The Emerging and Badly Needed Science of Drug Policy

Drug policy research is at best a modestly sized field. Nonetheless, its findings have significant potential to help societies develop more effective public policies regarding marijuana, heroin, cocaine, nicotine and other psychoactive drugs. I am therefore very glad to announce that an extension of the international drug policy research integration conducted for the book Drug Policy and the Public Good appears today in The Lancet. A generation ago, a reviewer of the world’s drug policy research findings would have been pressed to fill even one article in such a prestigious scientific outlet; the field has clearly matured since.

The three review papers have different foci:

*Louisa Degenhardt and Wayne Hall integrate the international evidence on the contribution of illicit drug use and addiction to the global burden of disease.

*Peter Reuter and Robin Room make their case that the international drug conventions succeed neither in providing medications (e.g., opiates) where they are needed nor in preventing the availability of widely abused drugs

*John Strang, Tom Babor, Benedikt Fischer, David Foxcroft, Jonathan Caulkins and I discuss “what works” in drug policy, reviewing the evidence on source country control, interdiction, policing, prevention and health and social services for drug addicted individuals.

Lancet has made the articles available with a free registration here.

A shorter take on some of the key conclusions in the third paper is also available for free in an op-ed by Jon Caulkins and me in The Guardian (UK) today.

I have spent too much time in public policy circles to be starry-eyed about the likelihood that scientific evidence will be always be heeded in a policy area that is often dominated by demagogues of various stripes. Yet I also see many positive signs in Europe and the U.S. of openness to information in quarters that had previously been a mix of loud voices and closed ears. Scientists cannot and should not control drug policy (that would be grossly undemocratic), but they certainly can contribute systematic and reliable findings to the policy debate and insist that serious research be given more weight than wishes, hunches and anecdotes. The reviews of the drug policy research knowledge base in The Lancet today are offered to policymakers and the public in that spirit.

Please consider this an open thread to debate and discuss anything in The Lancet papers if you are so led.

UPDATE: Here is a short interview with Dr. John Strang about the evidence for effective drug policy interventions

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College Lonon. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over ten thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

19 thoughts on “The Emerging and Badly Needed Science of Drug Policy”

  1. Wow! That Guardian op-ed starts off with a doozy:

    The loudest voices in US drug policy debates call either for enforcing prohibition with ever-increasing ferocity or for giving up altogether by letting corporations legally sell the currently illicit drugs much as they do tobacco and alcohol.

    So, legalization is “giving up altogether” and apparently necessarily entails the corporate business model of Big Tobacco & Alcohol to be applied to other drugs. So this is the balanced opening pitch by the True Centrists.

    Coming to the actual key positions, these include maintenance of prohibition (“Those high prices, which are solely due to the illegal status of drugs, substantially restrain use and dependence. Routine enforcement of the law is necessary to deliver those benefits“), expanding certain modalities of treatment, adoption of HOPE tactics, reducing sentences for lower-tier dealers and lackeys, and containing visible drug markets and activity by targeted enforcement. None of which tackle the violence in transit countries like Mexico or in producing countries which enforce prohibition, nor seem to tackle the basic robustness of the black market.

    One puzzling claim seems to be that it is the resulting high price which does much of the work of prohibition (“Those high pricessubstantially restrain use and dependence“). The long-term trend has been for the prices to come down, and yet drug use trends seem to oscillate periodically but basically remain stable.

  2. I’d add to daksya’s comment that we don’t know what a free market price for drugs is. Let’s assume that the prohibitionist stance is correct, that coke is more expensive because some is lost in transit, that dealing can be expensive, etc.

    First, has anyone done an analysis of the cost in total? Including national and international costs of attempting to keep drugs out of the bodies of those who want them.

    Second, and this is an issue that bothers me, but kills others, it would be nice if the RBC noted that their preferred policy means the end of a culture in the Andes.

    Just accept the cultural imperialist role. Say it.

    1. Jamie: “RBC” doesn’t have a preferred policy regarding drugs or anything else.

      Illegality affects prices dramatically and it is easy to see why. It costs a trafficker about $10,000 to move a kilo of cocaine from Bogota to Miami; shipping it Fedex would be about $150. If you did it on a largely scale you could move kilos for far less than that (container ships can move T-shirts made in Viet Nam to Europe for less than 5 cents per unit). Remember, coca is just an easy to grow plant, converted to a potent drug with cheap chemicals — if you could grow, process and deliver the plant legally you could turn a profit at less than a dime a dose for crack easily.

      Note the fact that some illicit drug prices have fallen is not germane to the effect of legality per se on price. Many things, legal and illegal, fall and rise in price, the question regarding illegality is whether the absolute value shifts and there is no doubt that it does (a price drop in an illegal market could make a rock of crack goes from $20 to $18, but the same price drop would be 20 cents to 18 cents a dose in a legal market).

