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Evaluating the Effectiveness of Harm Reduction Strategies vs. Prohibition

   

Added on  2019-09-22

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The immense harms thatdrugs(illicitdrugs, alcohol, and tobacco) cause both users and nonusers have prompted many governments to impose strictly enforced bans on production and possession of some of these substances. Such bans can help constraindruguse. However, prohibition also causes its own harms, including harms from black market crime and violence.Druglegalizationwould ameliorate the black-market harms, but increase some other harms by decreasing price and thus increasing use and dependence. This paper gives readers aframework forunderstandingthe pros and cons oflegalization, and some of its complexities, including the differences between state and national levellegalization, the monetary and human costs of regulation and enforcement, and effects of different policies on youth. It also discusses "middle path" policy options, such as decriminalization, policy changes under prohibition, and harm reduction. The aim is to peel away the rhetoric of thedruglegalization/prohibition debate, not to argue for any specific policy.Keywords: Substance abuse,legalizationIntroductionIn a sense,drugsare just consumer goods, like doughnuts and dietary supplements. But caveat emptor is no longer the rule for even routine consumer goods. Doughnut shops must comply withpublic health inspections, and nutraceutical manufacturers must follow good manufacturing practices, eschew false labeling, and report the adverse effects of their products. Regulation is not the same as prohibition, though. Governments generally do not block the open market from catering to consumer desires.There are exceptions, often rooted in cultural or religious mores. Both Judaism and Islam proscribe pork, a ban that several Muslim-majority states have incorporated into their national laws. Prohibitions of consumer goods are less common in contemporary secular societies, but still occur. Health, quality of life, ethics, and human rights concerns motivate laws forbidding prostitution, child pornography, and human organ markets. Other bans protect non- humans, such as those against the ivory and tropical hardwood trades. In 2006 Congress effectively banned eating horse meat by withholding federal funds for required slaughterhouse inspections. The prohibition remained in place for five years until the Obama Administration lifted it, even though in many countries eating horse meat is no more controversial than eating beef.Historically, intoxicants have been a frequent target of prohibitions. England's King James I tried to prohibit tobacco in the 17th century, and alcohol has been subject to numerous bans. Neither tobacco nor alcohol is prohibited in the United States today (a few "dry" counties aside), but the Controlled Substance Act places scores of other psychoactive chemicals into one of five "schedules" depending on their potential for abuse and their potential value in medicine. Schedule I substances include heroin and marijuana (high potential for abuse, no recognized medical value). Cocaine and methamphetamine are in Schedule II, despite high potential for abuse, because they have medical uses (as a topical anesthetic and as a treatment for ADHD and narcolepsy, respectively).Thatdruguse can harm users is, for some, sufficient justification for market intervention. Consumers are usually left to deal with their own odd choices, but overdoses of pet rocks and low-rider pants are not fatal.Drugsare different, so the argument goes, because they are so seductive and dangerous.Drug-induced behavior can impair decision-making processes throughdependence or intoxicated reasoning; the "choice" to continue abusingdrugsis something less than completely free. Users may not fully understand the risks before initiating use. After all, the great bulk of initiation is by adolescents and young adults, for whom immediate pleasures cloud judgments involving probabilistic risks of adverse outcomes that are mostly in the future. Precocious use is also a strong risk factor predicting subsequent dependence. Once users become dependent, it can be psychologically and/or physically painful to abstain. Furthermore, the minority of heavy users account for a disproportionate share of alldrugconsumption, which means that a goodly share of all "decisions" to imbibe are made while judgment is impaired by earlier doses.
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Whiledrugscan harm users, so can other unhealthy consumer goods or high-risk activities. Yet few laws forbid eating artery-clogging foods, competing in mixed martial arts, or bungee jumping.Though two states, Michigan and Florida, have introduced temporary bans on bungee jumping, and others highly regulate the activity. What makesdrugs-legal and illegal-different from those examples though, is their capacity to harm nonusers, including people completely uninvolved in the market. Nonusers suffer when passersby breathe secondhand smoke, whendruguse during pregnancy causes congenital defects in newborns, or when impaired drivers smash their cars into other cars, pedestrians, or property. More diffuse damage arises whendruguse reduces worker productivity orcreates healthcare costs others in the same insurance pool must bear. Such "externalities" make otherwise private consumption decisions a matter of public concern.However, these facts merely argue fordrugpolicies that are distinct from, and perhaps more assertive than, polices toward consumer goods generally. It does not imply that the policy must be to ban all non-medical use. Still, given the problems thatdruguse creates, prohibition has obvious appeal.Difficult policy choicesPublic policies often create unintended side effects or consequences. Abolishing the legal marketfordrugsmay reducedruguse, but it doesn't eradicate all use, and the residual consumption sustains black markets that generate other social problems including crime, violence, and corruption. Enforcement of prohibition can cause still other problems. The US incarcerates about 500,000 people fordrug-law violations at any given time, a number higher than the total prison population in any country save China and Russia. That burden falls disproportionately on minorities and the poor. Human Rights Watch, among other groups, sharply