The Battle over the Future of Drug Abuse Prevention
Presentation at the World Forum Against Drugs (WFAD)
September 8, 2008
Robert L. DuPont, M.D.
Institute for Behavior and Health, Inc.
Rockville, Maryland USA
Speaking with you is a joyful culmination of my four decades of work to prevent drug abuse. It is an honor to be here at this historic International meeting with more than 450 delegates from over 80 nations under the leadership of our distinguished Swedish hosts. It is no accident that this meeting is in Sweden. The Swedish experience with drug abuse defines the problems we face and the choices we must make.
Let’s begin by reviewing that experience. After the second world war Sweden faced an unprecedented epidemic of intravenous amphetamine abuse. Once the epidemic had taken hold in Stockholm and other Swedish cities the initial response was what today is called “harm reduction.” The government authorized the medical supply of amphetamines to help addicts “wean” themselves from their vicious drug habits and to prevent their resorting to crime to buy drugs. Over the next two years the results of this approach were clear. The officially supplied drugs were used by an ever widening circle of drug users. Worse yet, those who were addicted did not stop their drug use. This observation was the defining moment in the evolution of Swedish drug policy. The country, noted in the world community for its compassion and reasoned public policy, reversed course adopting a zero tolerance approach. Sweden rejected medically supplied amphetamines and opiates for drug abusers. With that change the epidemic abated.
Two aspects of this experience deserve special attention. First, “prohibition” followed “harm reduction” not the other way around. People who today claim that “harm reduction” – and by that label I mean policies that make it cheaper, easier and safer to use illegal drugs – misunderstand not only the Swedish experience with drugs but the world’s ongoing experience with drugs. Prohibition was caused by the terrible problems that arose when there was a rich availability of drugs and when there was a tolerance for drug use. It was the explosive increase in drug use that led to prohibition and not prohibition that led to an increase in illegal drug use.
Second, Sweden learned from this experience in drug policy because a consultant to the Stockholm police, Professor Nils Bejerot, personally interviewed many of these amphetamine addicts and followed them through their history of drug use. He saw that drug abuse spread like an infectious disease from drug user to drug user. He observed that the two major determinants of drug use were drug availability and the individual susceptibility to use. Especially vulnerable to drug use were risk-takers, most of whom were young. He noted that the well-meaning efforts to “wean” the addicts off drugs by giving them easier access to drugs were not only futile but that the medically-supplied drugs added fuel to the drug epidemic. Dr. Bejerot is the hero of the Swedish drug abuse story. It is to his memory that I dedicate my talk today. Drug addiction has been called “cunning, baffling and powerful” and it certainly is, for reasons I will describe shortly. But at the outset I want to emphasize that the decision to curtail medically-supplied drugs to drug addicts was difficult in Sweden precisely because there was a powerful impulse to “help” the drug addicts who clearly were “hooked” on drugs. It was only when this effort to help by giving them drugs was shown to be making their lives worse and to be spreading drug use in the larger community that the Swedish health officials reversed course. The drug user is at the center of this new Swedish approach to drug prevention. “Demand reduction,” to be effective, decreases the social tolerance for illegal drug use. Much of the rest of the world, especially in the developed nations with well-functioning welfare states, struggles with this approach since their national identify is defined as supporting tolerance to lifestyle choices of almost all individuals, even when those lifestyle choices are unpopular.
To understand why drug use is not an ordinary lifestyle choice, and therefore requires a different response, it is necessary to learn from modern biology, which has only in the last decade begun to understand the brain mechanisms that cause drug addiction. Drugs of abuse are uniquely powerful stimulants of the brain’s reward centers. These brain reward centers function in all mammals, including humans. They give the powerful signal “do it more.”
The natural stimulants of this brain reward mechanism include food and sex, the behaviors most obviously linked to the perpetuation of all species. Some observers of this biology have minimized drug using behavior by noting the “addictive” potential of such commonplace pleasure-producing behaviors as eating chocolate and sex. What this comparison misses is easily seen in animal experiments. Drugs of abuse produce brain reward that is far more powerful than any natural stimulation. For example, when rats are forced to walk across an electrified grid (which they hate) to get a reward they die from starvation or thirst, and abstain from sex, rather than walk across the grid. However once the rats have learned to use drugs they will walk across that grid to get drugs as if there were no shock.
The special power of drug reward is easily seen in the behavior of human drug addicts. A friend of mine who is dedicated to the civil liberties struggle in the United States said to me that to explain this to people who share her passion to civil rights I needed to explain that drug addiction is modern, chemical slavery. Drug addiction is not a life style choice. Let me repeat: drug addiction is slavery.