  3. I have spent too much time in public policy circles to be starry-eyed about the likelihood that scientific evidence will be always be heeded in a policy area that is often dominated by demagogues of various stripes.

    I’m not actually sure it should be. I think a lot of the reason we have such bad drug policies is precisely because of technocratic impulses. Once you decide, as your premise, that the government should get to determine what people are and are not allowed to ingest into their own bodies, and that the only issue is that what is best under some amorphous concept of the public health, what you end up with is exactly what we have; a policy that is the result of moral panic about substances that white middle class parents don’t use and complete abdication with respect to substances they do use. Because we gave the policymakers the power to control how people are allowed to medicate themselves.

    What we need isn’t more science. Science is great, but it’s always going to be politicized. We need, instead, a different starting point– a starting point that says that human beings have the right to use their bodies for pleasurable purposes so long as they do not hurt others while doing so. We’ve gotten to that starting point on sex, after centuries of sodomy laws and Comstock raids. We’re not there yet on drugs, but that’s where we need to be.

    Fundamentally, if someone wants to ingest a substance that the person feels they will enjoy ingesting but that a scientist says will harm the person, that’s their right, just as it already is with tobacco and alcohol. Our bodies do not belong to technocrats who tell us how we must use them.

  4. “human beings have the right to use their bodies for pleasurable purposes so long as they do not hurt others while doing so”

    Dilan’s point sound good, but has almost zero bite. An alky father could hurt his children in many different ways (physical or emotional violence, lost income and education, shame, etc.) A junkie driver could go on the nod, taking several people with her. A dopehead lawyer could write a dopey brief, to the detriment of her client. A smoker could poison others’ lungs, or die early to the detriment of his aged parents who rely on his income. A person on PCP is capable of almost anything. Etc.

    Third-party harm might be necessary to justify prohibition, but it isn’t sufficient. It is mighty easy to show third-party harm. Jeez, we could ban almost anything under this rationale. To make matters even more complex, prohibition isn’t the only policy tool around. There is taxation, controlled distribution, propaganda, substitution, inconvenience, etc., etc. And even worse, there are plenty of competing values constraining and shaping policy, of which personal autonomy is only one.

    Drug policy (or any other policy, for that matter) is damned complicated

    1. Ebenezer:

      People who have unprotected sex can transmit diseases or cause unplanned pregnancies too. And the pornography industry causes all sorts of secondary effects. And yet we’ve deregulated consensual adult sex.

      Further, those alcoholics you mention are already causing those harms, because we don’t apply the Prohibition model to alcohol. The dope that white middle class parents are addicted to cannot be criminalized, you see. It’s only the types that those poor degenerate n***ers and ch**ks and w**backs use that is a threat to our children and that we must prohibit.

      Drug policy is complicated, but for a different reason than you state. It’s complicated because there are all sorts of things that the government could still do while upholding the basic right of people to use or misuse their bodies as they would wish. Which is why we have all sorts of issues regarding anti-tobacco ad campaigns, drunk driving policies, etc. And it’s also complicated because the issue of health and safety claims made ABOUT drugs is separate from the issue of whether people should generally be able to abuse their bodies in ways that offend moral preeners posing as scientific technocrats. You’d still need an FDA.

      But the basic problem is actually one of first principle. Why does a person not own his or her own body? Why is the decision to ingest substances into one’s body not just as much a part of a person’s personal autonomy as the decision as to whose genitals one wishes to sexually stimulate? Drug warriors have never answered that– they don’t believe in human freedom. If the government can establish it knows better than you do, that’s all that matters.

      1. Dilan:
        Thanks for clarifying matters (I think.) Our main point of disagreement seems to be competing values, rather than a different take on the facts. You seem to view personal autonomy as an overriding value, subject to some restricted notion of third-party harm; I view it as one significant value among several. If I adopted (what I think are) your values, I would probably adopt your approach in toto. As is, I still agree with much of what you say, especially your disgust with a flatfooted prohibitionist approach.

        1. It’s true, I think personal autonomy is more important than cost-benefit analysis. I think you do too, by the way. There are actually very few true utilitarians out there. I’m sure you have heard the hypotheticals. (E.g., if someone has a nuclear bomb and says he will detonate it in a major city unless you commit a rape, are you obligated to commit the rape?)

          But as I said, I think the more provocative question is what’s the difference between drugs and sex? You can make all the arguments that prohibitionists make in favor of restrictive laws on sex. Sex can in many ways be much more harmful than drug use– drug use doesn’t create new human beings. And yet, we not only moved to a more libertarian understanding of sex, but when someone like Santorum comes along and wants to re-regulate it, we see that as an unacceptable imposition on our personal autonomy.

          So why does sex fall outside the cost-benefit analysis but ingesting drugs fall within it?