criticizes the U.S. onthis point, noting that black adults are sentenced to state prisons fordrugoffenses at ten times the corresponding rate for white adults (1).Formulatingdrugpolicy is not easy. Enormous social costs, including incarceration, follow from abuse of both illegal and legaldrugs, so neitherlegalizationnor prohibition is a panacea. In addition, new psychoactive chemicals are appearing with a frequency that tests the capacity of the current framework for "scheduling" substances. Given the complexities of the social problem ofdruguse and the various interests at stake, it should come as no surprise that the policy outcomes leave some people dissatisfied.Prohibitions are not unchangeable. In 1930, the US prohibited alcohol, but not marijuana. Ten years later the positions were reversed. Changing adrug's legal status, either legalizing adrugthat is now prohibited or prohibiting one that is now legal, such as tobacco, will not eliminate all problems; underground markets produce one set of problems, legal markets another. Changing the legal status of adrugis no silver bullet; it's more "trading the devil you know for the devil you don't know."Nevertheless, thinking hard about prohibition andlegalizationis valuable for three reasons: the devil you don't know might not be as bad, the exercise can inspire ideas for improving the currentlegal regime, and, as a practical matter, policy changes are happening regardless of whether or not one wants them.Some jurisdictions are tightening regulations on legaldrugs. Atlanta's recent ban on smoking in public parks is backed by fines of up to1,000andsentencesofuptosixmonthsinjail(2).VirginiaspenaltiesforfirsttimeDWIoffensesalreadyincludedfinesofupto2,500 and jail sentences of up to a year, but as of July 1st, 2012 those with restricted licenses were also required to install an ignition interlock system (a breathalyzer-like tool that prevents a car engine from starting if BAC is over a certain level) (3).Other jurisdictions are relaxing laws pertaining to marijuana. US states started decriminalizing marijuana in the 1970s and more are considering it now. California already treated possession of
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less than one ounce of marijuana as only a "citable" misdemeanor (typically leading to the equivalent of a traffic ticket) before California SB 1449 went into effect in January 2011, which downgraded the offense to a mere infraction. Seventeen states and the District of Columbia haveimplemented medical marijuana programs, and six more are actively considering it. In November 2012, Colorado and Washington voted for fulllegalization, including commercial production and sale for non-medical use.Other countries are also considering liberalization. Uruguay's President José Mujica recently proposed that the government supply marijuana to registered users. Current and former leaders of a number of countries, particularly in South and Central America, want open discussion about legalizing "hard"drugslike cocaine and heroin.Legalizing marijuana and legalizing harddrugsare very different choices, with significantly different stakes and likely outcomes. Marijuana is special for at least four reasons. First, marijuana markets are associated with much less violence, and (since marijuana rarely dominates the budgets of its users) its consumption is much less associated with income- generating crime. Second, regardless of the merits of the matter, there is essentially no prospect of the US legalizing cocaine/crack, heroin, or methamphetamine in the near or even medium-term future. Such proposals would have almost no public support. In contrast, marijuana prohibition is under active attack now. Third, 17 million Americans use marijuana in any given month, a figure that far exceeds use of all other illegaldrugscombined (except diverted pharmaceuticals). Finally, and perhaps most importantly, marijuana use is simply much less dangerous, in terms of risk of overdose, risk of disastrous intoxicated behavior, and risk of dependence coming to dominate one's life.Unfortunately, much of the literature onlegalizationcomes from advocates and opponents of legal change, in each case more committed to their cause than to objectivity. The following two sections attempt to give a more balanced overview of the merits, detriments and important considerations of first, prohibition, and second,legalization. (Space limitations necessitate an abbreviated discussion. MacCoun and Reuter (4) remains the single best book onlegalizationand we highly recommend it to those interested in further reading). The subsequent sections ask whether "middle path" options exist that could cherry-pick the best attributes of the two extremes.This chapter does not advocate one position or another. Our aim is not to sway readers, but to immunize them against naïve susceptibility to hyperbolic statements that both prohibitionists andlegalizationadvocates sometimes make.Current policy: ProhibitionProhibition constrains the number of users and the quantity they consum in four ways. First, prohibition probably reduces demand, on net. While there can be so-called "forbidden fruits" effects, meaning that the very act of prohibiting something can increase its allure, those are counter-balanced by factors that discourage the consumption of prohibited substances: the blackmarket's poor production quality control, minimal labeling information, and social disapprobation, not to mention the risk of arrest and other sanctions, such as loss of scholarships or opportunitiesto compete in interscholastic athletics (5,6). (Both the uncertain quality in illicitdrugs- uncertaintyabout the amount and identity of the active agents, and the risk of dangerous impurities - and user penalties tend to increase the harm-per-use of thosedrugs, compared to what it would be under legal availability, just as they suppress the quantity consumed. The net effect on overall health and other damage to users is uncertain.)Second, prohibition reduces availability. While the Monitoring the Future survey famously finds that the proportion of high school students reporting that marijuana is fairly or very easy to obtain (82%) is nearly as high as the corresponding proportion for alcohol (89%), marijuana is the exception. Those same surveys find much lower rates of availability for cocaine (31%), MDMA
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