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Beyond the Drug War: Drug Policy, Social Interventions, and the Future

By Balzafire, Jun 5, 2011 | Updated: Jun 5, 2011 | |
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  1. Balzafire
    View attachment 20581 Beyond the Drug War

    This week I reached a turning point. The drug war is over for me. It’s immoral, it’s destructive, and worse, it’s not effective.

    Supporting it, when legal drugs are both regulated and destructive and we make good efforts to figure out how to balance costs and benefits, is a fool’s errand. So figuring out what options we have besides “legalization” is an important task we must take on.

    We need better alternatives. If making drugs illegal is both wrong and carries enormous costs, what can we do differently?

    The Drug War Report

    On Thursday June 2nd, The Global Commission on Drug Policy declared that the “global war on drugs has failed.”

    The global war on drugs has failed, with devastating consequences for individuals and societies around the world… Fundamental reforms in national and global drug control policies are urgently needed.

    Vast expenditures on criminalization and repressive measured directed at producers, traffickers and consumers of illegal drugs have clearly failed to effectively curtail supply or consumption… Government expenditures on futile supply reduction strategies and incarceration displace more cost-effective and evidence-based investments in demand and harm reduction.

    Rather than repressive measures, the Global Commission recommends the end of criminalization and marginalization of users who do no harm to others, experimentation by governments to see what works between the balance of organized crime and public health, increasing health and treatment services across the board, harm reduction measures aimed at syringe use and infectious disease, and investing in activities that help both small-scale producers (e.g., farmers) and small-scale users (e.g., adolescents) with other viable life options.

    In one sense, it is everything one might hope from such a report – internationally respected figures weighing in on the problem, the use of scientific research (including citations!) to back up what they say, and a comprehensive range of recommendations written in clear and accessible language. You can even get the audio from the press release which features the high-profile former heads of states who spearheaded this report.

    As the Wall Street Journal summarizes:

    The report calls for drug policies based on methods proven to reduce crime, lead to better health and promote economic and social development. It said the U.S. must change its anti-drug policies from being focused on anti-crime approaches to ones rooted in health care and human rights.

    But as many of us know, such reports have been written before. That the drug war is failing has been common knowledge for two decades. That there are other options that could work better was right there in the initial critiques of this overarching policy. A science-based, politically expedient report isn’t enough.

    As Tom Chivers writes in The Telegraph, The nonsense of a ‘War on Drugs’: The Wire’s writers get it, governments consistently don’t. He captures the immediate response of governments to such a report.

    [A British Home Office] spokesperson said: “We have no intention of liberalising our drugs laws. Drugs are illegal because they are harmful – they destroy lives and cause untold misery to families and communities… We are taking action through tough enforcement, both inland and abroad”…

    [However] the evidence seems to suggest that there is no link between how harsh the drug laws are and how many people take drugs. Three studies, one by the Cato Institute looking at Portugal, one by the World Health Organisation, and one in the British Medical Journal found that by every measure, intelligently applied regulation of drugs is better than prohibition…

    The evidence seems, overwhelmingly, to suggest that prohibition is not just failing to fix drug problems, it is aggravating them… A systematic review in the International Journal of Drug Policy in March of this year… recommended that “since drug prohibition has not meaningfully reduced drug supply, alternative regulatory models will be required if drug supply and drug market violence are to be meaningfully reduced.”

    As for an enlightened US response, here is a White House spokesman:

    “Making drugs more available, as this report suggests, will make it harder to keep our communities healthy and safe.”

    Over at The Atlantic, Conor Friedersdorf writes in response:

    It’s been 15 years since William F. Buckley declared in National Review that the war on drugs is lost. We’re living under our third consecutive president who admitted using drugs in youth. Countless law enforcement personnel are willing to acknowledge the folly of prohibition. But the failed policies of old continue anyway against all evidence and common sense.

    Common sense isn’t enough. We need to face the problem of the drug war right in its face.

