management and prevention of adverse health conditions in groups of people, formally termed ‘populations’. The value of a population perspective lies in its ability to suggest appropriate policies and interventions that are most likely to benefit large numbers of people at the level of a community or a country. The concept of population assumes that groups of people exhibit certain commonalities by virtue of their shared personal characteristics (e.g. adolescence), shared environment (e.g. inner city neighbourhood), or shared cultural norms (e.g. sharing a cannabis cigarette), and those commonalities increase their risk of disease and disability (Fos and Fine 2000).
Why are these public health concepts important to the discussion of drug policy? During the twentieth century, public health measures have had a remarkable effect on the health of populations throughout the world. Life expectancy has increased dramatically during this period, owing in large part to the application of public health measures designed to improve sanitation, reduce environmental pollution, and prevent communicable and infectious diseases (Prüss-Üstün and Corvalán 2006). But even as epidemics of infectious and communicable diseases have receded, health risks associated with lifestyle behaviours and chronic diseases have increased in importance as major causes of mortality, injury, disease, and disability. When policymakers use population approaches instead of, or in conjunction with, individually-oriented medical and criminal justice approaches, the overall effects on health, disease, and even social problems are likely to be much more pronounced. As this book will show, public health concepts provide an important vehicle to manage the health of populations in relation to the use of psychoactive substances, partly because these interventions emphasize the need to change the environment as well as individual behaviour.
A public good perspective embraces public health but also goes beyond it. Indeed, a pure public health approach has significant limitations. As has been (p.9) noted by public policy scholars (e.g. Cook et al. 2002), societies do not weigh social problems solely on the basis of public health indicators. For example, when someone is killed in a gun battle between a drug dealer and the police force, people assess the resulting death differently depending on whether the person killed was the drug dealer, a police officer, or a bystander. But in a strict public health framework, a death is a death. Another limit of a pure public health approach is that the damage of drug use does not always become apparent in health statistics. Likewise, in a drug-motivated robbery in which no one is injured, the anger and sense of injustice experienced by the victims may warrant a policy response despite the lack of injury. Finally, there may be societies in which belief in individual liberty from government interference is so deeply valued that substantial health harm seems a reasonable price to pay for it.
1.5 Evidence-informed drug policy: is it possible?
Although most scientific research has policy implications, it was not until the 1970s that scientific investigators began to evaluate specific prevention, treatment, and enforcement policies in the area of illicit psychoactive substances. Chapters 2, 3, and 4 will show that researchers have applied the science of epidemiology with increasing sophistication to study the prevalence of drug use, the distribution of drug problems across population groups, and the underlying causal influences that account for substance use. Current epidemiological research methods, particularly social surveys and the monitoring of vital statistics (called disease surveillance), make it possible to estimate the prevalence of drug use with reasonable accuracy and to describe trends in drug use and drug problems. In addition to the expansion in epidemiological research tools, the necessary infrastructure has grown to support an international cadre of policy researchers focusing on the problems associated with psychoactive drugs (Babor et al. 2017). That growth is illustrated by the increasing numbers of addiction specialty journals, career professionals, specialized research centres, and scientific publications relevant to drug policy.
All of these developments make it possible to create a scientific evidence base for the evaluation and implementation of drug policy. As noted in Chapter 7, a variety of scientific methods are available to investigate the effects of different intervention strategies. Saltz (2005) has characterized these methods as falling into three broad categories:
1. Natural experiments: studies of variations in environmental forces, including policy changes, such as the initiation of a new drug enforcement programme, in relation to changes in drug use or its consequences within a population.
3. Effectiveness research: studies of the effectiveness of a particular intervention in natural settings.
In addition to these general research approaches, researchers have also investigated the effects of drug policies using the methods of historical analysis, economics, sociology, and ethnography (MacCoun and Reuter 2001b; Thoumi 2003). Given the variety of methods available for policy evaluation and analysis, we answer affirmatively the question of whether science can inform the development of drug policy.
1.6 A note on terminology
The choice of words is an important part of communication. Terms that are familiar and colloquial, like addict and addiction, lack precision and can be used in diverse and sometimes pejorative ways, promoting miscommunication. Terms like psychoactive substance, on the other hand, may seem overly technical. The authors have attempted to strike a balance between the economy of familiar terms and the precision of science.
