82 Clinical and Societal Implications of Drug Legalization
Herbert D. Kleber, Joseph A. Califano, Jr., and John C. Demers

Promising everything from lower crime to fewer hospital visits, proponents of legalization and other radical changes in drug policy argue that the fight against drugs has been lost. They claim that drug prohibition, as opposed to the illegal drugs themselves, spawns increasing violence and crime and that drug abuse and addiction would not increase significantly after legalization. They ignore or scorn the view that drugs like heroin and cocaine are not dangerous because they are illegal; they are illegal because they are dangerous—that these drugs are not a threat to American society because they are illegal; they are illegal because they are a threat to American society. This chapter will explore the evidence for these various contentions.

Historical Background and Terminology

In the last half of the nineteenth century, opiates and cocaine were widely and legally available both in their pure form and as ingredients in patent medicines promoted as remedies for ailments ranging from hay fever and sinusitis to arthritis and depression. Heroin and cocaine were touted as nonaddictive painkillers and as cures for morphine and alcohol addiction. But as the twentieth century began with hundreds of thousands of cocaine and opiate addicts (1), concern rose about the addictiveness and destructive nature of these drugs. President William H. Taft noted in a report to Congress in 1910 that "the misuse of cocaine is undoubtedly an American habit, the most threatening of the drug habits that has appeared in this country . . ." (2).

This concern over the effects of the legal use of drugs led to federal and state actions, which by 1920 had led to sharp decreases in the use of opiates and cocaine in patent medicines and the requirement of a physician's prescription to obtain them. By the 1930s cocaine and opiate use had markedly declined. Legislation in 1937 led to the illegality of marihuana and its subsequent decreased use ( 1).

While the same drugs are illegal in all 50 states and many have adopted schedules similar to those of the federal government, state penalties for possession and distribution vary widely, particularly with respect to marihuana. In a few states, possession of small amounts of marihuana is a civil violation punishable by fine rather than a criminal offense. Today, 32 states have mandatory minimum sentences; 14 distinguish between crack and powder cocaine (3). Like the federal government, states set higher penalties for selling drugs to minors and outlaw possession of drug paraphernalia and operation of premises where drugs are sold and used (4).

Terminology: Legalization, Decriminalization,Medicalization, Harm Reduction

The term "legalization" has been used to encompass a wide variety of policy options from the legal use of marihuana in private to free markets for all drugs. Four terms are commonly used: legalization, decriminalization, medicalization, and harm reduction—with much variation in each.

Legalization usually implies the most radical departure from current policy. Legalization proposals vary from making marihuana cigarettes as available as tobacco cigarettes to establishing an open and free market for all drugs. Variations on legalization include: making drugs legal for the adult population, but illegal for minors; having only the government produce and sell drugs; and/or allowing a private market in drugs, usually with restrictions on advertising, dosage, and place of consumption. Few proponents put forth detailed visions of a legalized market.

Decriminalization proposals retain laws that forbid manufacture, importation, and sale of illegal drugs, but remove criminal sanctions for possession of small amounts of drugs for personal use. Most commonly advocated for marihuana, such proposals suggest that possession of drugs for personal use be legal or subject only to civil penalties such as fines.

Medicalization refers to the prescription of currently illegal drugs by physicians to addicts already dependent on such drugs. The most frequently mentioned variation is heroin maintenance. Proponents argue that providing addicts with drugs prevents them from having to commit crimes to finance their habit and ensures that the drugs they ingest are pure.

Harm reduction generally implies that government policies should concentrate on lowering the harm to the individual associated with drug use, especially the risk of AIDS, rather than on reducing use itself or getting an addict off drugs. Beginning with the proposition that drug use is inevitable, harm reduction proposals can include the prescription of heroin and cocaine to addicts; removal of penalties for personal use of marihuana; advocating "responsible" drug use as opposed to no drug use; needle-exchange programs for injection drug users to prevent the spread of HIV infection; and "low threshold" methadone maintenance which does not require counseling or regular attendance.

Variations on these options are numerous. Some do not require any change in the legal status of these drugs. The government could, for instance, allow needle exchanges while maintaining current laws banning heroin, the most commonly injected drug. Others, however, represent a major shift from the current role of government and the goal of its policies with regard to drug use and availability. As has been pointed out, some advocates use the term "harm reduction" as a politically attractive cover for legalization (5).

Where We Are

Most arguments for legalization in all its different forms start with the contention that the fight against drugs has been lost and that prevailing criminal justice and social policies with respect to drug use have been a failure. Legalization advocates point to the 80 million Americans who have ever tried drugs during their lifetime, arguing that the laws have been futile and a liberal democracy should not ban what so many people do (6 -8).

The majority of these individuals, however, have used only marihuana; generally their use was only brief experimentation. The size of this number especially reflects the large number of young people who tried marihuana and hallucinogenic drugs during the late l960s and the 1970s when drug use was so widely tolerated that the 1972 Shafer Commission, established during the Nixon Administration, and, later, President Jimmy Carter called for decriminalization of marihuana (1, 9). It also reflects the period of the late 1970s when some physicians described cocaine as a relatively harmless drug even as related problems were escalating rapidly (10).

Since then, concerned public health and government leaders have mounted energetic efforts to denormalize drug use. As a result, current (past month) users of any illicit drugs, as measured by the National Household Survey on Drug Abuse, decreased from 24.8 million in 1979 to 13 million in 1994, a nearly 50% drop. Over the same time period, current marihuana users dropped from 23 million to 10 million and cocaine users from 4.4 million to 1.4 million ( 11). The drug-using segment of the population is also aging. In 1979, 10% of current drug users were older than 34; today almost 30% are (11). With these results and only 6% of the population over age 12 currently using drugs (11), it is difficult to say that drug reduction efforts have failed. This sharp decline in drug use occurred during a period of strict drug laws, societal disapproval, and increasing knowledge and awareness of the dangers and costs of illegal drug use.

Several factors, however, lead many to conclude that we have not made progress against drugs. This feeling of despair stems from the uneven nature of the success. While casual drug use and experimentation have declined substantially, certain neighborhoods and areas of the country remain infested with drugs and drug-related crime, and these continuing trouble spots draw media attention. At the same time, the number of drug addicts has not dropped significantly, and the spread of HIV among addicts has added a deadly new dimension to the problem.

The number of hard-core (at least weekly) cocaine users (as estimated by the Office of National Drug Control Policy based on a number of surveys including the Household Survey, Drug Use Forecasting and Drug Abuse Waming Network) has remained steady at roughly 2 million (12). (The accuracy of this figure may be called into doubt, however, because the drop in crime and murder rate in many cities across the country has been attributed to a decrease in cocaine, especially crack, addiction.) The overall number of illicit drug addicts has hovered between 5 and 6 million, a situation that many experts attribute both to a lack of treatment facilities (13) and the large numbers of drug-using individuals already in the pipeline to addiction, even though overall casual use has dropped. Further, after 13 years of sharp decline, teenage drug use increased from 1992 to 1995.

