10
Drug Control

For almost a century, the central component of U.S. illicit drug policy has been a legal structure under which the medical and scientific uses of opiates, cocaine, and other controlled drugs are tightly restricted and the production and distribution of these drugs for nonmedical and nonscientific uses are prohibited. Violations of those prohibitions are punishable by severe criminal sanctions under both federal and state laws. Additionally, federal and state penalties against commercial drug offenses are supplemented by criminal sanctions against users (i.e., for possessing drugs for one's own use).

The effects of drug control usually are not included within the ambit of ''drug abuse research" and are assumed to lie instead within the purview of criminal justice research. In the committee's view, however, the effects of legal controls, and of different strategies for implementing and enforcing them, should be seen as an important component of a comprehensive drug abuse research strategy. Conceived broadly, policy-relevant effects encompass all the benefits of legal controls (in reducing use, abuse, and dependence on illicit drugs and the associated adverse consequences) and the costs, or side-effects, of those controls (ranging from violence associated with the illicit drug trade to the costs of imprisonment). On many of these questions, there is no dearth of opinion but little in the way of systematic, rigorous research (Tonry, 1990). Any effort to explore the wide range of issues relating to the effects (benefits or costs) of drug control would far exceed the scope of this report and the committee's expertise. Instead, the committee discusses several areas of inquiry that



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Pathways of Addiction: Opportunities in Drug Abuse Research 10 Drug Control For almost a century, the central component of U.S. illicit drug policy has been a legal structure under which the medical and scientific uses of opiates, cocaine, and other controlled drugs are tightly restricted and the production and distribution of these drugs for nonmedical and nonscientific uses are prohibited. Violations of those prohibitions are punishable by severe criminal sanctions under both federal and state laws. Additionally, federal and state penalties against commercial drug offenses are supplemented by criminal sanctions against users (i.e., for possessing drugs for one's own use). The effects of drug control usually are not included within the ambit of ''drug abuse research" and are assumed to lie instead within the purview of criminal justice research. In the committee's view, however, the effects of legal controls, and of different strategies for implementing and enforcing them, should be seen as an important component of a comprehensive drug abuse research strategy. Conceived broadly, policy-relevant effects encompass all the benefits of legal controls (in reducing use, abuse, and dependence on illicit drugs and the associated adverse consequences) and the costs, or side-effects, of those controls (ranging from violence associated with the illicit drug trade to the costs of imprisonment). On many of these questions, there is no dearth of opinion but little in the way of systematic, rigorous research (Tonry, 1990). Any effort to explore the wide range of issues relating to the effects (benefits or costs) of drug control would far exceed the scope of this report and the committee's expertise. Instead, the committee discusses several areas of inquiry that

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Pathways of Addiction: Opportunities in Drug Abuse Research relate most directly to the public health and to the other fields of investigation explored in previous chapters. An integrated perspective that encompasses interventions aimed at both supply and demand can yield important advances by overcoming disciplinary and bureaucratic boundaries. Many aspects of drug control and its enforcement are inescapably related to mainstream fields of drug abuse research, especially etiology, prevention, and treatment. Because the law and its enforcement affect the price and accessibility of illicit drugs, drug control policies can affect many aspects of drug-using behavior, including which drugs are used and how they are ingested. A full understanding of factors relating to initiation or intensification of drug use might usefully encompass measures of perceived availability and the perceived likelihood that sanctions (both legal and social) will be imposed. Treatment outcome studies might take into account the impact of variations in drug availability on entry and retention, as well as the coercive "leverage" produced by the threat of prosecution or punishment. The design of community prevention programs might encompass measures of drug availability (e.g., price and access) as well as other variables relating to the intensity of law enforcement in the communities being studied. As noted in Chapter 7, the consequences of drug abuse (e.g., violence) are often intertwined with the sequelae of illicit drug markets and drug law enforcement. An important trend in public health research is the inclusion of legal controls and interventions within a single model of drug abuse research. A prime example is injury control. For example, the field of highway safety encompasses studies of the effects of mandatory seatbelt laws, mandatory helmet laws, speed limits, and various types of licensing restrictions. In recent years, injury control researchers have also focused on the effects of gun controls on firearms injuries. The compelling need to bring legal controls within a comprehensive public health research model has recently been recognized in the field of tobacco research, where studies are being conducted on the design and enforcement of youth access restrictions, the effects of advertising restrictions, and the effects of a significant increase in tobacco excise taxes (IOM, 1994). In fact, some public health officials and tobacco research funding agencies have come to believe that "policy research" is an essential component of a tobacco research program (Davis, 1995). RECURRENT ISSUES IN DRUG ABUSE CONTROL Arguments about drug control policy proceed too often on the basis of intuition and supposition rather than empirical data. Even though some of the disputed issues defy scientific investigation, many of the controver-