    Mexico and the Drug War

    Mexico shows the ravages of the drug war. Until this week, I hadn’t really made my mind up about the over-riding emphasis on criminalization and interdiction of drugs worldwide. I had been the good scientist, waiting for more evidence, and the good anthropologist, waiting for something that makes better sense.

    Certainly, open legalization is not what I advocate – releasing drugs to the unfettered powers of the capitalist market is not a good option. If they can’t even handle mortgages, what would happen with drugs? Put in that frame, embracing a move towards better policy requires something of a leap of faith. Or, more importantly, the fundamental recognition that something is deeply wrong with what we are doing. Something morally wrong.

    I had stayed studiously on the fence until this week. Intellectually I’d gone over it many times. Criminalization doesn’t work. The costs of the present “war” outweigh the costs of how greater access to illegal drugs will lead to an inevitable blip in use and abuse rates. But despite years of living in Colombia, I’d never really come face-to-face with the costs of the drug war there. I had read about, heard about, talked with people about it. But the devastation it causes, the destruction of people’s lives for money and control and profit, I hadn’t stood face-to-face with that. I hadn’t had my “plata o plomo” moment. I never had to choose.

    Then I saw these photos of what the drug war means in Mexico, along with the accompanying interview with the photojournalist Claudia Daut who has to edit such an incredible flow of violent images and acts, in Mexico. Here is the reality, captured in horrid violence and utter loss, captured in the moment, and in that photo, we can’t squirm away, we can’t simply forget or say it’s not so bad. It is that bad. These photos show it.

    I will only reproduce one here, the one that hurt me the most, the one that captures the human costs of such a war. A grandmother protecting her two grandchildren, and all of them shot dead. Here’s the caption:

    A dead woman cradles the bodies of two dead children at a house in Acapulco March 15, 2011. Hitmen stormed the house and shot dead the 70-year old woman and two boys aged six and three years, whom she had tried to protect from the bullets, according to local media.

    It would be easy to say the “drug traffickers did this.” But that’s such a poor story. The drugs they traffick flow almost exclusively to the United States. The demand comes from here. And for too many years, the Mexican government treated drug trafficking like just another corruption, manageable and profitable for those in power. And now the violence has hit as a storm of torture, death, and gruesome display.

    Nik Steinberg, writing in The Nation, shows that with his excellent journalism in The Monster and Monterrey: The Politics and Cartels of Mexico’s Drug War. Monterrey, the leading financial and industrial center of Mexico, has been run over by drug trafficking and violence. Steinberg eschews the easy story, that the traffickers are all to blame. There is a story here of a corrupt and complicit government that didn’t really know what they were dealing with. I saw the same thing in Colombia, and it cost incredible blood and money to break the cartels’ grip there.

    How could thriving Monterrey, the “Sultan of the North,” which only years earlier had been deemed one of the safest cities in Latin America, descend so quickly into chaos? If it could happen here, was anywhere in Mexico safe for long?

    Yet what from the outside looked like a sudden collapse was in reality decades in the making. At its root was the decay of the institutions entrusted with providing law and order, ones that, despite their chronic dysfunction and corruption, had been able to contain drug violence in the old state-run system. But when that system crumbled, and when, in the face of “the monster” of organized crime, Monterrey’s elite, politicians and public turned to those institutions to rescue them, they found them rotten to the core.

    Legalization

    The United States government is supposedly made of sterner stuff. Their corruption is not easy money and institutional decay. It’s the sheer rigidity of their approach – an approach of annihilation and denial eerily reminiscent of drug users themselves. It is tyrannical more than puritanical. A war can never be lost, no matter the cost, even when the enemy (demand) comes from our own people…

    Indeed, when declarations like the “drug war has failed” come along, many assume that the only option is capitulation, an unholy union of legal approval and immoral hypocrisy wrapped in one. With the framing of a drug war, losing it means giving free rein to drugs.