While strict drug laws and criminal sanctions are not likely to deter hard-core addicts, increased resources can be dedicated to prevention and treatment without changing the legal status of drugs. It is difficult to carry out effective prevention campaigns when drugs are available on every street corner and school corridor; witness the continued rise in teenage smoking in spite of major prevention efforts. The criminal justice system can be used to enhance treatment outcome by using such programs as an alternative to incarceration and by offering treatment in prisons. Though substantial problems remain, the significant progress in our struggle against drug abuse can be accelerated by improving the system rather than tearing it down.

Will Legalization Increase Drug Use?

Proponents of drug legalization claim that making drugs legally available would not significantly increase the number of addicts. They argue that drugs are already available to those who want them and that a policy of legalization could be combined with education and prevention programs to discourage drug use (6, 7, 14). Some contend that legalization might even reduce the number of users, arguing that there would be no pushers to lure new users and drugs would lose the "forbidden fruit" allure of illegality (7, 15). Proponents of legalization also play down the consequences of drug use, saying that most drug users can function normally (16). Some legalization advocates assert that a certain level of drug addiction is inevitable so that even if legalization increased the number of users, it would have little effect on the numbers of users who become addicts ( 17).

The effects of legalization on the numbers of users and addicts is an important question because the answer in large part determines whether legalization will reduce crime, improve public health, and lower economic, social, and health care costs or will have the opposite effects. The claimed benefits of legal change evaporate if the number of users and addicts, particularly among children, increases significantly.

Availability

An examination of this question begins with the issue of availability, which has three components:

1. Physical, how convenient is access to drugs

2. Psychological, the moral and social acceptability and perceived consequences of drug use

3. Economic, the affordability of drugs

Physical

Despite assertions to the contrary, the evidence indicates that presently drugs are not accessible to all. Fewer than 50% of high school seniors and young adults under 22 believed they could obtain cocaine "fairly easily" or "very easily" (18, 19). Only 39% of the adult population reported they could get cocaine; and only 25% reported that they could obtain heroin, PCP, and LSD (20). Thus, only one quarter to one half of people can easily get illegal drugs (other than marihuana). After legalization, drugs would be more widely and easily available. Currently, only 11 % of individuals reported seeing drugs available in the area where they lived (20); after legalization, there could be a place to purchase drugs in every neighborhood. Under such circumstances, it is logical to conclude that more individuals would use drugs.

In arguing that legalization would not result in increased use, proponents of legalization often cite public opinion polls which indicate that the vast majority of Americans would not try drugs even if they were legally available (21, 22). They fail to take into account, however, that this strong public antagonism towards drugs has been formed during a period of strict prohibition, when government and institutions at every level made clear the health and criminal justice consequences of drug use. Furthermore, even if only 15% of the population would use drugs after legalization, this would be triple the current level of 5.6%.

Laws define what is acceptable conduct in a society and express the will of its citizens. Drug laws not only create a criminal sanction, they also serve as educational and normative statements that shape public attitudes (23). Criminal laws constitute a far stronger statement than civil laws, but even the latter can discourage individual consumption. Laws regulating smoking in public and workplaces, prohibiting certain types of tobacco advertising, and mandating warning labels are in part responsible for the decline in smoking prevalence among adults, which seems to be leveling off at the high rate of 48 million nicotine addicts.

The challenge of reducing drug abuse and addiction would be decidedly more difficult if society passed laws indicating that these substances are not sufficiently harmful to prohibit their use. Any move toward legalization would decrease the perception of risks and costs of drug use, which would lead to wider use (18). During the late 1960s and the 1970s, as society, laws, and law enforcement became more permissive about drug use, the number of individuals smoking marihuana and using heroin, hallucinogens, and other drugs rose sharply. During the 1980s, as society's attitude became more restrictive and antidrug laws stricter and more vigorously enforced, the perceived harmfulness of marihuana and other illicit drugs increased and use decreased.

Some legalization advocates point to the campaign against smoking as proof that reducing use is possible while substances are legally available (6, 8, 14). But it has taken smoking more than 30 years to decline as much as illegal drug use did in 10 years (12, 24). Moreover, reducing use of legal drugs among the young has proven especially difficult. While use of illegal drugs by high school seniors dropped 50% from 1979 to 1993, tobacco use remained virtually constant and is now increasing (18).

Economic

Unless one repeals the laws of economics, it is likely that reducing the price of drugs will increase consumption (23, 25, 26). Though interdiction and law enforcement have had limited success in reducing supply (seizing at best only 25-30% of cocaine imports, for example) (12) the illegality of drugs has increased their price (27). Prices of illegal drugs are roughly 6 10 times what they would cost to produce legally. Cocaine, for example, sells at $60-80 a gram today, but would cost only $ 10 a gram legally to produce and distribute. That would set the price of a dose at 50 cents, well within the reach of a schoolchild's lunch money (28). ( For higher estimates of the differences between illegal and legal costs see references 8 and 23.)

Until the mid 1980s, cocaine was the drug of the middle and upper classes. Regular use was limited to those who had the money to purchase it or got the money through white collar crime or selling such assets as their car, house, or children's college funds. In the mid 1980s, the $5 crack cocaine vial made the drug inexpensive and more available to the poor and young. Use spread. Cocaine-exposed babies began to fill hospital neonatal wards, cocaine-related emergency room visits increased sharply, and cocaine-related crime and violence jumped (23).

Efforts to increase the price of legal drugs by taxing them heavily in order to discourage consumption would be accompanied by the black market, crime, violence, and corruption now associated with the illegal drug trade. Heroin addicts, who gradually build a tolerance to the drug, and cocaine addicts, who crave more of the drug as soon as its effects subside, would turn to a black market if an affordable and rising level of drugs were not made available to them legally.

Children

Drug use among children and adolescents is of particular concern since almost all individuals who use drugs begin before they are 21. Furthermore, adolescents rate drugs as the number one problem they face (19). Since we have been unable to keep legal drugs, like tobacco and alcohol, out of the hands of children, legalization of illegal drugs could cause a pediatric pandemic of drug abuse and addiction.

Most advocates of legalization support a regulated system in which access to presently illicit drugs would be illegal for minors (8). Such regulations would retain for children the "forbidden fruit" allure that many argue legalization would eliminate. Furthermore any such distinction between adults and minors could make drugs, like beer and cigarettes today, an attractive badge of adulthood.