Why has the modern drug epidemic occurred in recent decades? Several factors have not only changed the drug scene, they have created an entirely new reality. The first factor is the change of values as the world has shifted to tolerate, even to promote, individual choices over behaviors that in previous generations were limited by deeply held, collective values. This new tolerance for diversity, including a tolerance for drug using behaviors, has been exploited by drug sellers creating the second factor in the emergence of the modern drug abuse epidemic: an increasingly globalized, and far more efficient, modern drug supply system. The modern drug epidemic is caused by the synergistic combination of increased social and psychological tolerance for drug use and increased supply of drugs. This change has been accentuated by a third factor: drugs are now often used by far more potent routes of administration, especially smoking and intravenous injection. The fourth factor creating the modern drug epidemic is the huge range of abused drugs now available throughout the world. In sum the modern drug epidemic is the result of the greater availability of a wide range of drugs, the common use of potent routes of administration, increased social tolerance for drug use and the fact that entire national populations, especially youth populations, are now routinely exposed to abusable drugs. While many drugs have been around for centuries, even millennia, today’s drug abuse epidemic is as modern as the computer.
The most important questions facing us at our meeting this week are these:
1) What is the core of the drug problem?
2) What can be done to reduce it?
The answer to the first question is that the heart of the drug problem is the drugs that are illegal under international conventions that are now nearly a century old. Because these drugs have been recognized as serious public health threats they have been prohibited for nonmedical use. When the definition of the “problem” is widened to include a range of behaviors from gambling to sex, and from sweets to credit cards, the drug problem has been trivialized and meaningful action has been derailed.
As a person who has devoted his professional life to promoting the public health, including holding some of the highest positions in my own government’s public health efforts all the way to the White House, and based on what you have already heard from me this morning, I have three straight-forward suggestions for you to consider in answering the second question.
1) Reduce Drug Availability. One of the oddest aspects of the often misguided debates now occurring about drug policy is to pit law enforcement against treatment, as if the central policy question is “Do you favor law enforcement or do you favor treatment.” This is a tragically flawed framework. The simple answer is that neither law enforcement alone nor treatment alone is effective. The future of drug policy involves getting them to work together more effectively. One simple statistic makes this point: half of all of the people in drug abuse treatment in the U.S. are there because they have been forced into treatment by the criminal justice system. Taking law enforcement out of the drug abuse prevention equation would cut the treatment population in half. Drug supply, which is now global, flourishes in places that are outside the laws of modern nations. Drug profits are fueling terrorism and anarchy all over the world. Efforts to combat drug supply need to be global in scope and to enjoy robust support from all nations and all people.
2) Reduce the Social Tolerance for Illegal Drug Use. It is vitally important to respect drug users as people who are worthy of help and compassion, but not to respect their illegal drug use. The modern effort to “normalize” illegal drug use, including comparing it to alcohol and tobacco use, has the effect of decreasing the resistance of
3) Harness The Powers of Faith and Community. It is no accident that religion is the enemy of drug abuse. The most striking aspect of the drug user’s character is the selfishness and self-centeredness that take over the lives of drug abusers. Belief in something that is more important than one’s own immediate pleasure and a commitment to higher values are not necessarily religious, but they are powerfully anti-drug. Closely related, one of the most striking aspects of addicts’ behavior is dishonesty. In all parts of the world drug use, especially drug use by the drug addict, is seen as unhealthy, unsafe and unwise. The only way the drug abusers can keep using the drug is to hide their use from everyone who cares about them. So the antidote to addiction is honesty, especially honesty in the larger community in which the drug addict lives. The 12-step programs of Alcoholics Anonymous and Narcotics Anonymous, which have become global fellowships of recovery, harness both Faith and Community in brilliant, creative and highly effective ways. These free, voluntary programs are the “secret weapon” in the public health war against drug and alcohol addiction.
I have been a practicing physician for more than four decades working every week with my own individual patients and their families, often over the course of many years. This experience has powerfully informed my views on public policy. Families typically begin their relationship to drug problems by denying the problem, pretending it is not there and hoping against hope that it will go away. The drug problem gets worse until the family is eventually forced to confront it. When they do they often begin on the assumption that they can love their way out of the problem by “helping” their drug addicts. This too, fails as drug-caused problems mount. Only when families realize that they must intervene to separate their family member from drugs of abuse in the most forceful and sustained ways, is there hope for recovery. Although treatment is often part of this stage, treatment is likely to work only if it is combined with a strong stand that absolutely rejects further drug use.
In thinking about my work with families who have successfully overcome addiction I have considered where in these families’ lists of responses to their drug problems are the common harm reduction approaches to drug abuse to be found. For example, where does giving addicts drugs or giving intravenous drug users “clean” needles fit into the successful family’s strategy? Where does tolerance of continued nonmedical drug use fit into the highly personal family decision making process? Where does tolerance for relapse to drug use fit for these successful families?
My conclusion is simple and clear. I believe that this conclusion is similar to the experiences of all of you here today when you have confronted drug addiction in your lives, in your families and in your communities. When you tolerate drug use and when you make drug use cheaper, easier and safer for the drug user, the drug use continues and usually escalates. When you take a stand and say “no more” in ways that are credible and sustained, drug use is far more likely to end.
Why is this common experience so seldom applied to national and international drug policy? The only reason I can imagine is that most drug abuse policy discussions are political or ideological. They are not rooted in long-term experiences with real people. I am reminded of Professor Bejerot who carefully cataloged his personal experiences with individual drug addicts to come up with the profound truths he articulated so bravely even though his conclusions were sometimes misunderstood as unsympathetic or even harsh. Nothing could be further from the truth. The compassionate and respectful approach to drug addicts is to separate them from their drugs. To do otherwise is to disrespect them, to neglect their humanity and to perpetuate their chemical slavery.
