Gone, baby, gone

It appears that opium harvests greatly exceed demand for heroin and no one seems to know where the excess heroin is.

Dopey, Boozy, Smoky—and Stupid

The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren't all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policy should be to minimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.

That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

• Don’t fill prisons with ordinary dealers.
• Lock up dealers based on nastiness, not on volume.
• Pressure drug-using offenders to stop.
• Break up flagrant drug markets using low-arrest crackdowns.
• Deny alcohol to problem drinkers.
• Raise the tax on alcohol, especially beer.
• Eliminate the minimum drinking age.
• Prevent drug dealing among kids.
• Say more than “No.”
• Don’t rely on DARE.
• Encourage less risky forms of nicotine use.
• Let pot-smokers grow their own.
• Encourage problem drug users to quit without formal treatment.
• Expand opiate maintenance.
• Work on immunotherapies.
• Get drug enforcement out of the way of pain relief.
• Create a regulatory framework for performance-enhancing chemicals.
• Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
• Stop sacrificing foreign policy and human rights objectives to drug control.

Why is it so hard to help drug-addicted criminals?

Here's a column about a rejected proposal (Hamilton, Ontario) to house an addiction counselor in the police department to intervene at the time of arrest throughout the judicial process. The goal is to capitalize on the crisis of being arrested and charged with a crime as an opportunity for active linkage to help rather than a passive referral.

It was shot down because they wanted prevention programs. It's an interesting idea that could be effective.

What's more interesting is what this (and programs like drug courts) says about systemic ownership of the problem of addiction. Over the last decade or so the criminal justice system has been realizing that the drug problem is not a simple criminal matter and they they are not equipped to respond in an effective and humane manner. The response has been to incrementally develop therapeutic responses within the criminal justice system, many with decent results. However, it seems that the real issue is what system(s) should "own" the problem.

There's a push right now to move ownership from the criminal justice system to the public health system (not necessarily the treatment system). If this movement was successful, I suspect that within a generation there would be renewed calls for ownership to be transferred back to the criminal justice system.

Right now I'm thinking that it doesn't have to be and either/or decision. It seems that there could be shared ownership to some extent--maintaining some reduced measure of prohibition (I know that the work prohibition freaks people out, but we prohibit everything from speeding to murder. Pretty broad continuum of enforcement approaches, no?) and rebuilding access to a treatment system with continuous recovery management.

Singapore drug cases jump 42 pct on Subutex abuse

Singapore is reporting problems with buprenorphine misuse. It's too bad that the drug they've used is not Suboxone. Suboxone has naloxone added to reduce the potential for misuse. It will be interesting to see if the addition of naloxone is effective in reducing diversion.

Drug-abuse cases in Singapore soared last year, mainly because of a surge in the use of Subutex, a drug which was introduced to help wean drug addicts off heroin, Singapore's Central Narcotics Bureau (CNB) said.

Singapore introduced Subutex as a prescription medication five years ago to help wean addicts off heroin. But the narcotics agency said that 30 percent of abusers caught were hooked on Subutex, which is sometimes mixed with a tranquiliser or other drugs to produce a high.

But in mid-August, the government reclassified Subutex as an illegal drug. Since then, authorities have arrested a total of 347 people for abusing the drug. In all, Singapore has arrested 1,127 users last year, up 42 percent from 793 in 2005, the CNB said in a statement.

Do drug courts tame the meth monkey?

Utah's Governor starts a drug court push for meth addicted mothers and proposes significant investment in treatment:

Despite efforts to combat it, Utah's meth problem continues to grow - especially for women.
For five years, meth has been the top illegal drug of choice for Utahns entering public treatment. For women it surpasses even alcohol, the traditional front-runner, making it the only drug in history to have its female users outnumber males. Nearly half the women in treatment statewide have children.