The American experience with laws restricting access by children and adolescents to tobacco and alcohol makes it clear that keeping legal drugs away from minors would be a formidable, probably impossible, task. Today, 62% of high school seniors have smoked, 30% in the past month (18). Three million adolescents smoke cigarettes, an average of one half pack per day, a $1 billion a year market (29). Twelve million underage Americans dank beer and other alcohol, a market approaching $10 billion a year. Although alcohol use is illegal for all those under the age of 21, 87% of high school seniors report using alcohol, more than half in the past month (18). These rates of use persist despite school, community, and media activities that inform youths about the dangers of smoking and drinking and despite increasing public awareness of these risks.

Moreover, in contrast to these high rates of alcohol and tobacco use, only 18% of seniors use illicit drugs, which are illegal for the entire society (18). It is no accident that those substances which are mostly easily obtainable— alcohol, cigarettes, and inhalants such as those found in household cleaning fluids—are those most widely used by the youngest students (18, 30).

Supporters and opponents of legalization generally agree that education and prevention programs are an integral part of efforts to reduce drug use by children and adolescents. School programs, media campaigns such the Partnership for a Drug-Free America (PDFA), and news reports on the dangers of illegal drugs have helped reduce use by changing attitudes towards drugs.

Along with such educational programs, however, the stigma of illegality is especially important in preventing use among adolescents. From 1978 to 1993, current marihuana use among high school seniors dropped twice as fast as alcohol use (18). California started a $600 million antismoking campaign in 1989, and by 1995, the overall smoking rate had dropped 30%. But among teenagers the smoking rate remained constant—even though almost one quarter of the campaign targeted them (31).

In separate studies, 60-70% of New Jersey and California students reported that fear of getting in trouble with the authorities was a major reason why they did not use drugs (32, 33). Another study found that the greater the perceived likelihood of apprehension and swift punishment for using marihuana, the less likely adolescents are to smoke it (34). Because a legalized or decriminalized system would remove much, if not all, of this deterrent, drug use among teenagers could be expected to rise. Since most teens begin using drugs because their peers do (35)—not because of pressure from pushers (36)—and most drugs users initially exhibit few ill effects, more teenagers would be likely to try drugs (23, 36).

Hard-Core Addiction

A review of addiction in the past shows that the number of alcohol, heroin, and cocaine addicts, even when adjusted for changes in population, fluctuates widely over time, in response to changes in access, price, societal attitudes, and legal consequences. The fact that alcohol and tobacco, the most accepted and available legal drugs, are the most widely abused, demonstrates that behavior is influenced by opportunity, stigma, and price. Many soldiers who were regular heroin users in Vietnam stopped once they returned to the United States where heroin was much more difficult and dangerous to get (1). Studies have shown that even among chronic alcoholics, alcohol taxes lower consumption (37).

A systematic review of the relation between demand and criminal justice activities by Homer estimated that without retail-level drug arrests and seizures—which reduce availability, increase the danger of arrest for the drug user, and stigmatize use—the number of compulsive cocaine users would rise to between 10 and 32 million, a level 5-16 times the present one (38).

Not all new users become addicts. But few individuals foresee their addiction when they start using; most think they can control their consumption (28). Among the new users created by increased availability, many, including children, would find themselves unable to live without the drug, no longer able to work, go to school, or maintain personal relationships. In fact, as UCLA criminologist James Q. Wilson points out with regard to cocaine (39), the percentage of drug triers who become abusers when the drugs are illegal, socially unacceptable, and generally hard to get may be only a fraction of the users who become addicts when drugs are legal and easily available—physically, psychologically, and economically.

Harming Thy Neighbor and Thyself: Addiction and Casual Drug Use

To offset any increased use as a result of legalization, many proponents contend that money presently spent on criminal justice and law enforcement could be used for treatment of addicts and prevention (6). In 1995, the federal government spent $13.2 billion to fight drug abuse, nearly two thirds of that on law enforcement; state and local governments are spending at least another $16 billion on drug control efforts, largely on law enforcement (12). Legalization proponents argue that most of this money could be used to fund treatment on demand for all addicts who want it and extensive public health campaigns to discourage new use.

With changes in the legal status of drugs, the number of new prisoners would initially decrease because many are currently there for drug law violations. As use increased, however, costs would quickly rise in health care, schools, and businesses. Soon, wider use and addiction would increase criminal activity related to the psychological and physical effects of drug use and criminal justice costs would rise again. The higher number of casual users and addicts would reduce worker productivity and students' ability and motivation to learn, cause more highway accidents and fatalities, and fill hospital beds with individuals suffering from ailments and injuries caused or aggravated by drug abuse.

Costs

It is doubtful whether legalization would produce any cost savings over time, even in the area of law enforcement. Indeed, the legal availability of alcohol has not eliminated law enforcement costs due to alcohol-related violence. A third of state prison inmates committed their crimes while under the influence of alcohol (40). Despite intense educational campaigns, the highest number of arrests—1.5 million in 1993—is for driving while intoxicated (41).

Like advocates of legalization today, opponents of alcohol prohibition claimed that taxes on the legal sale of alcohol would dramatically increase revenues and even help erase the federal deficit (42). The real-world result has been quite different. The more than $11 billion in 1995 state and federal revenues from alcohol taxes (43, 44) paid for less than half the $40 billion that alcohol abuse imposed in direct health care costs in 1995 (45), much less the costs laid on federal entitlement programs and the legal and criminal justice systems, to say nothing of lost economic productivity. The $13 billion in federal and state tobacco tax revenue (43,44) was one sixth of the $75 billion in direct health care costs attributable to tobacco (45). This discrepancy between excise tax revenue and alcohol- and tobacco-related costs does decrease if one takes into account the "savings" from such programs as Social Security and Medicare due to premature death. The idea that a tobacco policy resulting in more than 400,000 deaths a year provides any kind of model for dealing with illegal drugs is hard to imagine.

Health care costs directly attributable to illegal drugs exceed $30 billion (45), an amount that would increase significantly if use spread after legalization. Experience renders it unrealistic to expect that taxes could be imposed on newly legalized drugs sufficient to cover the costs of increased use and abuse.

Public Health

Legalization proponents contend that prohibition has negative public health consequences such as the spread of HIV from addicts who share dirty needles, accidental poisoning, and overdoses from impure drugs of variable potency. Of those individuals who were newly diagnosed with AIDS between July, 1995, and June, 1996, more than one-third were among injection drug users who may have shared needles, cookers, cottons, rinse water, and other paraphernalia; many other individuals contracted AIDS by having sex with infected injection drug users (46).

