Monday, October 12, 2009

Preventing substance abuse through good public policy

The following essay was written by LEAP speaker Michael Gilbert. He originally posted it to a web site on substance abuse prevention and treatment operated by the federal government.

After following the discussion on the site for a few weeks, he noticed that several people had posted comments advocating tougher laws and more punitive sentences for drug crime offenses. Those who raised questions about the effectiveness of current policies and drug laws were admonished by site monitors that such comments were off-topic for a substance abuse prevention discussion board. This motivated Dr. Gilbert to write the essay below and post it on the web site.

This is Dr. Gilbert's first post on the new blog. We're lucky to have him as a member of LEAP and I look forward to more of his writing!

I am not a prevention professional but I'm deeply committed to reducing the accessibility of drugs to kids, reducing the harms associated with drugs used by those who choose to use them, and reducing the prevalence in drug use within the society.  These goals cannot be achieved with a limited, censored or restricted discussion.  The question is how to achieve these goals.

A censored discussion limited to "deterrence only", "accepted lines of thought" or the "moral model" cannot provide the robust thinking needed make long term progress toward these goals. To achieve lower drug use rates (i.e., prevention) it may be that we have to seriously look outside the box of prevention orthodoxy to consider ideas and perspectives that may have seemed heretical in the past.

My perspective on drug prevention is a bit different.  I have spent nearly 40 years working in and around the justice system as either a criminal justice practitioner, researcher, or educator.  A number of the comments have implied that "punitive approaches" will work to "deter" users.  From the empirical evidence I have seen in the last 40 years, drug use patterns are not suppressed by punitive criminal justice responses.  In fact, the evidence points in exactly the opposite direction - increased potency, greater access, reduced street prices, and greater availability.  Additionally, punitive approaches are viewed as deceitful by users and provide a rich business environment for black market drug distribution systems.  There is a lot of evidence on these issues if you want to follow-up.

Criminal justice policy responses are ineffective because they misdefine the problem and impose counterproductive  solutions.  Drug use is a deeply embedded health and education problem.  No amount of punishment can make users, as a class of people, stop using (general deterrence).

What can work to make progress toward lower drug use is health and education based prevention strategies based on an honest recognition of some basic facts:
*       Successful prevention depends mostly on caring, honest and believable communications from adults and those working in prevention.  Exaggeration of harms associated with experimental use or non-dependent use is easily discredited and dismissed by those receiving the message.
*       140-150 million people in the US (half the population) have used an illegal substance at least once in their life.
*       Between 20-25 million people are current users (within the last 30 days).
*       Roughly 3-5 million people are highly dependent users.
*       All past, current and highly dependent users could have been arrested, jailed and imprisoned had they been caught using or buying.
*       ONDCP reports that 75% of current users are employed and buy their drugs using legally earned income (not committing crimes to feed their habit).
*       Hustling (committing crimes to support a habit) is highly concentrated among the 3-5 million highly dependent users. Most crime associated with drugs are systemic crimes related to black market business transactions and conflicts NOT hustling by destabilized users.
*       Most current users are middle or upper class Whites who live in good neighborhoods rather than impoverished minorities.  Of these users, few commit crimes other than drug defined crimes of buying and using an illegal substance.
*       Millions of current users are hidden users who work, build and maintain careers, pay taxes, raise children, volunteer with community organizations and continue to use drugs (legal or illegal) without coming to the attention of police.
*       Hidden users by definition are hidden and are not included in the official data which suggests a drug-crime linkage.  If they were included in that data -- it would be clear that crime is associated with a small proportion of users, just as violence is associated with a small (but larger proportion) of alcohol users.

If we add to the user count those who have ever misused pharmaceuticals and those who use alcohol, tobacco, or caffeine it would encompass nearly the entire US population.  It is clear that our society has a love-hate relationship with drugs (see all the ads on television advising viewers to "have the talk with your doctor about ....").  There is an endemic problem with substance use within the society and most of it is concentrated among hidden users. This is the environment into which the prevention strategies are delivered.

Your efforts at prevention are important - no one wants more or wider use of drugs.  However, your efforts are dealt serious body blows everyday when public policies concentrate on criminal sanctions and ignore these realities.  Most of the resources needed for effective prevention are used in counterproductive and often destructive criminal justice responses that increase social harms associated with drugs use.  These resources could be more effectively used to fund the kind of prevention oriented health and education that you do.  Prevention strategies can be quite effective when not enmeshed with punitive justice responses.

For example, we have far fewer smokers per capita today, despite nicotine being more addictive than most illegal substances, because we dealt with the issue through health and education policy.  This is a model of effective prevention.

It is unlikely that such a dramatic reduction in tobacco use would or could have been attained if we had criminalized smokers, sellers, and manufacturers of tobacco.  The most likely outcome of that approach would have been the immediate creation of an underground black market in tobacco which made tobacco available to anyone with the right amount of money on any street corner.  It would also have driven huge profits into criminal tobacco syndicates operating black market distribution and sales of tobacco.  It have also create territorial disputes and business conflicts settled by violence.

Meaningful prevention policies and strategies are needed but they must be "real" from the perspective of the target population and evidence based.  Furthermore, they must be informed by all elements of the problem to be effective.

We should not assume that our current laws, policies or strategies actually work to facilitate prevention - my reading of the evidence is that current policies makes your job, working in prevention, much harder.  Let's not get trapped by our traditions simply because they are our traditions.  We should engage in a broader discussion about what "meaningful prevention" means and how it can be attained.  If the history and evidence reveals that current policies work against prevention we need to say so and not continue to pursue that which has not worked and is unlikely to work.

A lower drug use  society is an attainable goal but it is only attainable if deal we with the evidence and world as it really is, not as we wish it to be.

As far as I can tell everyone engaged in this discussion want to see less drug use.  Your work as prevention professionals is critical but not sufficient.  We also need wise policies that make prevention attainable.  At present the weight of the evidence suggests that our present drug control policies are counterproductive and make drug use problems far worse than they might otherwise be.  Let's keep all prevention issues on the table.

Stay dedicated to prevention but also think critically about how we got into this situation, what perpetuates it and how best to get out of it.

1 comment:

  1. Great piece.

    Approaching a problem rationally involves, by definition, an ability to consider all possible approaches. There is no a priori reason to pick any particular spot on the drug policy continuum between no policy at all and death to all drug offenders (unless you count the Constitution, although it's clear we're not doing that). What matters are the pragmatic results of the position we ultimately end up choosing.

    Without an open environment for inspecting hypotheses, we'll never have a scientific approach to this problem.


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