    Nothing could be further from the truth. Almost everyone recognizes the dangers of drug use, and if they don’t, it doesn’t take that much evidence to convince them – just look at the damages associated with alcohol and tobacco. The either/or mentality – either fully legal or stiff prison sentences – is just useless in trying to deal with drugs.

    Of course not everyone thinks legalization should even be an option. When drug policy came up on Fox News recently, host Sean Hannity said this about treating drugs as a public health issue, not a criminal one:

    How do you get the conservative base, a lot of which are Christian conservatives — the idea that America would legalize or go down this road is repugnant to me. I don’t think government should have that role in the moral destruction of a human soul, which is predictable by giving them those drugs.

    The legalization folks have tended to be rather inflexible when they argue for de-criminalization. The counter-argument is so easy – that’s immoral, or as we saw above, drugs destroy communities. Together, those make an easy argument for drug use as something criminal. How dare you even think of permitting something like that? What are you, soft on crime?

    Yet I believe legalization has to be on the table when discussing drug policy. Prescription drugs, alcohol, cigarettes – these are all addictive substances that can destroy communities. And they are legal, and we know a lot about regulating them. So thinking seriously about legalization is important.

    So here are some counter-argument to the immoral dismissal of drug legalization.

    -Sean Hannity, you’re the one soft on crime. You’re giving these criminal organizations their blood money, and they use it to kill people. Let’s get hard about organized crime, and also crimes that drugs users do commit, like assault or robbery.

    -Sean Hannity, you like making people sick, don’t you? Instead of getting people treatment, you’d rather throw them in jail, and spend millions of people’s tax dollars on keeping them in a cell.

    -Sean Hannity, I thought we were beyond “separate but equal” in the United States. Someone rich and famous can get off if they get caught with cocaine, but be a poor black kid with crack, and it’s off to jail.

    -Sean Hannity, I never realized you were so in favor of big government, of government telling us what we should do on our private time, and creating all this bureaucracy that is just adding to the national debt.

    The counter-arguments are easy to develop. And like good politicians everywhere, they don’t address the specific issue raised – they work to their own talking points.

    A Problem-Based Approach

    Full legalization is not even on the table anyway. Drugs are controlled substances, like lots others that we deal with on a daily basis. Does making possession of that substance a crime solve the problem of addiction? No. Does it create other problems, some of them terrible in nature? Yes.

    So, what do we do? The first step is to get away from thinking that there is only one answer – that drugs are a “one size fits all problem” either legal or illegal. One-size policy is a terrible idea for drugs.

    For example, even though Portugal has recently gone through a successful decriminalization of drug use, I wouldn’t suggest the same approach for the US as a whole, certainly not as a federal initiative. Rather, states and cities should have the ability to experiment for themselves, to find out what works for their local communities. At the same time, this experimentation will help us better figure what sorts of policies are effective in different situations, paving the way to more innovative approaches over the long-term.

    Developing ideas and evidence for policy is crucial. A more local approach also avoids another major mistake in the US drug war approach – a top-down, hegemonic approach, where policy is dictated by the federal government eager to maintain its powerful grip over chemicals of all sorts and to also have policy that supports foreign influence and intervention at various levels. But the top-down approach is also problematic for two related reasons.

    First, legalization, particularly at the level of state-controlled trade and decriminalization of possession, is not a panacea. Just look at alcohol and alcoholism, tobacco and cancer, prescription drugs and overdoses – legal drugs are problematic. Many frame these problems of legal use as “public health” problems. As Don Weatherburn (2009) writes in Dilemmas in harm minimization:

    Some of the harms associated with drug use are not, in any meaningful sense, ‘public health’ harms (e.g. loss of public amenity, poor school performance, theft). Rather than adopt any general guiding principle [like “public health”], it would make more sense to try to reach agreement on the specific drug problems we want to reduce and make their reduction the goal of illicit drug policy.