Advocates of medicalization argue that while illicit drugs should not be freely available to all, doctors should be allowed to prescribe them (particularly heroin, but also cocaine) to addicts. They contend that giving addicts drugs assures purity and eliminates the need for addicts to steal in order to buy them (47).

Giving addicts drugs like heroin, however, poses many problems. Providing them by prescription raises the danger of diversion for sale on the black market. The alternative—insisting that addicts take drugs on the prescriber's premises—entails at least two visits a day, thus interfering with the stated goal of many maintenance programs to enable addicts to hold jobs. Early results from the Swiss heroin maintenance project show that a substantial number of enrolled individuals are unwilling to make such ongoing visits and are unwilling to do without the heroin or cocaine combination they like—leading the organizers to propose take-out heroin and the ability to use cocaine as well. Neither the Swiss project nor heroin maintenance in Liverpool, England, appear to have improved employment among addicts.

Heroin addicts require two to four shots each day in increasing doses as they build tolerance to its euphoric effect. On the other hand, methadone can be given at a constant dose since euphoria is not the objective. Addicts maintained on methadone need only a single oral dose each day, eliminating the need for injection (48-50). Because cocaine produces an intense but short euphoria and an immediate desire for more (51), addicts would have to be given the drug even more often than heroin in order to satisfy their craving sufficiently to prevent them from seeking additional cocaine on the street. The binge nature of cocaine use renders it unlikely that cocaine could be given on a "medicalization" basis. Because powder cocaine can be readily converted into crack, any proposal to expand availability of the former will increase the number of crack users and addicts.

Other less radical harm reduction proposals also have serious flaws. As compared to comprehensive methadone maintenance, "low threshold" methadone maintenance programs, when objectively studied, show sharply in creased rates of illicit drug use and drug-related problems, and a failure tc reduce high-risk behaviors (52, 53). Distributing free needles does not ensure that addicts desperate for a high at inconvenient times would not continue to share them. But to the extent that needle exchange programs are effective in reducing the spread of the HIV virus, they can be adopted without legalizing drugs. Studies of whether needle exchange programs increase drug use, however, have generally focused on periods of no longer than 12 months (54). While use does not seem to increase in this period, data are lacking on the long-term effects of such programs and whether they prompt attitude shifts that in turn lead to increased drug use (55).

Some individuals do die as a result of drug impurities. But while drug purity could be assured in a government-regulated system (though not for those drugs sold on the black market), careful use could not. The increased numbers of users would probably produce a rising number of overdose deaths, similar to those caused by alcohol poisoning today. The deaths and costs due to unregulated drug quality pale in comparison to the negative impact that legalization would have on drug users, their families, and society. Casual drug use is dangerous, not simply because it can lead to addiction or accidental overdoses, but because it can be harmful per se, increasing worker accidents, highway fatalities, and children born with physical and psychological handicaps. Each year, roughly 500,000 newborns are exposed to illegal drugs in utero; many others are never born because of drug-induced spontaneous abortions (56,57). Drug-exposed newborns are more likely to need intensive care and to suffer the numerous consequences of low birth weight and prematurity, including early death (56, 58). The additional costs just to raise drug-exposed infants would outweigh any potential savings of legalization in criminal justice expenditures (58).

Substance abuse both leads to and aggravates medical problems. Medicaid patients with a secondary diagnosis of substance abuse (including alcohol) remain in hospitals twice as long as patients with the same primary diagnosis but with no substance abuse problems. Girls and boys under age 15 remain in the hospital three and four times as long, respectively, when they have a secondary diagnosis of substance abuse (59). One third to one half of individuals with psychiatric problems are also substance abusers (60). Young people who use drugs are at higher risk of mental health problems including depression, suicide, and personality disorders (56) and are more likely to engage in risky behavior such as unprotected sex (61,62). Such sexual behavior exposes these teens to increased risk of pregnancy as well as AIDS and other sexually transmitted diseases.

In schools and families, drug abuse can be devastating. Students who use drugs not only limit their own ability to learn, they also disrupt classrooms. Drug-using parents are more likely to provide inadequate or no economic support and put their children at greater risk of becoming substance abusers themselves (56). With the advent of crack cocaine in the mid 1980s, foster care cases soared over 50% nationwide in five years; more than 70% of these cases involved families in which at least one parent abused drugs (63).

Decreased coordination and impaired motor skills that result from drug use are dangerous not just to the individual but to society at large. A recent study in Tennessee found that 59% of reckless drivers, having been stopped by the police and tested negative for alcohol, test positive for marihuana and/or cocaine (64). Twenty percent of New York City drivers who die in automobile accidents test positive for cocaine use (65). The extent of driving while high on marihuana and other illegal drugs is still not well known because usually the police do not have the same capability for roadside drug testing as they do for alcohol testing.

The Workplace

Currently, three quarters of illegal drug users are employed full or part time (11); 15% of them admit to working under the influence of drugs (66). These workers impose costs on their employers and eventually society through their decreased productivity, health care needs, workplace accidents, and absenteeism. They drive buses and trucks, operate nuclear power plants, run the air traffic control system, perform surgery, deliver mail, and teach children.

Workers who use cocaine and marihuana are twice as likely to be absent from work and to be injured, and one and a half times more likely to be involved in an accident (56). Overall, workers who use drugs are three times likelier to be late for work, 10 times likelier to miss work, and three to six times likelier to injure themselves or others. Drug-using workers are responsible for 40% of industrial fatalities and experience more than 300% higher medical and benefits costs (67). In 1991, it is estimated that lost productivity due to illegal drugs totalled $35 billion (68, 68a).

Crime and Violence

Legalization advocates contend that drug-related violence is really drug trade-related violence, that antidrug laws spawn more violence and crime than the drugs themselves. Because illegality creates high prices for drugs and huge profits for dealers, advocates of legalization point out that users commit crimes to support their habit; drug pushers fight over turf; gangs and organized crime thrive; and users become criminals by coming into contact with the underworld (14, 16, 69, 70).

Researchers divide drug-related violence into three types: systemic, economically compulsive, and psychopharmacological (71):

1. Systemic violence is that intrinsic to involvement with illegal drugs, including murders over drug turf, retribution for selling "bad" drugs, and fighting among users over drugs or drug paraphernalia.

2. Economically compulsive violence results from addicts who engage in violent crime to support their addiction.

3. Psychopharmacological violence is caused by the short-term or long-term use of certain drugs which lead to excitability, irrationality, and violence, uch as a brutal murder committed under the influence of cocaine.