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Pathways of Addiction: Opportunities in Drug Abuse Research sies that have recurred throughout the history of drug control can be informed by systematic empirical research. Following a brief survey of potentially researchable issues, four specific opportunities for policy research are explored in some depth. Prohibition Versus Regulatory Discouragement At the broadest level, drug control policy requires a choice between a system of prohibition (under which drugs are not legally available for nonmedical use) and a strategy of regulatory containment or management (under which drugs are legally available for nonmedical use by adults). Each of these models can be implemented in a variety of ways. Within the prohibitory model, varying strategies of enforcement will differentially affect the price and accessibility of the prohibited drugs and the patterns and consequences of their use. Within the regulatory model, the channels of authorized access can be more or less tightly restricted, and the product and its marketing can be more or less heavily regulated, depending on whether and in what ways policymakers aim to affect the prevalence and circumstances of consumption. The basic choice between prohibitory and regulatory approaches has been a subject of ongoing dispute in the field of drug control. Although most commentators assess these choices within a cost-benefit framework (e.g., Nadelmann, 1989; Goldstein and Kalant, 1990), they tend to disagree about the consequences of adopting a regulatory approach in lieu of the existing prohibition. To what extent would the incidence and prevalence of drug use, abuse, and dependence, and the associated social costs, increase under a regulatory regime? To what extent would the costs incurred under the current prohibitory strategy be avoided under an alternative approach? What new costs would be incurred? Efforts to address these questions often draw on the experience of other countries that have adopted different approaches toward drug control (e.g., Reuter and MacCoun, 1995). However, meaningful comparisons are impeded by numerous cross-cultural differences and by inadequate or dissimilar data; the ongoing argument about the consequences and significance of de facto legalization of cannabis in some Amsterdam coffee houses (compare Kleber, 1996, with Ossebaard, 1996, and Sifanek and Kaplan, 1995) is illustrative. It should be noted, however, that crossnational studies of the effects of tobacco advertising restrictions have made a significant contribution to policy debate in this country (IOM, 1994). "Noisy data" on the epidemiology of illicit drug use and on the effects of drug control policies may be superior to anecdotes, but opportunities for significant advances in knowledge based on cross-national research will have to await improvements in data systems and in the