    Thus, instead of saying we want to minimize the harm associated with injecting drug use, we might (for example) simply say that we want only to minimize the number of new recruits to injecting drug use, encourage more injecting drug users into treatment, reduce the crime committed by injecting drug users and improve public amenity in areas where injecting drug use is prevalent.

    A problem-focused approach avoids the either/or of the drug legalization debate, while permitting us to focus ideas from different arenas on tackling specific problems related to legal and illegal drug use.

    Second, with an approach that maintains drugs as illegal, there are a variety of policy options which can make a difference. In other words, there are ways to change how we approach the problem of drug use right now.

    Here are four ideas. These are based on my own experiences. There are more out there, and I’ll cover some of them in the section below on Social Interventions. But these are ones that I think matter in the context of doing legal work and making a criminal justice approach more effective than it presently is.

    -Fairness in drug laws. This change is happening right now in the United States, in particular with the different sentencing that has happened for decades with cocaine possession versus crack possession. There should not be different laws based largely on social class and social control; similar drugs should be treated in similar manners. Being fair in application, and thus emphasizing justice in the law over moral and social condemnation of different types of users, should be a cornerstone of any legislation.

    -Focusing on the consequences that come with excessive drug use, rather than on simple possession. While alcohol remains legal over individuals over 21, policy has maintained a decades-long crackdown on drunk driving, which puts other people at risk and punishes people for the negative consequences of their behavior, rather than use itself. Similar policies that target harmful behaviors users commit is an utter necessity.

    -Mandated treatment and social restitution, rather than jail. Jail doesn’t fix an addict. It does punish them, and often that worsens things. Ramping up court-ordered programs and forcing users to face what they have done through making amends, as many innovative drug courts are doing, is an approach that fulfills one of the cornerstones of the criminal justice system – the long-term protection of the community and the rehabilitation of individuals found to commit acts in counter to commonly established laws.

    -An emphasis on small costs to drug users, things that are immediate and that provide feedback to users about their behavior. A jail sentence is rather like swinging to hit it out of the park, and with drug users, current policy is simply striking out. A switch to small ball, to a focus on what can help more in changing their behavior, is an important next step. Confiscation of drugs without further consequence, fines for possession, obliging users to show up in court and face social judgment, the development of short-course treatment programs (from a one day intensive program, to a series of short-term interventions over weeks), and one or two day jail sentences are all ways to generate change using a criminal justice approach.

    Addiction and Social Interventions

    Social interventions for addiction need continued development. Prevention programs are fairly well-developed but not particularly efficacious, especially over the long-term and with high-risk populations. Policy development is good with regards to tobacco but less so with alcohol and even less with illegal drugs. Besides tobacco control, the other well-developed intervention is targeting injection drug use and HIV transmission.

    Prevention programs largely focus on trying to reduce individual risk factors, particularly on providing individuals with knowledge about the dangers of drugs and training in skills to refuse drugs. In other words, prevention approaches have been largely cognitive-behavioral in approach, with some additional focus on families. The main message from examination of prevention interventions is that well-designed one can work (even though popular ones like D.A.R.E do not), but that their effects fade over time and “booster shots” are often needed. In other words, prevention needs to be a continual process.

    Here is one example, Spoth et al. (2008), Long-term effects of universal preventive interventions on prescription drug misuse. This program focuses on family and school programs that help reduce prescription drug misuse over a year, but do not necessarily produce permanent effects. For more about the program, you can see the Iowa Strengthening Families Program, especially this page on the program for families and youth ages 10-14.

    However, this type of prevention research has also been critiqued for not being rigorous enough to show that prevention really does its job: Midford, Is this the path to effective prevention? and and Gorman & Conde, Drawing reasonable conclusions about prevention.

    Addressing risk factors has been less successful, as many of the most powerful factors are social and impact broad arenas of health – for example, childhood adverse experiences, or delinquency and school failure during adolescence. Targeted intervention efforts to target specific risk factors for addiction, for example, early initiation into drug use, have not really been done, as either these same individuals face a suite of social problems or this type of effort gets wrapped up in a larger, more diffuse prevention effort.

