9
Final Thoughts: Unfinished Business

The legal foundation for the nation’s drug control policy was put in place nearly a century ago. The Harrison Narcotics Act of 1914 aimed to suppress use of narcotics (defined to include opiates and cocaine) outside approved medical and scientific channels. Over the course of the 20th century, federal prohibition was extended to marijuana (1937) and to a variety of stimulant, depressant, and hallucinogenic drugs (1965, 1968). Meanwhile, parallel prohibitions were adopted by all the state legislatures. Penalties for violating drug laws were significantly increased during the 1950s and then again in the 1980s.

Until the 1970s, the primary instrument of national drug policy was enforcement of state and federal drug laws, and the federal role was relatively minor. Total federal expenditures in fiscal year 1969 were $66.4 million, allocated primarily to federal law enforcement and to the operation of the two federal hospitals for the treatment of addicted prisoners. During the Nixon administration, however, national drug policy was fundamentally reshaped in response to an epidemic of heroin use in several major cities and an explosion of marijuana and other illegal drug use among college and high school students. Major new initiatives were undertaken to diversify the policy portfolio and to establish and coordinate a strong federal presence.

The Controlled Substances Act, enacted in 1970, established an integrated regulatory framework to replace the patchwork of federal statutes that had accumulated over the century. Two years later, Congress established a drug policy office in the White House, the Special Action Office



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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us 9 Final Thoughts: Unfinished Business The legal foundation for the nation’s drug control policy was put in place nearly a century ago. The Harrison Narcotics Act of 1914 aimed to suppress use of narcotics (defined to include opiates and cocaine) outside approved medical and scientific channels. Over the course of the 20th century, federal prohibition was extended to marijuana (1937) and to a variety of stimulant, depressant, and hallucinogenic drugs (1965, 1968). Meanwhile, parallel prohibitions were adopted by all the state legislatures. Penalties for violating drug laws were significantly increased during the 1950s and then again in the 1980s. Until the 1970s, the primary instrument of national drug policy was enforcement of state and federal drug laws, and the federal role was relatively minor. Total federal expenditures in fiscal year 1969 were $66.4 million, allocated primarily to federal law enforcement and to the operation of the two federal hospitals for the treatment of addicted prisoners. During the Nixon administration, however, national drug policy was fundamentally reshaped in response to an epidemic of heroin use in several major cities and an explosion of marijuana and other illegal drug use among college and high school students. Major new initiatives were undertaken to diversify the policy portfolio and to establish and coordinate a strong federal presence. The Controlled Substances Act, enacted in 1970, established an integrated regulatory framework to replace the patchwork of federal statutes that had accumulated over the century. Two years later, Congress established a drug policy office in the White House, the Special Action Office

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us for Drug Abuse Prevention (SAODAP), to spearhead the new demand-reduction initiatives. It also enacted the legal framework for a nationwide program of voluntary, confidential community-based treatment. Over the next several years, federal funds were appropriated for prevention and treatment programs administered through state and local agencies. (After a number of reorganizations, this money is now administered through the Substance Abuse and Mental Health Services Administration). Federal expenditures on all aspects of drug control rose more than 1,000 percent between 1969 and 1973, and two-thirds of this increase was allocated to treatment and prevention (National Commission on Marihuana and Drug Abuse, 1973:280). In 1972, Congress also established the interagency Strategy Council on Drug Abuse, cochaired by the chief federal drug law enforcement official and the head of the Special Action Office for Drug Abuse Prevention, and directed it to prepare a comprehensive, coordinated strategy for all federal drug abuse and drug trafficking prevention activities. The structure used to coordinate the growing federal effort has changed repeatedly over the past three decades, but national drug control strategy documents have been issued by the White House every year since 1973. SCIENCE AND DRUG POLICY: RECENT PROGRESS The first National Drug Control Strategy was sent to the President in March 1973, as was the report of the National Commission on Marihuana and Drug Abuse, Drug Use in America: Problem in Perspective. Both of these documents emphasized the urgent need to establish data systems for monitoring drug use and assessing the impact of drug control policies, and the importance of mounting an aggressive program of research to increase understanding of the causes and consequences of drug use and to inform policy. The challenge was set forth in the 1973 National Drug Control Strategy in the following words (Strategy Council on Drug Abuse, 1973:150): Much is still unknown. In every area from treatment to prevention, from control of illicit traffic to the long-term consequences of drug use, there are gaps in our knowledge. A rational strategy should include a systematic effort to acquire the needed information…. Current priorities include efforts to measure the size and rate of change in the drug-using population, the adverse consequences of use of various drugs, the natural history of drug use and addiction, and new approaches to treatment and early intervention, including the advantages and disadvantages of educational efforts and mass media campaigns. Research efforts are also needed to improve our capacity to control availability. These take the form of better methods to determine the origins of