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Pathways of Addiction: Opportunities in Drug Abuse Research conceptualization of policy-relevant variables (MacCoun et al., 1993, 1995). Another set of comparisons relates to this country's own evolving regulatory policies toward tobacco and alcohol. Tobacco policy has recently entered an intriguing period of transition from a laissez-faire approach to a tightened regulatory model explicitly aiming to discourage the use of tobacco products without prohibiting them. This use of legal tools to discourage consumption (advertising limitations, pricing policy, product regulation, public use restrictions) provides a model of public health regulation formerly absent in the drug abuse field (IOM, 1994). The effects of these new initiatives in tobacco regulation should be carefully studied, not only because reducing the toll of tobacco-related disease is a major public health priority, but also because these new regulatory initiatives in tobacco control may yield useful lessons for controlled substance regulation. Similarly, the public health effects of alcoholic beverage regulation should be carefully studied. A growing body of research on the relationship between density of retail outlets and alcohol consumption (Gruenwald et al., 1993) and on access to alcohol by underage drinkers (Waagenar et al., 1996) highlights methods of restricting availability within a regulatory framework and may also yield important insights regarding fundamental behavioral relationships between availability and consumption of psychoactive drugs. All of these issues are interesting and relevant to a broad understanding of the public health effects of legal controls on psychoactive drugs. Of more immediate relevance to the current research agenda, however, are questions regarding potential improvements in the implementation of the nation's prohibitory drug control strategy. Abuse Reduction Versus Medical Use Within a few years after enactment of the Harrison Narcotics Act in 1914, the difficulty of reducing illicit (nonmedical) use of narcotic drugs without interfering with legitimate medical use became evident. Federal enforcement authorities decided that maintenance treatment of persons already dependent on opiates, by private physicians or by local clinics, was incompatible with the goal of reducing drug dependence (see Musto, 1987). When methadone maintenance became a recognized treatment for heroin dependence in the 1960s, the debate resurfaced. The proper balance between therapeutic discretion and law enforcement efforts to suppress drug abuse and minimize diversion has been a source of continuing controversy (IOM, 1995b). Arguments about methadone maintenance often turn on empirical disputes about the magnitude of diversion associated with various treatment protocols and the "chilling effect" of enforce-

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Pathways of Addiction: Opportunities in Drug Abuse Research ment practices on medical care, particularly in preventing or discouraging physicians from prescribing methadone treatment and from utilizing other therapeutically indicated procedures (IOM, 1995b). Another source of continuing conflict has been the inhibiting effect of controlled substance regulation on other medical uses of the regulated drugs. Beginning with the Harrison Act, regulatory structures have been established to restrict the manufacture and distribution of regulated drugs (as a means of reducing nonmedical use) while allowing the continued use of such drugs in legitimate medical practice. The Controlled Substances Act, enacted by the Congress in 1970, established a hierarchy of regulatory controls purporting to balance abuse reduction and medical need. This act has served as a model for parallel controlled substance statutes in every state. Again, however, the preventive effect of those legal controls on abuse and their inhibiting effect on medical practice have been sources of continuing dispute (IOM, 1995a). These issues will be explored in greater detail below. Penalties for Users A legal strategy of prohibiting availability of controlled drugs for nonmedical use does not necessarily entail criminal penalties against users. (Possession of alcohol for personal use was an offense in only a few states during Prohibition.) Whether criminal sanctions should be prescribed for alcohol or tobacco possession by underage users or for possession of controlled substances or drug paraphernalia, depends at least in part on an assessment of the social benefits of these sanctions (in reducing use and, ultimately, in reducing abuse and dependence) and the social costs of enforcing them. In 1972, the National Commission on Marihuana and Drug Abuse recommended that criminal sanctions for possession of marijuana for personal use be repealed. The commission concluded that sporadic enforcement of criminal penalties for marijuana use did not achieve a substantial preventive effect and that whatever preventive effect such enforcement did achieve was outweighed by the social and individual costs of enforcing the prohibition. Although 11 states repealed criminal penalties for marijuana possession in the wake of the commission's report and most other states ameliorated the impact of criminal sanctions (Bonnie, 1977), this trend ended in the late 1970s in response to a substantial rise in adolescent marijuana use. Interestingly, there has not yet been a definitive study of the behavioral effects of decriminalization of marijuana use (compare Maloff, 1981, with Cuskey, 1981). Such a study faces two substantial methodological problems: (1) measuring and controlling for enforcement of the prescribed sanctions, and (2) disentangling the "declara-

