Addiction, Drugs and Crime: Transforming Our Strategy

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In my last posting on the 40th anniversary of the “War on Drugs, ” I wrote that we now know a great deal more about the science of addiction. In a follow-up post, I would like to outline a more effective strategy for dealing with the use and abuse of illegal and legal drugs.

I propose that we pursue a strategy that is based on empirical evidence about the science of addiction, the impact of drugs on the human brain, and the effectiveness of treatment. Since the past 40 years of enforcement-based efforts have proven largely ineffective, it’s time for a new approach.

The argument for a new strategy is more compelling than just change for change’s sake, however. The evidence has grown to a point where it is clear that the drivers of the drug problem are as much medical as anything; thus our strategy should be based on a public health model, not a criminal justice model.

I think it is important to acknowledge up front that changing our strategy in this way will be a tough sell because of a number of characteristics of contemporary American society:

  • there is a widespread lack of knowledge among the public, elected officials and policy makers about the science of addiction.
  • the tenacity of Americans’ belief that addiction is the result of poor choices and moral weakness.
  • our country’s pervasive reliance on a punishment-based response to drug abuse and addiction through the criminal and juvenile justice systems.
  • the lack of knowledge of, and engagement by, the broader medical community in the identification, diagnosis and treatment of drug and alcohol abuse and addiction.
  • a disturbing, anti-science mindset among a significant portion of the population, including prominent elected officials and candidates for higher office.

I find this situation puzzling in a country where medical science occupies such a revered status.

Many pioneering breakthroughs have eradicated diseases, alleviated suffering and improved the quality of life for millions of people worldwide. Ours is a country where medical treatment, especially with prescription drugs, is almost considered a birthright. Witness the passionate and often angry defenses mounted when the federal healthcare reform legislation was being considered, and even after it went into effect.

The medical science/health care/pharmaceutical industry is a huge part of our domestic economy, employing thousands and providing routine and emergency care to millions of Americans every day. Our standard of care is generally first rate, with the exception of drug and alcohol addiction.

In this area, we behave for the most part like it is still the 19th century.

In this country, we have a love affair with drugs of all types. I think it is fair to say that we are “addicted to prescriptions.” Just watch commercial television in prime time and you will be subjected to an endless parade of advertisements for prescription drugs to treat a variety of ailments and symptoms.

The phrase “talk to your doctor about…” is always heard, identifying a specific drug. Since when did it become the norm for the patient to diagnose an ailment (often based solely on the commercial) and suggest a drug to a physician? I think of the well-known phenomenon of students reading descriptions of diseases and convincing themselves that they have all of the symptoms.

Hopefully, physicians are diligent about diagnosing and prescribing, but the incredible rise in the number and type of prescriptions gives one pause. In a scathing critique of drug companies and doctors, Marcia Angell explores the dynamics of prescription practices and drug effects in mental health. It is hard not to conclude that drugs are being over-prescribed for behavioral disorders, particularly with children and adolescents.

While prescription drugs provide many benefits, they are not entirely benign. Legal prescription drugs are the fastest growing category of drugs of abuse. These are not heroin, cocaine or methamphetamines purchased on crime-ridden street corners in urban ghettoes. They are legal drugs, often obtained through legal means, which are then shared, sold or stolen. This phenomenon has the potential for widening the drug enforcement net to include many people who would not fir the typical profile of a drug abuser or addict. Perhaps this will be one of the drivers that could result in a change of strategy.

My first exposure to the emerging science of addiction was provided in the late 1990s by Alan Leshner, then director of the National Institute of Drug Abuse (NIDA), who gave a presentation which featured color slides of PET scans of the human brain under the influence of drugs.

It was the updated, and scientifically accurate, version of the old television commercial “This is your Brain on Drugs” showing an egg sizzling in a frying pan. Leshner’s slides graphically illustrated how human brain functioning was affected by drugs. This and other research led to the conclusion that addiction is a “chronic relapsing disease of the brain”, and does not result from a personal weakness or moral failure by the addicted person.

NIDA has continued and expanded this important research under the current director, Nora Volkow who is a specialist in scanning and mapping the brain structures and processes. She wants to shift the emphasis away from addiction as a criminal problem and make it a medical problem.