Gov. Jon Huntsman Jr. has proposed investing $2 million in Utah's drug courts and $2.5 million to build two residential clinics in northern and southern Utah to treat 600 women, giving priority to those involved with the child welfare system. But Huntsman will have to convince lawmakers it's a wise investment, no easy task considering the stigma attached to addiction and a dearth of data on treatment, including how patients and drug court graduates fare over the longer term.

Helping Utah's women poses another challenge: transforming a system that wasn't built for them.

"Substance abuse treatment has been historically geared for white, middle-aged male alcoholics," said Salt Lake County substance abuse Director Patrick Fleming. "We're a hell of a lot better at treating women than 10 years ago, but there's room for improvement."

I'd challenge the "dearth of data" statement. We have a lot of data on the effectiveness of treatment and drug courts.

Ending an Opium War: Poppies and Afghan Recovery Can Both Bloom

Washington Post columnist Anne Applebaum argues for the U.S. to start purchasing opium poppies from Afghanistan. She frames it through a lens of Afghan national stability and U.S. foreign policy interests. Her arguments are persuasive, unfortunately a couple toss away lines suggest a bias:

Of course it isn't fashionable right now to argue for any legal form of opiate cultivation.

...

The only good arguments against doing so -- as opposed to the silly, politically correct "just say no" arguments --...

What are the "just say no" arguments anyway? Am I silly for feeling queasy about the idea of further institutionalizing poppy farming and wondering if has the potential to increase international production?

I'd also challenge the "politically correct" and "unfashionable" feels spurious., she's hardly in the wilderness. Certainly, the White House is staunchly pro-war-on-drugs, but the media, academics, public health activists, and growing numbers of politicians and political thinkers on both ends of the spectrum are increasingly calling for radical changes in drug policy--including legalization

The other losing war

Commentary on the impact of the war on drugs in this hemisphere.

Big score holy grail for drug officers

A peak inside some of the culture problems in the narcotics unit in Atlanta. This article paints a picture of a unit that wants to make big busts but has so much pressure to generate arrests that they spend all their time arresting people with small quantities and sometimes cutting corners to get them. This is presented as the context for a shootout with a 92 year old woman that ended in her death.

Drug Wars in the blogosphere

Matthew Yglesias offers an interesting deconstruction of an all or nothing agrument against the war on drugs:

I guess this is something liberals and libertarians are supposed to agree about, but I consistently find it bizarre that there are some people who seem to think it would be a good idea if you could just walk into your local convenience store and pick up some heroin or crack along with your Fritos and Diet Coke. At times, people taking this line seem to argue that drug prohibition couldn't possibly be having any beneficial effects because, after all, you can still find heroin. Naturally enough, you don't see anyone proposing that the "war on mugging" be ended simply because mugging-prohibition has failed to actually eliminate the proscribed activity. That said, like any reasonable person I think many aspects of current crime-control and drug-control policy in the United States don't make sense. So I have a hard time knowing what to make of things like this from Jerry Taylor:

While it should be obvious to any fair-minded observer that our increasingly brutal war on drugs is a losing proposition on all counts, few of us seem to be fair minded observers. So allow me to pose a question to those of you still clinging to this benighted enterprise: Exactly what would it take to convince you that the drug war was causing more harm than good? Is there any bit of data, any hypothetical fact, or anything at all that would cause you to give up the policy ghost? Because if there is not, then we are in the realm of religious belief — and that’s about all that I can find to support this cruel, costly, and counterproductive jihad.

I mean, I'm not even clear on what question's being asked here. Do I think the status quo is preferable to total deregulation of currently prohibited drugs? I would say so. But considering how heavily regulated the use of alcohol and tobacco is, one hardly imagines that a heroin free-for-all (ads after school cartoons, for sale out of ice cream trucks) is a likely alternative policy. So, I don't know. What is the "war on drugs" exactly? Does it do more harm than good compared to what?