How do our policy opponents justify their positions, given this every-day reality? There is one more fact I need to highlight which may explain this apparent paradox. Let me give you a factual statistic for perspective: each time a drunk driver gets behind the wheel of a car there is a one in 2,000 chance that that drunk driver will have an accident. That means that 1,999 times out of 2,000 when people are intoxicated they arrive safely at their destinations. Of course the risk of a sober driver having an accident is 100 times less but my point is that even with the dramatically elevated risk of an accident of a drunk driver, the odds of arriving at the destination without an accident are high. That is why it is so important that all nations have socially-imposed consequences to prevent dunk driving. It is not practical to learn from personal experience with those odds. Having worked with many drunk drivers, even when they cause accidents, many of them deny that their drinking had anything to do with the accident. In summary, drunk driving is widely recognized to be a serious problem even though in any single instance of drunk driving the odds are very large that the drunk driver will not have an accident or injure someone else or himself.
Illegal drug use is like drunk driving in that many illegal drug users, especially early in their history of drug use, use drugs without obvious harm to themselves or others. Like the drunk driver in my example they conclude that their drug use is benign. Some drug users escape harm for many years just as some drunk drivers never have accidents.
When drug use is looked at in the community the universal finding is that illegal drug use is associated with virtually all negative outcomes, from accidents and school failures to mental illnesses and violence. Our drug abuse prevention policy opponents look only at the “safe” users of illegal drugs. Their policies protect these people’s “civil liberties,” the rights they have to their lifestyle choices. Why don’t our drug policy opponents also work to protect the civil liberties of drunk drivers given the fact that many times when the drive drunk these drunk drivers do not cause accidents? They do not defend drunk drivers because they know that if they did that they would be hooted off the public policy stage. If alcohol manufacturers were to champion the rights of drunk drivers they would suffer the fate of cigarette manufactures who claimed cigarette smoking was not addictive.
Clear thinking is difficult when dealing with illegal drugs in part because we must overcome a determined opposition who focus on the “safe” illegal drug users. Our policy opponents begin by claiming that “the war on drugs has failed.” The facts are otherwise. In the United States illegal drug use is down substantially from 24 million users at the peak in 1978 to the current 19 million even though the US population has increased substantially in the past three decades. Worldwide the level of illegal drug use has stabilized in recent years. It lags far behind the use levels of either alcohol or tobacco. People who understand pharmacology know that the levels of use in the world of any of dozens of illegal drugs – from marijuana and cocaine to heroin and methamphetamine – would exceed the levels of use now seen for alcohol and tobacco if they were legalized or made more freely available because they produce far more intense brain reward than either alcohol or tobacco.
“Harm reduction” as a drug prevention policy sounds humane and compassionate. While many diverse policies fly under the harm reduction flag, the central tenant of this policy is the acceptance of the inevitability of increasing numbers of illegal drug users. Once the inevitability of rising illegal drug use is accepted, harm reduction seeks to make better drugs available cheaply and safely to drug users to prevent their turning to crime to support their habits and their acquiring diseases, like HIV-AIDS, as a result of their drug use. Harm reduction seeks to increase the social acceptance of illegal drug use. In drug abuse treatment, harm reduction accepts as inevitable continued drug use during treatment and it accepts relapse to drug use after treatment. However well-meaning, these policies increase illegal drug use and thereby they increase the harm that is caused by this drug use. Harm Reduction policies accept and even extend chemical slavery, as they did in Sweden in the 1960s.
My conclusion about what needs to be done to improve international drug policy is simple: DO NOT SURRENDER TO ILLEGAL DRUG USE. The rise in illegal drug use can be stopped throughout the world.
It is not an accident that the name of our meeting is the World Forum Against Drugs. That is the right name for our new global drug abuse prevention policy, a policy that is deeply rooted in, and validated by, the Swedish experience with its initial drug abuse epidemic half a century ago.
The modern illegal drug abuse epidemic is a major threat to our most precious resource: the world’s human capital. The most vulnerable people are youth and those with economic and other handicaps, including mental illness. Although drug abuse is a massive global threat, it is a threat that can be overcome.
At this meeting, and in our important work that is to follow, we must work together to achieve our shared goals to reduce drug availability, to reduce the social acceptance of illegal drug use, and to increase the use of Faith and Community in our efforts to combat this insidious, often misunderstood modern epidemic.
Here is a motto that I have found to be helpful:
You Alone Can Do It, But
You Cannot Do It Alone
Together We Can Do More
For more information about the future of international drug prevention policy see the website of the Institute for Behavior and Health: www.ibhinc.org. IBH has two specialized websites: www.PreventionNotPunishment.org which focuses on random student drug testing, the best new idea to reduce the onset of illegal drug use, and www.StopDruggedDriving.org, the best new idea to improve highway safety and to reduce the level of drug use in the community.