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us samples of illicit drugs, to gather and analyze intelligence on illicit traffic, and to analyze the relationships between enforcement activity, judicial actions and the price and availability of illicit drugs. Until these gaps are filled, our policies and strategies must be considered tentative and subject to revision. The national commission summarized its urgent call for research in the following words (National Commission on Marihuana and Drug Abuse, 1973:367–370): Throughout this report, we have pointed out numerous gaps in knowledge about the causes, consequences and control of drug-using behavior…. While research cannot answer all of the questions, much more information is urgently needed, not only to develop more rational policy for the future, but also to implement effectively the policies we now have…. Even a partial listing of the unanswered questions is startling. We do not know: why people choose to use drugs in spite of criminal laws against use and obvious dangers of dependence and disruption; why some individuals who use drugs with high dependence liability become dependent and others do not; why some populations seem much more susceptible to use or to dependence than others; what social forces precipitate the periodic “epidemics” of drug use and what causes the lulls between these increases; how drug law enforcement operates and what effect it has on use and distribution; how, in terms of effectiveness, the various treatment modalities compare and why each seems to work well for some users, and not at all for others; what is the impact of information on the decisions to use or not use drugs. We do not even know the incidence or prevalence of various patterns of drug use…even though this knowledge is essential to sensible planning. Important steps were taken over the next several years to generate the data and research needed to fill the large gaps in knowledge identified by these two major reports in 1973. These initiatives created an infrastructure for monitoring trends in drug use, enhancing understanding of the determinants and consequences of drug use, and evaluating new prevention and treatment programs. All of the information systems described in Chapter 3 used to monitor trends in drug use were created during the 1970s. Most significantly, a separate research agency, the National Institute on Drug Abuse (NIDA), was created in the National Institutes of Health to establish and maintain an infrastructure of both extramural and intramural research. Over the past 25 years, NIDA funding, which supports 85 percent of the world’s research on drug abuse and addiction (Institute of Medicine, 1996), has underwritten substantial advances in the understand-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us ing of neurobiological and behavioral aspects of drug use and has stimulated the development and testing of new modalities of treatment and their introduction into clinical practice (Institute of Medicine, 1996, 1998). Other funding streams in SAMHSA and other federal agencies have been developed for evaluating prevention and treatment programs. In recent years, new collaborative research efforts relating to offender populations have been undertaken by the National Institute of Justice and the Office of Juvenile Justice and Delinquency Prevention and the National Institute on Drug Abuse and the Substance Abuse and Mental Health Service Administration. Although, as this report details, the existing data systems need to be strengthened, and knowledge regarding the effectiveness of treatment and prevention activities still has significant gaps, an impressive body of research has emerged in these areas over the past several decades. UNFINISHED BUSINESS The nation has failed to make an equivalent investment in data and research on the effects of enforcement. Federal and state drug enforcement expenditures amounted to $19.5 billion in 1991 (the last year for which aggregate figures including state and local enforcement are available). Expenditures for federal enforcement (including interdiction and international enforcement) increased more than tenfold between 1981 and 1999. In 1998, 1.6 million people were arrested for drug offenses, three times as many as in 1980, and 289,000 new drug offenders were incarcerated in state prisons, more than ten times as many as in 1980 (23,900). The benefits and costs of these policies have been the subject of heated and continuing debate for decades. Yet policy makers are in no better position to evaluate the effectiveness of these activities than they were in 1973, when the National Commission on Marihuana and Drug Abuse and the first National Drug Control Strategy called attention to the “startling” gaps in knowledge about the effects of enforcement. A small number of economists and policy analysts, supported by ONDCP and other agencies, have doggedly attempted to fill the void by developing analytic models and theories of illegal markets and by making efforts to predict the effects of different types of enforcement interventions. These efforts have helped to characterize the complex interactions of producers, dealers, and users and the subtle processes through which enforcement and other drug control policies might affect prices and consumption. However, as the committee noted in its Phase I report (National Research Council, 1999), even the most creative and sophisticated analytic model cannot inform policy making in the absence of sound data. The weaker the data, the less confidence one can have in the inferences