    For more general information, head over to the Guide to Community Preventive Services, with science-based reviews and recommendations on alcohol, obesity, and tobacco, as well as a range of other health problems.

    Harm reduction and harm minimization have been reasonably well received. A good overview of public health and harm reduction is in this 2010 annual review article by leading addiction researcher Alan Marlatt and Katie Witkiewitz, Update on Harm-Reduction Policy and Intervention Research.

    The major focus has been on reducing HIV transmission due to injection drug use, including needle exchange programs and the provision of cleaning materials to sterilize equipment. This paper on HIV & injection drug use, Auerbach (2009), Transforming social structures and environments to help in HIV prevention, covers how this approach works, and how social policy and institutional engagement are a necessary part of this type of approach.

    The best evidence for social interventions is with smoking. Policy change (e.g., taxes, access, public spaces), health information (warning labels, disseminating evidence on links to cancer), and social change (stigmatization) came together to drive major reductions in smoking in the United States. But the core group of smokers remaining is, not surprisingly, the most socially marginalized, where inequality and stress/trauma come together and where smoking still works as a social marker of identity.

    Here’s a recent review of what smoking interventions might work best for “social inequalities in smoking” – Thomas et al. 2008, Population tobacco control interventions and their effects on social inequalities in smoking: systematic review. Also, a review of smoking cessation and socioeconomic status, Hisock et al. (2011), Social inequalities in quitting smoking: what factors mediate the relationship between socioeconomic position and smoking cessation? This paper highlights the role of quitting treatment in not sticking with quitting, but then doesn’t ask the obvious question of why poorer people don’t stick with treatment. This sort of research is sorely needed, linking social context and embodied risk with the factors epidemiology reveals to make a difference at the micro-level.

    Thankfully, Tim Rhodes’ (2009) excellent paper does just that – Risk environments and drug harms: A social science for harm reduction approach.

    Harm is contingent upon social context, comprising interactions between individuals and environments… The relations between individuals and environments impact on the production and reduction of drug harms, and this is reflected by broader debates in the social epidemiology, political economy, and sociology of health…

    Social epidemiology takes us beyond a focus on individual risk factors, while political economy us the tools to understand how and why risk is spread differently across contexts. Public health isn’t merely for the public good, but also a way to govern populations – something that can hamper how social interventions are developed and instituted. And the everyday habits and practices of users help us to understand how these “structural risk environments” get incorporated into experience

    .

    This use of social theory and research to augment our thinking about social interventions is important. Equally important is building evidence-based approaches to social interventions. This too is a field in development, and a suite to recent articles focus on the methods and evidence needed to establish that these types of efforts make a difference. In doing so, they also cover studies that document good social interventions in a broad array of areas, so it’s a win-win.

    Brownson et al. (2009), Evidence-based public health: A fundamental concept for public health practice

    Ogilvie et al. (2005), Systematic reviews of health effects of social interventions: 2. Best available evidence: How low should you go?

    Braveman et al. (2011), When do we know enough to recommend action on the social determinants of health?

    Bambra et al. (2010), Tackling the wider social determinants of health and health inequalities: Evidence from systematic reviews

    In the end, thinking about targeting communities and targeting policy is a very different way of thinking than how most prevention people and medical doctors work. Moreover, government officials are largely focused on monetary policy in one way or another, from taxes to funding schools to social security.

    Community-based policy, with social interventions that take place outside the rubric of determining funding for programs and provisioning information and skills to individuals, has not been part of what institutions do – these institutions fear they cannot control it and have little experience with it. But with drugs, this type of societal approach is desperately needed.


    By daniel.lende
    June 5, 2011
    http://blogs.plos.org/neuroanthropo...g-policy-social-interventions-and-the-future/

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