Good news from the new Congress

The new Congress appears interested in revisiting the 100 to 1 disparity (see this post for an explanation) in powder vs. crack cocaine sentencing guidelines:

Key lawmaker Rep. John Conyers (D-Mich.), chair of the House Judiciary Committee, and Rep. Robert Scott (D-Va.) have signaled their intention to hold hearings on mandatory sentences for nonviolent offenses. Conyers said that the current sentencing disparity between crack and powdered cocaine offenses -- crack offenders face much harsher penalties -- is the "most outrageous example of the unfairness of mandatory minimums."

Changing tactics: Recovery programs crucial to winning drug war

A Kentucky paper discusses an alternative to the war on drugs:

No one thinks drug abuse is OK. The question is how best to fight it.

There are signs that the answer is shifting toward fighting drug abuse one person at a time, helping users recover, preventing others from getting hooked.

It's slow, it's personal, it's expensive. But without it, history and economics say, we are doomed to failure.

Afghan heroin surge

The LA Times reports that the DEA is denying a surge in heroin from Afghanistan in spite of an internal memo released by Senator Feinstein:

Heroin-related deaths in Los Angeles County soared from 137 in 2002 to 239 in 2005, a jump of nearly 75% in three years, a period when other factors contributing to overdose deaths remained unchanged, experts said. The jump in deaths was especially prevalent among users older than 40, who lack the resilience to recover from an overdose of unexpectedly strong heroin, according to a study by the county's Office of Health Assessment and Epidemiology.

...

According to a Drug Enforcement Administration report obtained by The Times, Afghanistan's poppy fields have become the fastest-growing source of heroin in the United States. Its share of the U.S. market doubled from 7% in 2001, the year U.S. forces overthrew the Taliban, to 14% in 2004, the latest year studied. Another DEA report, released in October, said the 14% actually could be significantly higher.

Poppy production in Afghanistan jumped significantly after the 2001 U.S. invasion destabilized an already shaky economy, leading farmers to turn to the opium market to survive.

Not only is more heroin being produced from Afghan poppies coming into the United States, it is also the purest in the world, according to the DEA's National Drug Intelligence Center.

Despite the agency's own reports, a DEA spokesman denied that more heroin was reaching the United States from Afghanistan. "We are NOT seeing a nationwide spike in Afghanistan-based heroin," Garrison K. Courtney wrote in an e-mail to The Times.

He said in an interview that the report that showed the growth of Afghanistan's U.S. market share was one of many sources the agency used to evaluate drug trends. He refused to provide a copy of DEA reports that could provide an explanation.

The agency declined to give The Times the report on the doubling of Afghan heroin into the U.S. A copy was provided by the office of U.S. Sen. Dianne Feinstein (D-Calif.), a member of the Senate Caucus on International Narcotics Control.

This potent heroin, which the DEA says sells for about $90 a gram in Southern California, has prompted warnings from some officials who deal with addicts that they reduce the amount of the drug they use. Many addicts seeking the most euphoric high employ a dangerous calculation to gauge how much of the drug they can consume without overdosing. An unexpectedly powerful bundle of heroin, therefore, can be deadly.

"I tell people, 'If you're using it, only use half or three-quarters of what you used to,' because of the higher potency," said Orlando Ward, director of public affairs at the Midnight Mission on Los Angeles' skid row.

[via: New Recovery]

Dynamic Drug Policy

An editorial in the new issue of Addiction questions the static drug policy models that dominate current policy debates:

Drug researchers have long understood that there can be long-term waves of greater and lesser drug use and that upswings can involve epidemic-like spread. These and other dynamics discussed below imply that policy ought to vary over the course of a drug use cycle, but drug policy debates have not yet internalized this perspective.

...

Because drug problems vary in these complex ways, it seems plausible that drug policy should vary over time as well; yet it is rare to hear someone couch their drug policy recommendations in these terms. This is striking and more than a little troubling. It suggests that the mental models guiding policy discussions implicitly superimpose a static framework on an intrinsically dynamic phenomenon, akin to popular nostrums for get-rich-quick investing that never vary even as economic conditions change over the business cycle.