Here is what we mean by the most important terms the reader will encounter in this book. The term psychoactive drug (or drug for the sake of economy) refers to a substance capable of influencing brain systems linked to reward and pleasure. In general, we use it to mean substances, otherwise known as illicit drugs, which fall in the sphere of drug policy as defined in Section 1.3 ‘What we mean by the term drug policy’, where the non-medical supply or use of the drug has been widely prohibited. This definition covers both diverted pharmaceutical agents that may have therapeutic value, such as opioid pain medications, as well as the more common substances prohibited in most countries, such as heroin, cocaine, and cannabis. We use the term drug use because it is transparent, neutral, and free of moral judgement: it covers drug taking, of which society may approve or disapprove. Similarly, we use the terms drug misuse, harmful use, or problematic drug use to describe the point at which psychoactive substances cause problems for the user or for society. We favour these terms over the more familiar term drug abuse, which has often been used with the same meaning as ‘drug use’ and may convey pejorative meanings, and because our main purpose is to distinguish use that is relatively free of apparent consequences from use that causes social, psychological, or medical problems.
Another important term, drug dependence, refers to a psychobiological syndrome characterized by impaired control of drug use, an acquired ability to (p.11) tolerate large amounts of the drug, continued drug use in the presence of adverse personal consequences, and the experience of withdrawal symptoms when drug use is stopped. Drug dependence has now replaced the term drug addiction in formal medical diagnostic terminology used in the International Classification of Diseases (World Health Organization 1992). We use the term drug-related problems when referring to the social, legal, psychological, and medical consequences frequently associated with the use of psychoactive substances. Other terms indicated in bold letters throughout the book are defined in the Glossary at the end.
Finally, whenever we employ drug-related terms in this book, the reader should assume that we are not referring to alcohol or nicotine. Although these psychoactive substances have the potential to cause as much harm to individuals and society as illicit drugs, their legality in most societies creates a major contrast from a policy perspective. For reasons of convenience as well as consistency, we do not deal with these other psychoactive substances except for some important comparisons drawn in Chapter 2.
We do, however, give considerable attention in this book to psychoactive medications, which are typically available in industrial societies only with a doctor’s prescription. Though the prescription system strives to keep the market for medications separate from the markets for illicit drugs, there are many points of overlap, and considerable blurring of the boundaries between the two markets. It is thus increasingly necessary to take psychoactive medications into consideration when formulating policy concerning illicit drugs.
1.7 The structure of this book
The chapters in the first section (‘Introduction’) provide a conceptual overview of the ways in which illicit drugs can be understood from a public health perspective. The chapters in the second section (‘Epidemiology: the global dimensions of drug misuse’) describe the extent of drug use throughout the world, significant trends in drug epidemics, and the global burden of disease and disability attributable to drug misuse. Section II also includes two chapters on the nature of the drug markets that produce drugs and distribute them as economic commodities. After a brief overview of the rules of evidence necessary to evaluate the scientific basis of drug policy in Chapter 7, the third section (‘The evidence base for drug policy’) describes the research supporting different strategies and interventions that are part of the policy response to drug use in many countries. These include school-based prevention programmes, attempts to control the supply of drugs, criminal sanctions applied to drug users and drug sellers, health, rehabilitation, and social services for heavy drug users, and ways to prevent diversion of prescription drugs to illicit use. The fourth section (p.12) (‘Drug policy and system issues at the international level’) contains three chapters that discuss the international drug control system, the organization of treatment services and the critical issue of legalizing illicit substances such as cannabis. The final section (Section V, ‘Synthesis and conclusions’) summarizes the main themes of the book and draws conclusions about the impact of various drug policy options.
We believe that any review of drug policy should evaluate what it is, how it works, and whether it is effective. The analysis should also discuss why we need drug policy, which is where we begin the scientific part of this book, and what science can tell us that will serve the public good, which is where we end our book. By including a scientific perspective and public health concepts in our analysis of the connection between drug policy and the public good, we challenge the reader to join our search for effective drug policy.
(1.) 1998 Political Declaration and Plan of Action available at: https://www.unodc.org/documents/commissions/CND/Political_Declaration/Political_Declaration_1998/1998-Political-Declaration_A-RES-S-20-2.pdf (accessed 30 January 2018).
(2.) 2009 Political Declaration and Plan of Action available at: https://www.unodc.org/documents/commissions/CND/Political_Declaration/Political_Declaration_2009/Political-Declaration2009_V0984963_E.pdf (accessed 30 January 2018).