In a study of 130 drug-related 1984 homicides in New York State (but outside New York City), 60% resulted from the psychopharmacological effects of the drug (usually used with alcohol); only 20% were found to be related to the drug trade; 3.1 % were committed for economic reasons. The remaining 17% either fell into more than one of these categories or were categorized as "other" (72). As the crack trade developed in New York City in the late 1980s and fighting over drug turf became prevalent, a later study by the authors found drug trade-related deaths to be the most common (73). As the crack trade has matured, the proportion of these types of homicides to the total number of drug-rated deaths has appeared to decrease, contributing to the decrease in the overall murder rate in the city.

U.S. Department of Justice statistics reveal that six times as many homicides, four times as many assaults, and almost one and a half times as many robberies are committed under the influence of drugs as are committed to get money to buy drugs (40). Given these facts, any decreases in violent acts committed because of the current high cost of drugs would be more than offset by increases in psychopharmacological violence, such as that caused by cocaine-related effects.

The threat of rising violence is particularly serious in the case of cocaine, crack, methamphetamine, and PCP. Unlike marihuana or heroin, which depress activity, these drugs are often associated with increased irritability and physical aggression. For instance, past increases in the New York City homicide rate have been tied to increases in cocaine use (74).

Because addicts engage in criminal behavior for different reasons, repeal of drug laws would not affect all addicts in the same way. A small proportion of addicts is responsible for a disproportionately high number of drug-related crimes and arrests. Virtually all of these addicts committed crimes before abusing drugs and use crime to support themselves as well as their habits. Their criminal activity and drug use are symptomatic of chronic antisocial behavior. Legally available drugs at lower prices would do little to discourage crime by this group (75, 76). Fagan, for example, found that the expanding crack markets attracted individuals with an extensive history of violence and drug selling rather than initiating individuals into such careers (77). For a second group, criminal activity is associated with the high cost of illegal drugs. For these addicts, lower prices would decrease drug-related crimes. For a third group, legally available drugs would mean an opportunity to create illegal diversion markets, as some addicts currently do with methadone (75, 76). (Under medicalization schemes, there would still be an illegal drug market for novice users and those unwilling to abide by program rules.)

Legalization advocates point to exploding prison populations and failure of drug laws to lower crime rates (78). From 1980 to 1993, arrests for drug offenses doubled from 470,000 to I million (41). Some 60% of the 95,000 federal inmates are in prison for drug law violations (41). Rising prison populations are generated in large part by stricter laws, tough enforcement, and mandatory minimum sentencing laws—policy choices of the public and Congress. But the growing number of prisoners is also a product of the high rate of recidivism—a phenomenon tied in good measure to the lack of treatment facilities, both in and out of prison. Eighty percent of state prisoners have prior convictions and 60% have served time before (40). Despite the fact that more than 60% of all state inmates have used illegal drugs regularly and 30% were under the influence of drugs at the time they committed the crime for which they were incarcerated (40), fewer than 20% of inmates with drug problems receive any treatment (79).

While strict laws and enforcement do not deter addicts from using drugs, the criminal justice system can be used to get them in treatment. Because of the nature of addiction, most drug abusers do not seek treatment voluntarily, but many respond to outside pressures including the threat of incarceration (76). Where the criminal justice system is used to encourage treatment participation, addicts are more likely to complete treatment and stay off drugs (80, 81).

The Lessons of Prohibition

Legalization advocates often cite the era of national alcohol prohibition from 1920 to 1934 to support their case. As ratified in the 18th Amendment, Prohibition banned the "manufacture, sale, or transportation of intoxicating liquors within, the importation thereof into, or the exportation thereof from the United States...." Proponents of legalization contend that the failure of the 18th Amendment supports their argument that prohibitions of this kind of individual behavior are not effective (21).

The alcohol prohibition drug control law analogy is a false one. There are two important distinctions between Prohibition and current drug laws. First, Prohibition was in fact decriminalization because possession for personal consumption was not illegal. Second, alcohol, unlike illegal drugs, has a long history of widespread social acceptance and use in Western culture dating at least as far back as the Old Testament and Ancient Greece. Most Americans who drink do not get into trouble with alcohol. Thus, the public and political consensus favoring Prohibition was short-lived. By the early 1930s, most Americans no longer supported it. Today, on the other hand, the public overwhelmingly favors keeping illegal drugs illegal (19).

Despite these differences, which made alcohol prohibition more difficult to enforce than current drug laws, Prohibition reduced the amount of alcohol consumed, as well as the incidence of alcohol-related medical problems and violence. It is important not to confuse federal Prohibition with state laws restricting alcohol. Advocates of legalization point to the decline in consumption and cirrhosis pre-l919 to argue that consumption declined more before the 18th Amendment then after. Given the fact that by 1919, 36 of the 48 states had established some form of prohibition, this argument is true but disingenuous. At the beginning of the twentieth century, Americans consumed 2.6 gallons of alcohol per person. By 1919, this amount dropped to 1.96 gallons per person. In 1934, the first full year after repeal of national Prohibition, alcohol use stood at .97 gallons per person. From then on, consumption rose steadily to its present level, roughly three times as high as that immediately after Prohibition (82).

Death rates from cirrhosis of the liver corroborate available consumption statistics. Cirrhosis death rates fell from 12 per 100,000 in 1916 to 5 per 100,000 in 1920, and remained at that level throughout Prohibition before beginning to rise steadily again after repeal (83). Among men such rates declined even more sharply, from 29.5 per 100,000 in 1911 to 10.7 per 100,000 in 1929 (42).

The decrease in consumption had other positive health consequences. Admissions to mental health institutions for alcoholic psychosis dropped by more than 60% from 1919 to 1922. Arrests for drunkenness and disorderly conduct dropped 50% between 1916 and 1922, and welfare agencies reported dramatic declines in the number of cases due to alcohol-related family problems (42).

Nor is Hollywood's guns and gangsters depiction of Prohibition accurate. Homicide experienced a higher rate of increase between 1900 and 1910 than during Prohibition, and organized crime was well established in cities before 1920 (42).

Legalization proponents also argue that during Prohibition, an increased number of drinkers died from the consumption of dangerous wood and denatured alcohol, which were used as substitutes for commercial alcohol, just as today addicts die from impure drugs. The data do not bear this out. Through 1927, the rate of death from these substitutes remained nearly constant at its 1920 level (42).

The public may agree that the freedom to drink is worth the public health consequences. Worried by the high rate of alcohol-related disease and crime, the residents of Barrow, Alaska, the northernmost city in the United States, voted in 1994 to ban alcohol completely. Despite the 70% drop in crime and the immediate and persistent decline in alcohol-related emergency room visits from 118 in the month before the ban to 23 in the following month, residents voted to repeal the ban in 1995. In the two weeks after the ban was rifled, the detoxification center began to fill with patients and alcohol-related murders were on the rise (84).