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us generated by the model about policy effectiveness. As this report demonstrates, no significant progress can be made in assessing the effectiveness of enforcement policy (or its cost-effectiveness in relation to other policy instruments) in the absence of better data on drug prices and consumption. The need for better data is highlighted in the National Drug Control Strategy for 2000, the latest in the series issued annually by federal drug policy officials since the 1973 federal strategy quoted above. In 1998, ONDCP inaugurated its Performance Measures of Effectiveness System to assess the impact of drug control activities on drug use, drug availability, and the consequences of drug use. The system includes 60 quantitative “performance targets,” 12 of which (called “impact targets”) relate to “ultimate” outcome measures of drug availability, use, and consequences. ONDCP deserves a great deal of credit for taking the first steps to assess the impact of current policies, including enforcement, on availability, use, and consequences. However, the project is still in an embryonic stage. In its National Drug Control Strategy for 2000, ONDCP reported to Congress on its progress in developing the Performance Measures of Effectiveness System, pointing out that data do not now exist in relation to 20 of the 60 quantitative performance targets identified in the report. With regard to the impact targets, measures are available for four “use” targets—national prevalence, youth prevalence, workplace prevalence and initial age of use—but not for number of chronic users. Some data are available to develop rough aggregate estimates for the two “consequences” targets—drug-related crime and violence and health and social costs. However, as ONDCP acknowledges, data are presently lacking for the availability targets. A method being developed by ONDCP for estimating the flow of cocaine and heroin into the country is still in an early state of development, and the agency concedes that it does not yet have measures of domestic cultivation and production, trafficker success rate, or an aggregated measure of “availability.” It should be emphasized that, even if data were available to develop valid outcome measures in all these domains, ONDCP still has no way of assessing the impact of enforcement interventions (or other interventions for that matter) on these impact targets. It is revealing in this connection that none of the many other outcome measures relates to the price of illegal drugs. THE WAY FORWARD Data The central problem, in a nutshell, is that the nation lacks the data needed to inform policy. Nearly all of the uncertainties regarding the

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us effectiveness of drug control policies stern from the limitations of existing data on illegal drugs. Throughout this report, the committee has repeatedly concluded that essential policy-relevant data are missing or inadequate. In some areas, the data are nonexistent—for example, on total consumption or numbers of heavy users—or are nearly useless for policy purposes—for example, on price. In other areas, the existing data are not generalizable to other populations of interest—for example, the Arrestee Drug Abuse Monitoring Program—or are only modestly helpful in informing policy (cross-sectional prevalence estimates). The top priorities, in the committee’s judgment, are to rectify the two major deficiencies in existing data systems: the absence of adequate consumption data and reliable price data. These data are absolutely critical for evaluating the effectiveness of supply-reduction activities. Specifically: Better measures are needed of the distribution of consumption, encompassing frequency, amount, and intensity of use (and escalation or de-escalation of use over time). Only if these measures are available will it be possible to estimate total amount consumed at the population level. The simple prevalence data now available may be sufficient for assessing the impact of policy interventions on initiation and termination of use, but they are not sufficient for assessing the responsiveness of users to enforcement, treatment, and other interventions, the relationship between intensity of use and the consequences of use, or the responsiveness of demand to changes in price. Reliable data are needed on retail prices in order to assess the impact of supply-reduction activities on the operation of drug markets. Moreover, price data are essential to evaluate the sensitivity of the demand for drugs to the available supply. Research Infrastructure The federal investment in research on the causes of drug abuse and the effects of prevention and treatment amounted to approximately $668 million in 1999, representing about $1 for every $7.33 spent on prevention and treatment. In contrast, the investment in research on illegal drug markets and the effects of enforcement was approximately $113 million, representing about $1 for every $107 spent on enforcement. In other words, although the federal government spends more than twice as much on enforcement as it does on prevention and treatment—and the nation spends more than three times as much, taking into account state and local expenditures—it spends only one-fourteenth as much on research designed to assess the effects of enforcement as it does on treatment and prevention research (controlling for size of investment).

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us A suitable institutional structure needs to be put in place to plan and implement a major new research effort on the effects of drug control laws and their enforcement (including both interdiction and domestic enforcement), on drug use and its consequences, and on the costs and unintended consequences of enforcement activities. At the present time, only a small number of researchers are working in this important area, and only a few research organizations have made a commitment to it. Established career paths for researchers are unavailable. In order to nurture and harness the intellectual resources that will be needed to mount a successful research effort, it will be necessary to recruit talented social scientists and to establish the necessary incentives, including reliable and stable sources of funding, access to data, and scientific independence. Funding and Sponsorship The committee recommends that the National Institute of Justice, the National Science Foundation, and the Bureau of Justice Statistics should be assigned joint responsibility and given the necessary funding to build the scientific infrastructure for research on illegal drug markets and the effects of drug control interventions. The committee recommends lead roles for both NIJ and NSF in order to ensure that investigators are drawn to this barren field from all the social sciences, including criminology, economics, operations research, and public policy analysis. The research envisioned by the committee would draw these diverse disciplines into a collaborative effort to investigate all aspects of the market for illegal drugs, the strategies and activities of enforcement agencies, and the adaptations of offenders to these activities. To carry out this challenging program successfully, it will be necessary to draw on NIJ’s contacts with criminal justice organizations and research constituencies, access to offender populations, and experience in collaborative work with the National Institute on Drug Abuse. At the same time, however, NSF provides the expertise and research constituencies in economics lacking at NIJ and can also provide a check against the possibility of insularity and political interference that can arise when any operational agency is given complete control over research bearing on the effectiveness of its operations (e.g., enforcement). In implementing this new research initiative, NIJ and NSF should take advantage of the full array of mechanisms at their disposal, including investigator-initiated proposals, centers, and research consortia. It is essential that both agencies establish strong collaborative partnerships for this program with the National Institute on Drug Abuse, in order to capture the relevant expertise and to connect investigations with its intramural program in drug epidemiology.