          1. I wasn’t thinking of cost-benefit analysis as one of the competing values. It couldn’t be: cost-benefit analysis presupposes a choice of values, and some means of rendering them commensurable. My list of things that are good-in-themselves apart from personal autonomy: equality, majoritarianism, civil society, subsidiarity (i.e., delegating power, when possible/practicable to lower-level governments,civil society, or individuals), health and wealth. (Most people would probably environmental protection to this list. I don’t–not because I’m opposed to it, but it isn’t something I value all that highly.)

            All of these things are incommensurable. On the drug wars, some point to a prohibitionist approach (majoritarianism and maybe health), and others point away (civil society, wealth, and personal autonomy, at least.) That’s why well-informed people disagree in good faith: they have different values, and weight these values differently.

  5. I was about to express my opinion on the subject, and found that Dilan said it all much better than what I had in mind. Thank you.

  6. Keith,

    Nice op-ed and the Lancet piece is extremely useful. I just have a couple of questions:

    1. Any reason why erradication and source-country/transit-zone interdiction were barely covered in the review? I know the scholarly literature on those issues is rather thin, but still it would have been nice to see your thoughts on those issues.

    2. Given the emphasis on the public good, I missed seing some discussion on the distributive consequences (both at the national and international levels) of drug policies. Any literature you can recommend on those issues?

    Best regards.

  7. Hi Alejandro: Thank you, that is high praise coming from someone with your expertise. In terms of reviewing the international interdiction literature, we had a little more space to do this in the book than in the Lancet article, but fundamentally the problem as you know is that there just isn’t much to review.

    A book that came out after we wrote the paper but is worth reading in terms of international distributive consequences and international source control efforts is here

    I don’t agree with all of it but Daniel is a rising star and very much worth reading, and the book gives a perspective on drug control from scholars in a producer country rather than a end market country.

    1. I believe there is a good number of Colombian scholars writing about the issue (for instance Alejandro Gaviria, Francisco Thoumi, Rodrigo Uprimny, Ricardo Vargas, Daniel Rico to mention but a few). My guess is that they are not well know because they write mainly in Spanish. Talking of which, Daniel Mejía & Pascual Restrepo made and interesting & rigorous economic evaluation of Plan Colombia, the US initiative to combat drug trafficking in Colombia, here:

      Gart Valenc
      twitter: @gartvalenc

  8. It’s not as simple as prohibition/regulation/freedom. You need to think about what drugs, where. There’s a good case for putting, say, cannabis and possibly ecstasy on much the same footing as alcohol (fairly minimal direct effects, not too many secondary effects, use increasingly socially controlled). Hard to make a good case for doing the same for heroin, methamphetamine or crack cocaine, all of which change the brain in ways that very often make people violent (crack or meth), or incapable of functioning socially (crack and heroin). In short, the fewer people using these the better for themselves and everyone round them. And I know these things don’t happen to ALL users, but they do to a lot (around one in four people who try heroin go on to addiction).

    The relationship between prohibition and price is also not simple. Price seems to relate more to extent of use than to illegality as such, and the prime effect of effective enforcement (which is not always possible) is not to change the price but to limit availability. Again, you have to first ask if it’s possible in any given circumstance to effectively enforce prohibition – it’s a good strategy for some drugs where it can be done, and a lousy one for others and where it can’t be done.

    1. In that case, you have different models of legalization for different drugs. Certainly it would be silly to sell heroin in the same way as alcohol, while it may be fine to sell marijuana in the same way as coffee. You can (and should, in my opinion) have different legalization regimes for different drugs. This doesn’t mean you have to turn to prohibition and all its destructive ills. We simply need to have the imagination to set up different regulatory schemes — and I find it baffling that we have to turn to the academics in the UK for any real research in this area (just as Canada is doing the only legitimate research on drugged driving). Check out Transform’s “After the War on Drugs: Blueprint for Regulation” to see just a few examples of regulations for different drugs that might be employed.

  9. I agree. But note that any regulation has an enforcement counterpart (as an example you can be fined or jailed for selling tobacco to minors, smuggling tobacco, selling tobacco without a license and so on, and all this is essential to effective tobacco policy). Regulation does not end the need for enforcement. Nor, with the really dangerous drugs, is it possible to regulate generally. Heroin prescription, for example, seems to work fine as palliative care for addicts (see the Zurich or Sydney examples), but it still requires effective enforcement to keep heroin from being widely available. And crack and ice seem to simply too dangerous to be countenanced.

    One area that is under-researched is how to best enforce regulations. There is a small literature using anthropological-type inquiry which point to very different solutions to the usual police approach, but getting the police to take notice is hard, and getting them to change tack even harder. My experience is that success in this field is largely accidental – yet when it happens, it can make a huge difference (see the reasonably well-reseached Australian heroin drought).

    The producers of this short film are both recovering addicts who have both spent time living and indulging with drug addiction in Vancouver’s Downtown Eastside. Today they are both clean and sober with multiple years of recovery
    Addiction: Chaos in Vancouver

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