These facts are presented to set the record straight and to dispel the exaggerated or false consequences often attributed to Prohibition. They are not an argument for the resumption of alcohol prohibition, which we oppose, but they do offer some lessons on the relevance of illegality to reducing drug use.

The Lessons of Legal Drugs

Legalization proponents point out that alcohol and tobacco cost society much more in lost productivity, increased health care, and criminal justice expenditures and lead to more deaths than all illegal drugs combined (7, 8, 14). From that, they conclude that we spend too much time and energy fighting. illegal drugs, as compared to legal drugs. Alcohol and tobacco are indeed responsible for far more deaths and costs to society than illegal drugs, but this is precisely because alcohol and tobacco are legal and therefore widely available, used, and abused.

Illegal drug-related deaths are estimated at 20,000 annually. Tobacco is responsible for more than 400,000 deaths and alcohol for more than 100,000 deaths every year (85). Fetal alcohol syndrome is the leading known cause of mental retardation (86). Smoking by pregnant women kills up to 7,000 newborns annually and leads to as many as 141,000 miscarriages (87). Cigarettes are as addictive as heroin and spawn health problems ranging from lung cancer to emphysema and heart disease (88). Of the $66 billion that substance abuse cost federal health and disability entitlement programs in 1995, $56 billion were attributable to alcohol and tobacco (89). Of the $29 billion in Medicare costs attributable to substance abuse, 80% was related to smoking. Seventy percent of the $21 billion that Medicaid spent because of substance abuse is due to cigarettes and alcohol (45).

The high costs attributed to legal drugs do not indicate that we are concentrating prohibition on the wrong drugs, but rather that when drugs are legal, and therefore widely acceptable and available, they adversely affect more individuals and require more attention and resources. Indeed, the nation's experience with tobacco and alcohol send a warning about the dangers of making illegal drugs readily available. As drug policy expert Mark Kleiman has noted, "Until success is achieved in imposing reasonable controls on the currently licit killers, alcohol and nicotine, the case for adding a third or fourth recreational drug . . . will remain hopelessly speculative" (90).

Another argument made by legalization proponents is that the general decrease in consumption rates of both legal and illegal drugs in the past 15 years has nothing to do with law enforcement policy, but rather with education and increased societal concern with personal health (8). Yet despite widespread awareness of the risks of smoking and heavy media attention to tobacco-related problems, roughly 25% of Americans continue to smoke (24), and smoking is on the rise among young people (12). On the other hand, the number of illegal drug users has dropped by half over the last 15 years, to 6% of the population (11). Arguing that we should treat illicit drugs as we do tobacco, using education instead of prohibition, also implies a false dichotomy between education and prohibitive laws. In curbing illegal drug use, when law enforcement and education complement and reinforce each other, they are most effective.

There are more than 48 million nicotine addicts, 12-18 million alcoholics and alcohol abusers and 5-6 million illegal drug addicts. Making illegal drugs more available would drive the number of marihuana, heroin, and cocaine users closer to the number of alcohol and tobacco users.

Marijuana

Marihuana is the most commonly used illegal drug in the United States and its use is particularly high among adolescents. Because relatively little street-level violence attends the marihuana trade, the legalization and decriminalization debate here centers on how harmful the drug is to the user, whether marihuana use leads to the use of harder drugs, whether marihuana use would increase, and whether any increase would translate into a decrease in alcohol use (21, 91, 92).

While clearly not as dangerous as snorting cocaine or shooting heroin, smoking marihuana is detrimental both physically and mentally, especially to adolescents. The effects of one marihuana joint on the lungs are equivalent to four cigarettes, placing the user at increased risk of bronchitis, emphysema and bronchial asthma. The active ingredient in marihuana, tetrahydrocannabinol (THC), is fat soluble and remains in the brain, lungs, and reproductive organs for weeks. Marihuana weakens the immune system, and regular use can disrupt the menstrual cycle and suppress ovarian function (93, 94). Regardless of socioeconomic status, prenatal use of marihuana by the mother appears to reduce significantly the IQs of babies (95). Marihuana impairs short-term memory and ability to concentrate (94) at a time when the main task of its young users is education. And marihuana use diminishes motor control functions, distorts perception, and impairs judgment, leading among other things to increased car accidents and vandalism. Marihuana toxicity, especially anxiety and panic attacks, is a frequently cited cause of emergency room visits, and treatment of marihuana dependence has become a common reason for seeking substance abuse treatment, treatment which is usually psychological rather than pharmacological. As Millman and Beeder note, stopping chronic cannabis use often results in "a marked and rapid improvement in mental clarity and energy levels" (96).

The link between the use of marihuana and the subsequent use of harder drugs has been the subject of much debate, with supporters of marihuana decriminalization and legalization arguing that many individuals who smoke marihuana never use hard drugs. While the latter is true, the statistical association between the teenage use of marihuana and the later use of other drugs such as cocaine is powerful. Even though the biomedical or other causal relationship for this has not yet been adequately explained, 12- to 17-year-olds who smoke marihuana are 85 times more likely to use cocaine than those who do not. Adults who as adolescents smoked marihuana are 17 times likelier to use cocaine regularly. Sixty percent of adolescents who use marihuana before age 15 will later use cocaine. These correlations are many times higher than the initial relationships found between smoking and lung cancer in the 1964 Surgeon General's report (9-10 times), high cholesterol and heart disease in the Framingham study (2 4 times), and asbestos and lung cancer in the Selikoff study (5 times) (97).

Marihuana use has been associated with many high-risk behaviors among young people. According to the U.S. Centers for Disease Control and Prevention, adolescents who smoke marihuana are twice as likely to attempt suicide and carry a weapon as those who do not. Adolescent marihuana smokers are three times as likely to have sex and far more likely to do so without a condom, putting themselves at much greater risk of teen pregnancy and sexually transmitted diseases (61).

Past experiences with marihuana decriminalization illustrate the consequences of more tolerant policies. During the 1970s, 11 states decriminalized personal possession of marihuana by making the offense a civil violation punishable by a fine. In 1975, the Alaska State Supreme Court decriminalized at-home personal use of small amounts of marihuana for individuals older than age 19. By 1988, 12- to 17-year-olds in Alaska were smoking joints at more than twice the national average. Marihuana use became part of the lifestyle of many teenagers and the age of initiation declined (98, 99). Because of this, in a 1990 referendum, Alaskans voted to recriminalize personal possession.