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us Access to Data The agencies charged with responsibility for establishing the data systems recommended in Chapter 3—the National Institute of Justice, the Centers for Disease Control and Prevention, and the Bureau of Labor Statistics—and for building the research infrastructure outlined above— the National Institute of Justice and the National Science Foundation— will be faced with a common challenge: removing the legal impediments to collecting and using data on illicit activities. Talented and ambitious researchers will not be willing to enlist in the new research initiative envisioned by the committee unless they are assured reasonable access to pertinent data. The statutory authority appears to be in place for the Department of Justice to grant the necessary immunity for collecting data. It should develop and promulgate clear and specific guidelines or instructions regarding the conditions for securing immunity for data collection under existing law and, if the existing authority is insufficient, should seek the necessary authority from Congress. The paucity of data also bears on funding strategies for research. The funding agencies should be prepared to fund grants for a sufficient period to enable researchers to carry out primary data acquisition, notably surveys. This is essential in an area such as research on illegal drug markets, in which high-quality datasets are not already available. And we point out again that, when large and influential datasets such as Monitoring the Future have been developed with public funds, there is no excuse for allowing data-collecting organizations to curtail access to these data by other investigators. All funding agencies should ensure public access to nonidentified data. The responsible government agencies should take maximum advantage of developing communications technologies to maximize researcher access to available data. Scientific Independence In its final report in 1973, the National Commission on Marihuana and Drug Abuse applauded a 400 percent increase in the federal investment in research from 1969–1973, urged intensification of the investment in research, and emphasized the importance of free scientific inquiry in what had been a highly politicized domain (NCMA, 1973:368–370): This commitment to research…reflects a significant change in official policy. For many years, research into the effects of prohibited drugs and into the behavior of users was viewed as an attempt to question and subvert government policy. In addition, the aura of criminality surrounding drug-using behavior and the overly rigid protocol requirements often made this area unattractive to researchers. When…re-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us searchers became [interested], they were often hindered by the law enforcement community…. At last, this has begun to change. With the significant increase in drug use during the 1960’s the government recognized the need for information which could come only from expanded research efforts. Prohibited drugs have been made available for legitimate research; confidentiality has been extended to research subjects; and now, public resources are being devoted to this important area…. In urging [increased] research, the Commission cautions against research that points in only one direction. In the past, government agencies have sometimes used drug research to support policy rather than shape it. Studies that produced the answers they wanted were promoted and publicized; projects which appeared to document the “wrong” results were quietly buried and not released. [New research] should specifically include studies that examine without bias alternate hypotheses and approaches. It is no less important in the year 2001 to emphasize the need for scientific independence in research on illegal drugs than it was in 1973. THE CHALLENGE AHEAD Three decades ago, Congress decided to diversify the federal response to drug problems, investing in surveillance, biobehavioral and etiological research, and education and treatment. As a result, the nation has the data systems and research infrastructure needed to assess the effectiveness of preventive and therapeutic interventions. Although further improvements are needed in these areas, as explained in this report, the data and research capacity are in place. In stark contrast, neither the data systems nor the research infrastructure needed to assess the effectiveness of drug control enforcement policies now exists. It is time for the federal government to remedy this serious deficiency. It is unconscionable for this country to continue to carry out a public policy of this magnitude and cost without any way of knowing whether and to what extent it is having the desired effect. REFERENCES Institute of Medicine 1996 Pathways of Addiction. Washington, DC: National Academy Press. 1998 Bridging the Gap Between Practice and Research; Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: National Academy Press. National Commission on Marihuana and Drug Abuse 1973 Final Report. Drug Use in America: Problem in Perspective. Washington, DC: U.S. Government Printing Office.

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us National Research Council 1999 Assessment of Two Cost-Effectiveness Studies on Cocaine Control Policy. C.F.Manski, J.V.Pepper, and Y.F.Thomas, eds. Washington D.C.: National Academy Press. Office of National Drug Control Policy. 2000 National Drug Control Strategy: Budget Summary February 2000. Washington, DC: U.S. Government Printing Office. 1999 Drug Data Summary. Rockville: ONDCP Drug Policy Information Clearinghouse. Available on line at http://www.whitehousedrugpolicy.gov Strategy Council on Drug Abuse 1973 Federal Strategy for Drug Abuse and Drug Traffic Prevention. Washington, DC: U.S. Government Printing Office.