A friend of mine asked me to imagine what facts about current drug problems and policies I’d want the new Administration to be aware of: not a set of plans, just a status report, and brief enough for busy people to read. That seemed like an interesting challenge, so I ran it past a few of the usual suspects in the drug-policy world, and here’s what we came up with.
As usual, comments are welcome. The “comment” function is still in the grips of what was supposed to be a spam-blocker but turns out to block everything, so send email instead.
1. Total cocaine consumption continues to drift down; now perhaps as much as a third below its peak. The original cohort of heavy crack users continues to account for a large share of total demand, but initiation levels in subsequent cohorts mean that cocaine has established itself as an endemic drug.
2. Cocaine prices somewhat higher now than in the recent past.
3. Heroin prevalence not markedly up despite low price and high purity, though there are reports (as there have been before) of increasing non-injection use among middle-class teens. Opiate overdoses down in Chicago linked to naloxone/Narcan availability.
4. Methamphetamine still a major problem in some areas, and continuing its spread to new areas, but the exponential-growth phase of the epidemic is largely over. High prevalence in some criminal justice populations. Evidence of more persistence of problem use than was true in previous meth epidemics.
5. Cannabis prevalence holding steady. Age-at-first-use still distressingly low (middle school). Increased numbers of treatment entries, perhaps due to higher potency and/or higher ratio of THC to cannabidiol.
6. “Medical marijuana” is now big business in California, despite some Federal enforcement efforts. Reports of high-status parents routinely acquiring “recommendations” to protect their children from arrest. Research and development efforts on medical use of whole cannabis (e.g., using a vaporizer to minimize lung damage), cannabis extracts (Sativex), or specific molecules still stalled by regulatory roadblocks and lack of funding.
7. Prevalence of illicit drugs in offender populations holding steady.
8. Prevalence of alcohol, tobacco, most illicit drugs among adolescents down noticeably over the decade, but with declines seemingly flattening out. The illicit-drug numbers are dominated by cannabis.
9. Prevalence of diverted opioids and diverted stimulants among adolescents high and rising, with initiation at record levels. Little knowledge about how much damage this does; the pattern of peer-to-peer and internet distribution seems not to be generating problem drug markets or violence.
10. Overall, drug market violence apparently steady at the much lower levels established earlier in the decade.
11. Drug-related arrests and incarceration not falling, likely still rising along with the rest of the prison population; about half a million behind bars for drug-defined crime. Drug convictions account for more than half the Federal prison population, and drug prisoners have led to the development of gang and violence problems in the high-security parts of Federal prison system that resemble the problems in some of the bad state prisons. Drug prisoners still overwhelmingly African-American and Latino.
12. Tobacco consumption and prevalence down noticeably after Master Settlement and the subsequent wave of tax increases.
13. Alcohol volume trending back up over the past decade after a period of gradual decline. Alcohol still accounts for more than 80% of the substance abuse disorder and the bulk of drug-related illness and violence. Taxes still at historically low levels; strong evidence that alcohol use, including problem use, is sensitive to tax rates. No real effort to deny access to problem users (e.g., convicted drunk drivers and drunken assailants). Some progress against adolescent DUI via zero-BAC laws. Massive prevalence of false ID (50%?) among those just below the legal drinking age.
14. Infectious disease due to needle sharing still substantial but no longer dominating total HIV transmission.
15. Developments in treatment methods: buprenorphine makes opiate maintenance available outside the clinic system; contingency management appears to work (impressive clinical trials, demonstrated success in a street trial in San Francisco); some new pharmaceuticals of possible value in reducing craving, especially for alcohol; immunotherapy looks much less interesting in real life than it did in open-label trials. Some apparent progress in measuring the treatment process and managing for results.
16. Treatment as actually delivered, especially in drug-diversion programs, continues to suffer from low compliance and inappropriate modalities (e.g., drug-free counseling for heroin addiction). Parity for addiction treatment a useful start, but separation of addiction treatment system from physical health treatment system (both finance and service delivery) may discourage treatment participation and limit the adoption and diffusion of evidenced based practices and cost-effective therapeutic approaches.
17. Demonstrated success of testing-and-sanctions for drug-using probationers in a mostly methamphetamine-using population in Hawai’i. Drug use and re-arrest both down substantially; high compliance leads to relatively rare actual sanctions.
18. Developments in enforcement methods: low-arrest drug markets crackdowns (e.g., High Point) may point the way to shrinking both street drug markets and incarceration rates.
19. No noticeable progress in the efficacy of prevention as delivered; DARE remains dominant in the schools and useless, national media campaign not much better. Some evidence that general-purpose efforts to reduce risk behaviors (e.g., the “good behavior game”) may be effective.
20. Afghanistan still being wrecked by poppy growing and poppy eradication efforts; impact on U.S. drug problem is trivial.
21. Mexico continues to supply large volumes of cocaine, heroin, cannabis, and methamphetmaine to the U.S. market. Drug market violence in Mexican border cities now amounting to virtual civil war, with thousands dead and no guarantee that the government, even using the military, will prevail. Increased enforcement pressure seems to be forcing some of the traffic into the Caribbean. Increased enforcement against Caribbean smuggling may shift the problem back towards Mexico. Enforcement planning rarely considers such effects. Some undetermined amount of the Mexican bad guys’ guns come from the U.S.
22. Data gathering and analysis is a mess.
Almost all the money is spent on two big and very expensive annual surveys: NS-DUH (household) and Monitoring the Future (school-based), which give information about prevalence but not about problems.
ADAM, which was a cheap way to monitor drug use in the criminal-justice population, was shut down early in the decade. A proposal to do the same thing even more cheaply by relying on the drug tests done routinely on probationers and parolees never happened.
The DAWN system to measure drug-related emergency room visits and deaths has broken down.
The Community Epidemiology Work Group no longer collects original data.
The DEA Stride data set on drug prices and purities is no longer available for statistical analysis.