Proponents of legalization cite several surveys and studies which report that when Oregon, Maine, and California decriminalized marihuana, rates of use among teenagers did not increase significantly (100). These surveys, however, have severe shortcomings. They lack controls for other historical and demographic factors, such as sex, income, and education, and employ vaguely defined measurement criteria to estimate the prevalence of marihuana use (101, 102). They do not reflect the impact of legalization on long-term usage rates because they were conducted only 1-3 years after decriminalization laws were passed, and they fail to recognize that even minimal annual increases in use become significant when they accumulate over time. Though reported marihuana use increased only slightly following decriminalization, the time period surveyed was not long enough to allow the educational and attitude-forming aspects of the previous strict drug laws to dissipate.

Measurement problems also exist in trying to compare usage rates in states that decriminalized versus states that did not. The comparison is problematic because many states that did not decriminalize reduced penalties for marihuana use, and others chose not to enforce laws prohibiting personal use of marihuana. During the 1970s, many states and the federal government adopted more tolerant attitudes towards the drug. Nationwide, use rose significantly during this time, reaching almost 40% of high school seniors before beginning its long decline in 1979 (18).

Teenagers are not likely to stop using alcohol when they begin smoking marihuana. While on individual occasions teens may choose to get high on either marihuana or alcohol, these drugs are often used together. From 1975 to 1978, as the percentage of teens using marihuana increased from 27 to 37%, the percentage of teens who drank increased from 68 to 72%. Marihuana use then dropped to 12% of teens by 1992; alcohol use dropped to 51 %. The recent rise in teenage marihuana use has been accompanied by little change in the percentage of students who drink (18).

Proponents of legalization argue that while smoking pot has detrimental health and social effects, so does use of our two legal drugs, alcohol and tobacco, and to be consistent, we should legalize marihuana. But legalizing marihuana would add a third drug that combines some of the most serious risks of the other two (94). Marijuana offers both the intoxicating effects of alcohol and the long-term lung damage of tobacco. It would be irresponsible to legalize or decriminalize marihuana and create a third legal drug, especially when we are still learning about its physical and psychological health effects as well as its relationship to other drugs and a variety of dangerous behaviors. One of the most serious drawbacks of marihuana legalization, Kleiman notes, is its "virtual irreversibility if it goes badly wrong" (103).

The European Experiences

Many legalization advocates point to the policies of European countries as models for approaches to the American drug problem. They claim that some countries, notably the Netherlands and Great Britain, are more innovative because their aim is to minimize the harmful impact of drug use on the user and society, even if this requires legal change (104).

While the Netherlands' laws regarding illegal drugs remain unchanged, Dutch enforcement policy since 1976 has distinguished between "drugs presenting an unacceptable risk" (commonly termed "hard drugs," such as cocaine and heroin) and "cannabis products" (83). Special "coffee shops" were established where anyone age 18 can purchase marihuana. Legalization proponents claim that this policy has not increased drug use among young people or the population in general (16, 105, 106).

These claims are not supported by the facts. Though marihuana use did not explode immediately following decriminalization, it has recently been increasing, suggesting that the effects of decriminalization may only be fully realized in the longer term. Between 1984 and 1992, Dutch adolescent marihuana use increased nearly 200% (107); over the same period, marihuana use among American adolescents plummeted 66%. Since 1988, the Dutch have seen a 22% increase in the total number of registered addicts, and a 30% increase, from 1991 to 1993, in the number of registered cannabis addicts (108). From 1990 to 1995, the proportion of users who had smoked cannabis for the previous five years increased from 2 to 9%, suggesting that increased availability will be associated with longer term use (109). The same study found that between 1990 and 1995, the percentage of 11 - to 18 -year-olds who had ever used marihuana more than doubled from 7 to 17% (109). Several marihuana "coffee shops" in Amsterdam have already been shut down for illegally selling hard drugs. Responding to pressure from other European countries and its own citizens, the Dutch Parliament passed restrictions in 1996 cutting the number of coffee houses in half and reducing the amount of marihuana an individual can buy from 30 to 5 grams (110).

The other country that legalization advocates cite favorably is Great Britain for its policy of allowing specially licensed doctors to prescribe drugs to addicts (111). Prescribing heroin to addicts, it is claimed, has lowered the rate of addiction and reduced crime (112); neither of these claims have been verified.

Nationwide, British doctors maintain 17,000 heroin addicts on methadone and less than 400 on heroin. Given the 150,000 heroin addicts in England, claims that maintaining a few hundred of them on heroin has driven drug dealers and drug-related crime from the streets are unfounded. There has been no movement among doctors in England to adopt heroin maintenance on a large scale (113).

In general, much confusion surrounds British policies. Until 1968, the government allowed all doctors to prescribe drugs to addicts in the context of their medical treatment, but this policy failed to contain the problem of addiction. Doctors carelessly or willfully abused their privilege and unlawfully supplied drugs to many individuals. Addicts diverted legally obtained drugs to the general population. In response to increasing rates of addiction, Britain mandated in 1968 that only doctors specially licensed by the Home Office could prescribe illegal drugs and that doctors must register all addicts with the Home Office (114). Over 100 doctors are currently licensed, of whom fewer than 20 prescribe such drugs (113).

The rate of increase in heroin addiction in England subsequently slowed until the late 1970s, when a large influx of black market heroin from southwest Asia fueled a sudden increase in new addicts that continued through the 1980s (115). This increase was not, as some legalization proponents claim, due to the fact that the British, following the American lead, adopted harsher drug laws. While on the national level, the government responded to this increase in addiction by emphasizing supply reduction, prevention, and criminal justice deterrents, at the local level officials emphasized harm reduction and loosely enforced antidrug laws. These conflicting national and local approaches persisted until the late 1980s, when concern over the spread of AIDS by injection drug users prompted national policy makers to shift towards such harm reduction programs as needle exchanges and condom distribution (116).

In short, the increasing number of addicts in Britain was not a result of strict national laws and "zero tolerance" policies. Rather, these policies were a response to the increased addiction. Moreover, strict national antidrug laws mean little if local enforcement is lax. One celebrated experiment in harm reduction and drug tolerance is less often mentioned now that it has been terminated. Beginning in 1987, Switzerland allowed all addicts and users to congregate in a park—the "Platzspitz," or "Needle Park," as it became known—in the center of downtown Zurich, where they could buy and use drugs freely. Strict enforcement of antidrug laws continued in the rest of the city and country. Like many proponents of harm reduction, Swiss policy makers believed that if drug dealing and use was going to happen anyway, it might as well occur in the open where the police and health officials could monitor it. In Needle Park, public health officials gave addicts free needles, condoms, medical care, counseling, and the opportunity for treatment (83).