It is not clear why policy is not discussed more often in dynamic terms. Perhaps disciplinary boundaries and stove-piped bureaucracies create single-issue advocacy. Perhaps both the health and criminal justice perspectives favour individual-level analyses. Whatever the reasons for their absence to date, dynamic perspectives on drug policy are, in fact, possible.

What are the policy implications? The author discusses the stage-specific limitations and strengths of several approaches:

Preventing an initiation in the early stages of an epidemic is tremendously valuable, because it short-circuits a chain reaction that would have involved many people. (In technical terms, the reproductive rate at that point would have been large.) However, primary prevention cannot be timed to react to a burgeoning epidemic because of intrinsic lags. For example, the median age of cocaine initiation in the US is 21 years, but students in school-based prevention programmes are younger, often only 13 years old. Therefore, if school-based prevention interventions were to have any hope of affecting cocaine initiation dramatically, the ideal time to have run them would have been in the early 1970s, 8 years before the peak in initiation. However, no one knew in 1970 that there was a cocaine epidemic brewing. Conversely, the vast majority of cocaine consumed from 1985 to 2005 was consumed by people who were already older than 13 years in 1985. For instance, over 85% of people the Treatment Episode Data Set (TEDS) records as receiving treatment for cocaine between 1992 and 2003 were born before 1973. Consequently, prevention programmes initiated around the time the cocaine epidemic became salient could not possibly have had a dramatic effect on use over the next generation, regardless of how effective they were.

Treatment also has limited ability to stave off a burgeoning epidemic, because early in the epidemic most users do not have a treatable medical condition. Precise estimates are not available because population-level estimates of treatment need exist only for recent years, but need for treatment is correlated with average duration of use. In 2003, 39% of respondents reporting past-year cocaine use to the US Household Survey had been using for 10 or more years. In 1979, the peak year for cocaine initiation, that proportion was just 3%. For drugs that are not injected, the role of harm reduction strategies is similarly limited when most users are not experiencing significant harms with their use.

Enforcement's effectiveness at suppressing drug use declines markedly as the size of a drug market grows. However, enforcement has unique ability to focus its effects in both space and time. If a crack house opened next door, neither funding school-based prevention nor additional treatment slots would bring rapid relief. Parking a patrol car in front of the crack house would at least displace the activity. Similarly, assume treatment was five times more cost effective than incarceration at reducing drug use. Incarceration could still be twice as cost effective at reducing drug use this year—because incarceration's effects on drug use are concentrated in the present whereas treatment's effects may be spread over a decade or more. Hence, these models suggest that supply control programmes may have a unique capacity to disrupt the contagious spread of a new drug, but limited ability to eradicate established markets. (Enforcement may also be able to displace established markets into less destructive forms, such as forcing visible street dealing to convert to discreet meetings arranged by cell phone.)

Harm reduction offers particular advantages later in the epidemic cycle, when use has stabilized at high endemic levels. For injectable drugs in countries with low violence and few street markets, harm reduction may focus on syringe exchange programmes, supervised injection rooms and training ambulance crews to treat overdose. For drugs that are not injected and which are supplied through violent street markets, harm reduction may focus instead on using enforcement to target the minority of dealers who cause the greatest social harm. In either case the premise is that, with or without the harm reduction, the flow of new people into problem drug use will be modest, so reducing harmfulness of drug use has few drawbacks. That may not be a safe premise early in an epidemic, when there are feedbacks that can amplify small shocks to the system into dramatic effects on its trajectory.

I'm not sure I agree with the author's assumptions about the strengths and limitations of he various approaches, but he makes a compelling argument:

• that the static models currently being debated and advanced all have their place in policy;
• they are all inadequate by themselves;
• and, that there isn't even a correct formula because the needs, opportunities, crises, etc. are constantly changing.