What we know and don’t do in drug policy

If you want an scientifically-based approach to drug policy, the current Lancet offers a terrific compendium of the evidence. Authors include my colleagues Keith Humphreys, Peter Reuter, and Jonathan Caulkins, along with a veritable murderer’s row of other leading drug policy researchers– Louisa Degenhardt, Wayne Hall, Robin Room, John Strang, Tom Babor, Benedikt Fischer, and David Foxcroft. They provide as good a source as any in understanding what’s known about what actually works to address the many serious harms associated with substance misuse.

These authors report that well-implemented opiate substitution therapies–principally methadone maintenance–may be the most solidly supported intervention out there to reduce the mortality, morbidity, and wider social costs associated with opiate dependence, and that syringe exchange and related efforts are important in the control of blood-borne disease. The evidence base for other interventions is decidedly more dicey. The literature regarding prevention efforts is mixed. Regarding supply-side enforcement efforts…

There is good evidence that high street drug prices bring important benefits:

Empirical evidence supports five broad conclusions about the effectiveness of supply control in keeping prices high. First, if law enforcement can keep prices high, drug initiation and use will be reduced. Many empirical studies show that indicators of problem drug use, such as records from emergency departments and arrestees’ urinalysis results, respond to changes in purity-adjusted prices.4 Second, illegality and some basic level of enforcement makes illicit drugs far more expensive at retail in developed countries than plausible estimates of the cost of their production and distribution would suggest….

Unfortunately, the available levers to maintain high drug prices are weak. Purity- and inflation-adjusted street prices for many illicit drugs are far below the levels observed thirty years ago. Even worse, law enforcement policies to disrupt illicit markets have brought socially toxic side effects:

Third, modelling studies, such as those pioneered at RAND,6 have consistently shown that increasing imprisonment is a very expensive way to increase prices in established drug markets—findings from empirical studies are generally not encouraging about the potential success of such control methods. For example, Kuziemko and Levitt7 estimate that an increase in the number of prisoners detained on drug-related offences in the USA from 82 000 to 376 000 between 1985 and 1996 increased retail cocaine prices by only 5—15%. Fourth, very little evidence exists for the effectiveness of alternative development programmes in source countries, and no evidence exists that they affect the availability or price of drugs in final-market countries (although they can possibly trigger a shift in location of production).2

Fifth, supply shocks can substantially reduce drug availability, purity, use, and harms in consumer countries—eg, metamfetamine precursor controls,8 the Taliban opium ban,9 the 1989—90 war on Colombian drug traffickers,10 and the Australian heroin shortage.11 These successes often stem from a convergence of fortuitous circumstances that governments can rarely reproduce by design. Occasionally they follow deliberate actions such as introduction of legislation to regulate precursor chemicals involved in illicit drug preparation,12 although results are not always predictable or simply generalisable.13 However, their success lasts for only as long as it takes the market to adapt. Many attempts to disrupt supply produce no detectable effects.14 Their effects on drug users can sometimes be adverse15 and sometimes beneficial;16 the difference is probably related to age, regularity, and disadvantage of the users.11, 16 The cost-effectiveness of these efforts is not easily assessed.[cites available in the original].

The lack of solid research support for such interventions is striking—as is the lack of demand among policymakers for such evidence before sinking impressive resources into further supply-side interdiction efforts. The United States now incarcerates more people for drug offenses than Western Europe incarcerates for all crimes. We don’t get a lot of value in return. We have long waiting lists in many places for methadone maintenance and other treatment interventions. Congress has reinstated the ban on federally funded syringe exchange.

Consider what is happening in Russia, which has a particularly serious constellation of social problems connected to substance use. A Saint Petersburg study suggests an annual overdose fatality rate of 2.1 percent among active injectors. Extrapolating these figures nationally, this would imply more than 20,000 overdose deaths per year. (Then there’s alcohol. As in the U.S., that is specifically excluded from Ivanov’s portfolio.)

Russia has about half the population of the U.S. It still has as many people living with HIV, and it probably experiences more new infections every year. Almost everyone in Russia living with HIV and AIDS was infected over the past decade. Most are young, and hence likely to be sexually active.  About 80 percent are injection drug users, though 1/3 of recent cases are estimated to occur outside the population of injection drug users. Many are diagnosed late, with obvious consequences for both individual and public health.

As previously noted here, I moderated a conversation at the Chicago Council on Global Affairs between the American and Russian drug czars R. Gil Kerlikowske and Victor Ivanov. (Kerlikowske’s official title is “Director, White House Office of National Drug Control Policy.” Ivanov’s is “Director, Federal Drug Control Service of the Russian Federation.” You can listen to my conversation with Ivanov and Kerlikowse here.  I elaborated on some aspects of this event on Bloggingheads with my RBC colleague Mark Kleiman here.)

Ivanov is a warm person who has compassionate things to say about individuals and families affected by drug use. He was visiting substance abuse treatment facilities such as Haymarket and Phoenix House, as well as medical treatment sites that are implementing valuable new screening interventions. He noted that Russia cannot arrest its way out of its serious drug problems, and that law enforcement should fight organized crime but not individual drug users.

Yet his comments underscored how misguided the Russian Federation’s drug and HIV policies actually are. He opposes methadone and other maintenance therapies: “We [cannot] call replacing one drug with another drug a real treatment…replacing one drug with another.” He denied that there is “enough clinical evidence” of methadone’s effectiveness, and suggested that efforts to promote methadone reflect “lobbying the interests of certain chemical companies that need to just sell their goods.”

He opposes syringe exchange, which he believes is sending the wrong message towards illicit drug use. “When the country is flooded with Afghan heroin, this program would be a bit too encouraging for the addicts…. Handing out about a billion syringes in the residential districts would be just killing.”

In short, Ivanov’s litany of policy specifics is the precise opposite of what leaders in the field of substance abuse policy and HIV prevention have been recommending for decades. It’s a tragic situation.


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