Dr. Volkow has said “My obsession is to engage the healthcare system in addiction” The title of the article on Volkow identified her as a “general in the drug war.” A reader subsequently wrote to the editor, correcting that perception by noting that Volkow and NIDA are not fighting a war but rather “are devoted to uncovering knowledge on addiction as an illness and to finding evidence-based methods to help people recover.”

This is a quest that underpins the rationale for a change of strategy.

In addition to the development of a robust body of research on the science of addiction and its treatment, there are some other hopeful signs that change may be feasible. The popularity and effectiveness of drug courts has largely restored the legitimacy of treatment as a response to drug abuse and addiction. Drug courts have grown over the past two decades to become an accepted component of an evidence-based approach to drugs and crime.

A number of states (New York and New Jersey among them) have revised their drug laws to reduce their severity and make it easier for the offender to get treatment. The enormous cost of building and operating prisons to incarcerate thousands of non-violent drug users is also causing states to reconsider community-based treatment alternatives.

Texas, a legendary law and order state, is prominent among the states that have redirected funding away from prisons and into treatment and community supervision of drug offenders.Based on the ineffectiveness of the law enforcement/punishment strategy and the promise of an evidence-based public health approach, I propose the following as a framework for a more rational, humane and effective drug policy.

1. Shift the primary emphasis from law enforcement and punishment to demand reduction. The present approach is massively expensive and largely ineffective in significantly reducing demand. As we can see with recent history in Mexico, drug distribution and enforcement activities are incredibly violent and destructive of civil society.

2. Invest in research and development on addiction, and on the technology transfer work to implement research finding in practice. The pending merger of NIDA and its alcohol counterpart, the National Institute on Alcohol Abuse and Alcoholism should produce synergies to advance research. One example of a promising avenue is addiction vaccines. It would seem prudent to redirect some of the funds now allocated to enforcement to an expanded research program.

3. In Increase the engagement of the medical community in primary prevention and interventions. Too many people begin their addictions with behaviors that should be red flags for medical professions with the proper training. Medical practitioners at all levels should be the first line of defense.

4. Develop and deploy a broad-based educational public effort on the science of addiction and its treatment. This campaign should target citizens, parents, educators, elected officials, policy-makers as well as the health care community. Public health campaigns have proven effective for initiatives as diverse as stopping smoking and increasing seat belt use.

5. Build on successful efforts to address abuse and addiction through interventions and treatment. As noted above, drug courts have made great strides to demonstrate the efficacy and cost-effectiveness of treatment for substance abusers. Unfortunately, such courts are not universally available and only reach a fraction of the drug abusers in the justice system. More juvenile drug courts are especially needed. Larger statutory and policy-based efforts to redirect resources and offenders to treatment in the community should be encouraged and reinforced.

6. Highlight the cost-benefit aspects of the public health model over the criminal justice model. Numerous high-quality studies have shown the significant financial benefits that accrue from a treatment-based approach to addiction. People remain in the community, maintain their ties to family and work, pay taxes and build social capital. A more aggressive public health approach can reduce the costs of untreated substance abuse even when the abusers are not involved in the justice system. The costs of untreated drug and alcohol abuse to businesses and employers include lost productivity, accidents and health insurance costs.

It is rather simple to articulate the framework for such a change in policy. There will no doubt be need for elaboration and refinement. Gaining broad acceptance and succeeding at implementation will be much greater challenges.

But I believe the potential is there for transforming our society and reducing the harm we now inflict on our fellow citizens, our communities and other sovereign nations.

William D. Burrell is a regular blogger for The Crime Report. An independent corrections management consultant specializing in community corrections and evidence-based practices, he was a member (2003-2007) of the faculty in the Department of Criminal Justice at Temple University in Philadelphia. Prior to joining the Temple faculty, Bill served for 19 years as chief of adult probation services for the New Jersey state court system. Bill is chairman of the Editorial Committee for Perspectives, the journal of the American Probation and Parole Association (APPA) and serves on APPA’s Board of Directors. He has consulted, and developed and delivered training for probation and parole agencies at the federal, state and county levels. He welcomes reader comments.

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