This experiment in harm reduction had unintended consequences. The number of addicts in the park increased from a few hundred in 1987 to 20,000 in 1992. Twenty-five percent came from outside Switzerland, drawn to the park by its tolerant policies. Drug-related violence and crime rose rapidly in the area; 81 drug-related deaths were recorded in 1991, double the previous year. The city's chief medical of ficer reported that doctors were resuscitating an average of 12 people a day who had overdosed, and up to 40 on some days (117). Because of these high costs, the park was closed in 1992, but the fallout from this policy was damaging. The heroin-related death rate in Switzerland had become the highest in Europe and North America (118). Addicts wandered the city streets and open air markets proliferated. Three years after the experiment ended, Swiss police tried to disperse the continuing drug bazaar that had moved to an unused railroad station (119). To deal with their burgeoning heroin problem, Swiss authorities have since begun an experiment with heroin prescription for addicts. That Switzerland's tolerant policy has proved difficult to reverse even after its harmful consequences became apparent serves as a warning to those who claim that we can quickly reverse liberal drug policies if they have negative consequences.

Italy is infrequently mentioned by advocates of legalization despite its lenient drug laws. Personal possession of small amounts of drugs has not been a crime in Italy since 1975, other than for a brief period of "recriminalization" between 1990 and 1993 (though even then Italy permitted an individual to possess one daily dose of a drug). Under decriminalization, interpretation of the precise quantity allowed was left to individual judges, but generally, possession of two to three daily doses of drugs such as heroin was exempt from criminal sanction (120). Today, Italy has 300,000 heroin addicts (121), the highest rate of heroin addiction in Europe (118). Seventy percent of all AIDS cases in Italy are attributable to drug use (121).

In contrast, Sweden offers an example of a successful restrictive drug policy. Sweden has tried a variety of approaches to drugs (though none have involved legalization) since its first experiment with the prescription of drugs, particularly amphetamines, to addicts in 1965. This experiment ended two years later because eligible addicts diverted prescribed drugs to friends and acquaintances and, contrary to the expectation that freely available drugs would decrease crime among addicts, crimes committed by legal users increased.

In 1972, Swedish policy shifted towards harm reduction; enforcement became more lax, concentrating primarily on drug kingpins. Arrests for drug offenses dropped by half and police allowed possession of up to a week's supply of a drug. During this time drug use remained high and heroin use began on a large scale.

By 1980, increasing deaths from heroin use shifted public opinion and government policy toward a more restrictive approach to drugs. The aim of Swedish drug policy, like that of the United States, became a drug-free society. Possession of anything more than a single joint of marihuana was punished; drug arrests tripled in three years. In 1982, Sweden introduced mandatory treatment commitments. During the 1980s, drug use declined rapidly, particularly among the young. By 1988, the percentage of military conscripts using drugs fell by 75%; current use by 9th graders dropped 66%. The population of drug users aged considerably. In 1979, 37% of daily drug users were under age 25; in 1992, 10% were (122).

In short, the claim that permissive drug policies in some European nations stand as a success story is specious when measured against the facts and hardly an example for the United States to emulate.

Can we improve the present situation?

For all of the above mentioned reasons, particularly the increased numbers of users and addicts and the threat to our children, legalization would open a dangerous Pandora's box. The claimed panacea—change the legal status of drugs and the problems associated with them will disappear—is illusory. More questions and problems arise than are answered by proponents.

Legalization is a policy of despair, one that would write off millions of our citizens and lead to a terrible game of Russian roulette, particularly for children. It is not born of any new evidence regarding the nature of addiction or the pharmacological, public health, or criminal effects of drug use. At the beginning of the century, the visible results of widespread recreational opiate and cocaine use prompted the first antidrug laws. With so much more new knowledge about the devastating consequences of drug use, it would be foolhardy to turn back the clock.

To reject legal change, however, is not to accept all of current policy. We have not yet mounted an all-fronts assault on illegal drug use in America, a fact reflected in the recent increase in teenage drug use. We should provide equal protection in the enforcement of drug laws by ending the acceptance of open-air drug bazaars in Harlem, southeast Washington, DC, and south central Los Angeles, which would not be tolerated in Manhattan's Upper East Side, Georgetown, or Beverly Hills. This should be coupled with expanded opportunities for treatment (123), strengthened prevention campaigns, and increased research efforts to make treatment and prevention more effective.

Research on abuse and addiction has been woefully underfunded. The National Institutes of Health spend almost $5 billion in research on cancer ($2 billion), AIDS ($1.4 billion), and cardiovascular diseases ($1.3 billion), but only about 10% of that amount on research on addiction and abuse of illegal and legal drugs—the largest single cause and aggravator of all three of these killers (124). If a mainstream disease like diabetes or cancer affected as many individuals and families in this country as substance abuse and addiction do, this nation would mount an effort on the scale of the Manhattan project to deal with it.

Prevention is the least expensive way to reduce the burden of drugs on our society; a dollar spent on prevention saves up to $ 15 in health care, criminal justice, and other costs (125). An aggressive strategy of prevention should be aimed at the entire population, but with special attention to those currently at high risk of drug abuse (126). Prevention programs should target children and adolescents, because individuals who go from age 10-20 without trying illegal drugs are unlikely to use them. Community-wide organizations such as Fighting Back and Community Partnership Programs should be supported and expanded.

Treatment is both absolutely and relatively cost-effective. It pays for itself over time by saving $7 in criminal justice, health care, and welfare costs for every dollar invested (127). To reduce heavy cocaine use, an additional dollar spent on treatment is seven times more cost effective than an additional dollar spent on domestic enforcement and 20 times more cost effective than attempting to control supply in source countries (128). Still, more research is needed to raise treatment success rates, as well as to discern which types of treatment are most effective for which individuals.

Court-imposed treatment should be expanded and combined with programs that reintegrate the ax-offender into the community by providing continued substance abuse counseling and support groups, as well as education and job training. Treatment and aftercare can decrease recidivism by giving ax-offenders a new chance to become productive members of society. As many as 800,000 inmates have prior convictions. If treatment reduced recidivism by just 20%, there would be 160,000 fewer inmates; a 50% reduction would mean 400,000 fewer inmates.

Mandatory minimum sentencing laws need to be revisited to ensure that we are appropriately using and targeting the scarce commodity of prison cells. Alternatives to incarceration, especially those that coordinate the criminal justice and treatment systems, such as Drug Courts and Treatment Alternatives to Street Crime (TASC), should be expanded.

The objective of a drug-free America, derided by advocates of legalization (8), is a statement of hope that a generation of children can come of age less exposed to the life-destroying effects of illegal drugs. (For a similar statement from Sweden, see reference 122.) Our policies should aim to reduce drug use and addiction to a marginal phenomenon and to rehabilitate drug abusers. At its best, America strives to give all its citizens the chance to develop their talents. Cornering millions of individuals into drug addiction insults this fundamental value and demeans the dignity to which each is entitled.

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