Controlling psychoactive substances: can we reach a stable equilibrium?[1]
Robin Room
Centre for Social Research on Alcohol and Drugs
Sveavagen
Stockholm University
S-106 91 Stockholm, Sweden
ABSTRACT
The last 20 years have seen substantial changes in the situation and in the social definition of heavy use of different psychoactive substances. Cigarette smoking has become increasingly enclaved and indeed marginalized in daily life, and new efforts are being made to develop a system of international controls. Meanwhile, controls have been further relaxed on alcohol beverage consumption, while our understanding of the consequences of drinking has complexified, with new emphases both on potential health benefits of drinking and on social and casualty harms from drinking. Illicit drugs have moved more into mainstream culture in societies like Britain, while the international prohibitionary control structure has on the one hand increased its ambitions but on the other hand fallen further and further short in controlling the market.
Is there a stable and rational equilibrium in controls to aim for in the new millennium? Outright prohibition has failed, and thinking about decriminalization and legalization has increased. On the other hand, it has proved increasingly difficult to sustain serious market controls on legal substances. Individual-level controls such as rationing are viewed as an intolerable intrusion on personal freedoms, except in the medical context of the prescription system. Aggregate measures such as high taxes, government monopolies and limited sales hours have been considerably weakened for alcohol. Some principles are suggested for consideration in thinking about control of psychoactive substances.
Trends in consumption, in problems, and in societal responses in the last 20 years
In the last twenty years, much has changed, and much has stayed the same with respect to psychoactive substances. In 1979, an international group of scholars of which I was a member was in the middle of considering what had happened to alcohol consumption, problems and policies since the Second World War (Mäkelä et al., 1981; Single et al., 1981). We documented a substantial rise in alcohol consumption in most developed societies (other than wine cultures) over the preceding thirty years, although we noted signs that the trend was stabilizing or even reversing in the late 1970s. Sure enough, there was a period of slowly declining consumption in many places in the 1980s and 1990s, though this period too seems to be coming to an end. With respect to tobacco, the last 20 years have seen in most developed societies a definite reversal of the long rise in cigarette consumption in the preceding decades. Looking back, the peak of psychoactive drug experimentation by American youth came about 20 years ago, succeeded first by a long slow decline in drug use, and more recently again by an upturn. The picture is more complex concerning trends in Europe. In Britain the number of heroin users has increased manyfold in the last 20 years. Youth in corners of Europe like Finland are now experimenting with drugs, where before they stuck with alcohol. In the Netherlands, however, where drugs had come earlier, the picture in the last two decades has shown more stability. With respect to psychopharmaceuticals, the barbiturates have disappeared from use in developed societies, and amphetamines have moved out of the clinic and onto the street, but, what with the benzodiazepines and the anti-depressants, not to mention methadone and nicotine, psychopharmaceutical prescribing has if anything increased its importance in medical practice.
The last twenty years have also seen both stability and change with respect to societal responses to the problems of psychoactive substance use. There is a long-term drift towards greater control of tobacco marketing, but changes on this have been painfully slow, reflecting the power of economic interests and entrenched habitual use. Quitting smoking, which twenty years ago was primarily a matter for the individual smoker, has become more of a social concern, and to some extent medicalized with nicotine replacement therapies. For alcohol, the picture in most English-speaking places and in northern Europe has been of the continuing gradual erosion of the structures of alcohol control set in place three generations ago. Alcoholic beverage producers and marketers have become ever more globalized, though many of their products now carry quaint cottage-industry labels (Jernigan, 1998). While tobacco companies find themselves increasingly in the status of social pariah, alcohol companies have been increasingly effective in their influence on policy and the research world. Alcohol treatment, increasingly combined with drug treatment, has been whipsawed by efforts to contain the growth of welfare and health care costs, but has mostly held its own.
The one dramatic exception for alcohol has been the experience of the former Soviet Union, which undertook in 1985-1988 the most thoroughgoing campaign anywhere since the 1920s to change the cultural position of alcohol (White, 1996). Though it was quickly apparent that this top-down campaign rapidly became politically unpopular, it has taken longer to document that while it lasted it did have very favourable effects on the health of Soviet drinkers. Male life expectancy rose from 61.7 in 1984 to 64.9 in 1987 (Leon et al., 1997). The picture was dramatically reversed in the early 1990s, with the abandonment of the campaign, the shrinking of alcohol treatment provision, and the state’s loss of control of the alcohol market. Other changes in this period also had adverse effects on health. By 1994, the average age of death of Russian men fell to 57.6, a level which had not been seen for many years in industrialized countries. The statistics suggest that the situation in the countries of the former Soviet Union has stabilized and may even be improving in the later 1990s.
