The Drug War versus Health Care

Yesterday President Bush gave a speech on the success of his drug policies in celebration of a new report showing that teen drug use has continued a decline that began in 1997. But it is not entirely clear that there is much cause for celebration: use of some of the most hardcore stuff—such as cocaine, crack, LSD, and heroin—has held steady over the past five years or so. True, recently the use of marijuana, amphetamines, and methamphetamines has dropped, but that’s hardly reason to declare victory in the war on drugs.

Like any good president, Bush wants to take credit for good news. But as the lack of progress in the battle against heroin and crack suggests, the U.S. is on the wrong track when it comes to drugs. Our institutional bias is still to see drug use and drug control as criminal justice issues when we should really be thinking about them as public health concerns.

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program. 

If you take a look at the President’s 2008 drug control budget, it may look as if it emphasizes treatment over enforcement, since it claims a 3.4 percent increase (the most of any other sector of drug control) from 2007. But take this number with a grain of salt—there are a lot of questions marks beneath the surface. In 2001 The Boston Globe reported that drug officials had no methodology to formulating the drug control budget, admitting that “we made it up” and that budget reports did not reflect how money was actually being spent through drug policy. Since 2003, there have been worries that the Office of National Drug Control Policy (ONDCP) budget inflates its commitment to treatment by including alcohol and tobacco in its numbers for SAMHSA, even though by statute ONDCP is excluded from dealing with those substances. Worse, since 2003 the ONDCP drug budget hasn’t reported incarceration costs and costs related to the prosecution of drug cases, resulting in an artificial parity between enforcement and treatment.

Still, assuming we don’t spend enough on treatment still leaves us with an obvious question: can we afford to spend more? The U.S. health care bill is immense and ever-growing—we should be careful about throwing money at every new problem. 

But as it turns out, a serious commitment to treatment would actually end up being cost-effective. A landmark RAND study from 1994 found that treatment is 10 times more cost-effective than efforts to prohibit and intercept drug shipments in reducing the use of cocaine in the U.S. The same study found that every additional dollar invested in substance abuse treatment saves taxpayers more than $7 in societal costs, where as additional domestic law enforcement costs 15 times as much as treatment to achieve the same reduction in societal costs.

A 2006 study by the National Institute on Drug Abuse showed that sending 150 New York City drug offenders to a drug treatment program instead of prison saved the criminal justice system more than $47,000 per person during the six-year period studied—for total savings of more than $7 million.

A year earlier, a GAO study found that drug courts—community-based courts where drug offenders are sentenced to treatment and supervision programs—yield a net benefit because they reduce the overall cost per case. This stems from the fact that the recidivism rate for drug court graduates is much lower than for those who don’t go through the drug court system. Anywhere from 4 to 29 percent of graduates re-offend, compared to a whopping 48 percent of other users.

Yes, a greater investment in drug treatment would increase the health care bill in the U.S. We’d need to develop more recovery programs, support more community health centers, build more local coalitions, employ more doctors, and maybe even use more of certain types of prescription drugs helpful to rehabilitation. But in the end it’s much costlier not to fund treatment. It costs more to punish than it does to heal. 

Unfortunately, there’s a pretty fundamental conflict between the criminal justice and health-centered approach to drug polices—not just philosophically, but practically. There are some things that are acceptable from a health perspective that are not from a criminal justice one. The best way to illustrate this tension may be to look beyond the U.S. at two entities who have found themselves at loggerheads on this issue: Canada and the UN.

The International Narcotics Control Board (INCB) is the self-described “independent and quasi-judicial monitoring body for the implementation of the United Nations international drug control conventions.” Translation: it’s the part of the UN that’s asked to enforce international drug laws. INCB’s function is to monitor, regulate, and enforce UN drug control provisions—in other words, it’s a law enforcement body through and through.

As such, it’s not happy with a high-profile clinic in Vancouver called Insite that represents the opposite end of the spectrum: a completely non-punitive approach to drug policy focused on reducing harm. Insite runs needle exchange programs, allows users to take drugs on premise under supervision in order to avoid overdoses, and offers rehabilitation and counseling for those who want it. According to the Canadian press, 20 peer-reviewed academic studies show that Insite has “reduced public drug use, reduced dangerous syringe sharing, reduced HIV/AIDS and reduced publicly discarded syringes.”

Insite’s exclusive focus on healthier conditions and a judgment-free approach has brought it into conflict with the hard-headed INCB. INCB has publicly criticized Insite, and according to an Open Society Institute report from earlier this year tried to silence UN officials supporting the clinic. The report further contends that, in its drive for enforcement, INCB has praised countries that have abused human rights while trying to stem drug use.

Obviously the INCB-Insite spat represents an extreme case: the INCB has absolutely no interest in treatment and health, and Insite is entirely focused on reducing the harm that users do to themselves at the expense of any efforts to eliminate drug use. But that’s what makes this such a good example: it illustrates the extremes of drug policy: of criminal justice vs. health care.

This isn’t to say that a treatment-paradigm has to be as permissive as Insite; but so long as both the enforcement and treatment mission statements are given equal weight, something’s got to give. More often than not, treatment is going to lose out because it lacks the populist, kick-you-in-the-gut political salaciousness of punishment. In fact, Insite’s federal authorization is due to run out in June 30th of next year, and things don’t look good for an extension. Meanwhile, in October Canadian Prime Minister Stephen Harper announced a U.S.-style drug war focused on “toughness.” Apparently even Canadians occasionally feel a little bloodlust.

But Canada would do well to re-think this declaration of war. In the U.S., where toughness trumps treatment, things have not been going well. It’s not just that treatment is more cost-effective than enforcement; enforcement has been failing even on its own terms. Contrary to popular belief, the original goal of getting tough on drugs wasn’t just to put dealers in jail. The war against drugs also was supposed to constrict supply,  and make the drug trade so risky that suppliers would have to charge huge amounts for their product—more, it was assumed, than users could afford.

But things haven’t gone as planned. As two researchers from Carnegie Mellon and the University of Maryland reported last year, “incarceration for drug law violations (primarily pertaining to cocaine and heroin) increased 11-fold between 1980 and 2002, yet…cocaine and heroin prices fell by 80 percent. Methamphetamine prices also fell by more than 50 percent...and marijuana prices…fell during the 1990s.” For all our crackdowns, drugs have only gotten more affordable.

Meanwhile, we know that treatment is cheaper and that it works. Yet still we fudge the numbers to artificially inflate the treatment budget, chip away at SA treatment funds, and dial up drug arrests.

Our leaders may be eager to celebrate their success when it comes to drug policy. But the party’s premature. We can only break out the streamers when we see a fundamental paradigm shift away from INCB and toward Insite; away from criminal justice and toward health care. And that just hasn’t happened yet.

Comments

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[William Maner]

Drugs and their use in this country may be a problem, but they are a HEALTH issue that demands a healthcare industry solution. This is no place for law enforcement. As the numbers show, building more prisons to incarcerate American citizens who generally do only harm to themselves is a failed policy. The War on Drugs, in fact, has been shown to cause more damage to peoples' lives and families than the drugs themselves. This must be the very definition of a failed policy.
If law enforcement would focus on real crimes, rather than on tracking down crack pipes and maijuana cigarettes, they may have time to stop burglaries, rapes, murders, etc. Legalization and regulation of drugds is a better choice. Turn the Drug Enforcement Agency into the Drug Regulatory Agency, and stop pumping billions into prison building - put those dollars into treatment programs.

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adamgilcrist
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