Twenty years ago, America had already experienced, under Nixon, its first modern “drug war”; the mid- and late 1980s saw its second, under the Reagans and Bush. The medium-term result has been a dramatic explosion in the numbers in U.S. prisons. In 1980, approximately 50,000 Americans were incarcerated for drug-law violations; today, about 400,000 people are in U.S. jails for nonviolent drug-related offenses (Baker, 1999). Meanwhile, under the initial impetus of the threat of AIDS, the societal response to drugs has been transformed in the last decade in much of Europe, with “harm reduction” approaches coming to the fore. At the local level, despite the continuing rhetoric from Washington, some of the same changes have come to the United States. Even in northern Europe, the societal response to drugs is now premised on the idea that illicit drug use will be a continuing feature of the society, rather than something temporary and alien.
Changes in international control systems
So far we have considered only experiences and reactions at the national level, interlinked as these may be. There are also ongoing changes in the response to psychoactive substances at the international level. Twenty years ago, the international drug control system was in the course of expanding its mandate, under the 1971 Convention on Psychotropic Substances, from dealing only with plant-derived substances – opiates, cocaine and marijuana – to dealing also with synthetic psychopharmaceuticals. The system’s ambitions expanded yet again with the 1988 Convention on illicit trafficking, which seeks to control the markets in precursor chemicals used in manufacturing drugs, and includes provisions on money laundering and extradition (Room and Paglia, 1999).
This year has seen two further moves to expand the scope of international control on drugs. One was the action of the World Conference on Doping in Sport, last February in Lausanne, which decided that “an independent International Anti-Doping Agency shall be established so as to be fully operational” in 2000 (World Conference..., 1999). This action reflected the transition of the issue of doping in sports from the hands of the sports federations into being a matter for intergovernmental action.
The other action was the agreement by the World Health Assembly to move forward with negotiations on a Framework Convention on Tobacco Control, to be completed by 2003. The Framework Convention is a centrepiece of an anti-tobacco program which is one of the World Health Organization’s main current priorities (World Health Organization, 1999).
The crescendo of activity at the international diplomatic level is at least in part a reflection of trends in international drug markets. The market in illicit drugs has grown year by year, in the teeth of the international efforts to combat it. “I am reminded of the film title, Same Time Next Year”, said the representative of Interpol, the international police organization, at the annual meeting of the Commission on Narcotic Drugs in 1995; “as the years go by, there is no real improvement in the situation.... Next year we hope for serious progress, but we can’t report it today” (Room and Paglia, 1999). The issue of drugs in sports attained its highest media profile ever with the events of the 1998 Tour de France. With the dissolution of the Soviet Union and the opening of eastern European markets, the international tobacco companies have increased their dominance of the global tobacco market.
The conspicuous exception, in terms of international control attention and activity, is alcohol. There is some irony in this, since alcohol was the first psychoactive substance subject to international control a century ago, in the long-forgotten treaties among European powers to prohibit the sale of spirits for use by natives in colonial Africa (Pan, 1975). In terms of international trade treaties and dispute mechanisms, currently alcohol is primarily treated as an ordinary commodity like wheat noodles or steel tubing. The European Union, Canada and the U.S. have spent considerable energy through trade dispute mechanisms on efforts to break down each other’s internal alcohol controls (Room and West, 1998), and similar official attacks on market controls have been directed at Asian and other developing countries (e.g., Korea Herald, 1999). No international mechanism is available or currently planned which would commit countries, for instance, to mutual support in controlling alcohol smuggling.
With the World Health Organization study of the Global Burden of Disease, we have for the first time estimates of the relative health impact of the different psychoactive drugs. The unit of analysis in the GBD study is “DALYs” -- disability-adjusted life years. That is, the study takes into account disability as well as death, and years of life lost to disability or death rather than just the fact of disability or death regardless of age. On a global basis, according to the GBD study, 0.6% of DALYs are lost because of drugs under international control, 2.6% because of tobacco, and 3.5% of DALYs because of alcohol (Murray and Lopez, 1996). For the “established market economies” -- countries like Britain – the figures are 2.3% for illicit drugs, 11.7% for tobacco, and 10.3% for alcohol. Against these figures for the relative scope of the problems we can set the level of staff effort devoted to the three classes of drugs by agencies of the UN system. In terms of full-time equivalent staff, there are over 200 positions devoted to illicit drugs, about 20 to tobacco, and about one to alcohol. Perhaps a goal for the next two decades should be to reach a better match between the extent of the problems and the international effort devoted to them.
Lessons for the path forward
Out of the welter of experience of the last twenty years, then, there are four lessons which we might draw in considering paths forward in the new millennium. The first is, in the words of a recent headline in the Daily Telegraph (4 September 1999), that “drugs are here to stay” -- that experience suggests that we must abandon as an illusion the idea that a prohibition regime will put the genie back in the bottle, once a drug has gained a significant foothold even in a subculture within a society. The second is that the emphasis on illicit drugs has distracted attention from where our biggest health and social problems with drugs lie -- which are with tobacco and, particularly, with alcohol. The third is that, when all psychoactive drugs are taken into account, they are responsible for a very substantial portion of the burden of disease, disability and social problems in societies like ours; there is certainly no justification in the figures from the Global Burden of Disease study for slackening off on efforts to limit the social and health harm from psychoactive substances. And the fourth is that we would be well-advised to be realistic and limited in setting goals and strategies for governmental and international action in the field. It can be argued that governmental actions have played only a limited part in the great shifts in the last two decades in the amount and patterning of psychoactive drug use. International action, while potentially important in backing up national actions, cannot substitute for responses and policies at community, regional and national levels.
Regulating the market in psychoactive substances
The conclusion that “drugs are here to stay” implies that there will continue to be markets in psychoactive substances, whether licit or illicit, and raises the issue of how governments should seek to manage those markets. Discussions of this topic until recently have revolved particularly around two substances: alcohol and marijuana. With respect to alcohol, such comparative analysis has been invited by the diversity of control systems which have existed in places like North America and Europe in the current century. Kettil Bruun suggesting in 1970 that alcohol control strategies could be divided into three categories, according to the aspect of use which they aimed to control: the "phase of choice", i.e., of decisions to use, the "phase of use" and the "phase of consequences" (Bruun, 1971). In the context of discussions of control systems for psychoactive substances, the special contribution of the alcohol literature has been the recognition that a full public health control strategy must involve much more than simply the prohibition or regulation of the availability of the substance.
With respect to marijuana, the emphasis in typologies of control has been on prohibition and its alternatives. In his 1970 analysis, John Kaplan discussed four alternatives: the "vice" model of decriminalizing possession and use; the "medical model" of medical prescriptions for use; the licensing model, modeled on alcohol control; and the "sugar candy" model, where the substance is regulated only as a foodstuff would be (Kaplan, 1970).
Neither for alcohol or marijuana has there been much elaboration on these general models in the last 20 years, although we have a learned a great deal empirically about when and how much particular strategies are effective, particularly in alcohol control. Only recently has systematic discussion begun of alternative control systems for the whole range of psychoactive substances. A useful and thought-provoking analysis by Rob MacCoun, Peter Reuter and Thomas Schelling in 1996 ranges control regimes on a single dimension of restrictiveness, according to "the extent of justification a user has to provide to obtain the drug". Their categories are “pure prohibition”; “prohibitory prescription” where a doctor’s prescription is required, but the prescription is for limited purposes and cannot be for maintenance; “maintenance” by prescription; “regulatory prescription”, where the purposes of the prescription are not controlled; “positive license”, where an adult would have access on gaining a license; “negative license”, where an adult would have access unless forbidden to use; “adult market”, where use is forbidden for children; and “free market” (MacCoun et al., 1996). It will be noted, however, that this schema includes levels of restriction both of the consumer and of prescribing doctors. It is questionable whether control regimes can usefully be ranked on any single dimension of restrictiveness.
Implicitly, discussions using such a single dimension tend to be organized around prohibition as one end of the spectrum. But even most regimes which are labelled prohibitionary have some exceptions, often involving regulation. National Prohibition of alcohol in the United States, for instance, involved few restrictions on the buyer or consumer, and provided for production and sale for religious and medical purposes. The international prohibitory regime for opiates, cannabis, cocaine and other psychoactive substances excludes medically-prescribed use from the prohibition, and in fact spends considerable energy organizing the global supply for legitimate pharmaceutical use. Furthermore, depending on the national laws, some drugs subject to international control may be available from pharmacies or elsewhere without a doctor’s prescription. Some forms of codeine, for instance, are available in Canada without prescription.
Legalization of a product, even under a restrictive regime, opens up avenues for state influence on the market which are not available where the product is entirely prohibited. Those producing, selling, or authorizing provision of the product in legal channels can be licensed. They then have a strong interest in following the state’s regulations, if they wish to maintain their license. They also have a common interest with the state in eliminating competition from the illicit market.