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Pathways of Addiction: Opportunities in Drug Abuse Research tive" or moralizing effect of the sanction from the other social forces influencing people's beliefs and attitudes about marijuana use (Bonnie, 1986). The debate about criminalization of drug users has intensified in recent years, partly in response to European developments (Reuter et al., 1993). Although criminal penalties have been ameliorated in Italy, Spain, Switzerland, and Germany, decriminalization in Italy and Spain has been associated with substantially higher rates of opiate dependence (CASA, 1995; Reuter and MacCoun, 1995). Because of the absence of reliable data and the relatively passive enforcement of sanctions against users in most Western European countries (outside Scandinavia), it is impossible to assess the impact of decriminalization through comparative studies. Perhaps the most significant policy-relevant research on the effects of criminalization in recent years pertains to the effects of needle exchange programs. Two important empirical questions lie at the center of the policy debate about these programs and about the enforcement of existing prohibitions against possessing needles for purposes of illicit drug use: whether and to what extent needle sharing (and therefore the risk of transmitting HIV disease) is reduced, and whether and to what extent the legal availability of clean needles increases illicit drug use. As noted in a recent National Research Council report (NRC, 1995), research has shown that needle exchange programs have the ability to retard the spread of HIV infection among participating injection drug users, do not affect the level of self-reported drug use among the participants, and do not appear to recruit new users to injection drugs, at least in the short term. The public health imperative of containing HIV transmission argues for continued research on the long-term impact of these programs and on ways to improve their effectiveness along the lines recommended in the NRC report. In light of well-established methods of monitoring the incidence and prevalence of HIV infection, this area may be ripe for cross-national policy research. Strategies of Enforcement Not surprisingly, criminal justice specialists have often disagreed about the relative utility of various strategies employed to suppress the availability of illicit drugs. These strategies include an international effort to eradicate naturally growing sources of illicit drugs; interdiction of shipments intended for the U.S. market; investigation, penetration, and disruption of trafficking networks; and state and local police actions directed at street-level retail dealing and use. From a public health perspective, the central question is how the contending strategies might be deployed most effectively to reduce consumption and its adverse consequences, while

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Pathways of Addiction: Opportunities in Drug Abuse Research also avoiding increases in crime and violence. These important empirical questions should be amenable to systematic investigation (Moore, 1990). Research in this area is explored further below. Severity of Penalties Over the course of the twentieth century, criminal penalties for drug offenses have escalated, de-escalated, and re-escalated. The differential impact on drug trafficking and consumption is difficult to assess, in large part because the behavioral effects of threatened sanctions are mediated by many factors, including the probability of punishment, the strength of other social deterrents to offending, and the strength of peoples' incentives to offend. However, substantial resources have been allocated to the apprehension, prosecution, and incarceration of drug offenders, often at the expense of other potentially useful interventions, particularly treatment. For this reason, it is important to assess the behavioral effects of various types of criminal punishment in reducing drug abuse and dependence. This subject is explored below. Conflicting Aims of Treatment and Punishment One of the most puzzling features of drug control policy is the inherent tension between two public attitudes about drugs—that illicit drug use should be penalized, while people with drug problems should be helped. These divergent inclinations produce numerous contradictions in legal policy. For example, the desire to facilitate treatment of drug users sometimes leads to policies that insulate illicit drug use from discovery and ameliorate its punishment in favor of therapeutic dispositions. Drug offenses are not the only context in which criminal law is used as a device for achieving therapeutic effects—therapeutic referrals are not uncommon following charges of family violence, for example. However, the practice has become more formalized and more routinized in drug cases than in other contexts. The empirical issues here are important and numerous. Does the availability of a therapeutic disposition erode the deterrent effect of the criminal sanction? Alternatively, does the perceived threat of punishment undermine the effort to recruit people into treatment? Does the use of criminal sanction as therapeutic leverage produce better treatment outcomes than would be achieved by either erasing the threat of punishment or relying on punishment alone? These questions, too, are further explored below. The remainder of this chapter discusses in greater detail four opportunities for research on the public health effects of drug control: (1) the

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Pathways of Addiction: Opportunities in Drug Abuse Research effects of controlled substance regulation on legitimate medical use (including medical modalities of drug abuse treatment); (2) the effects of supply reduction on drug consumption; (3) the effects of criminal sanctions against users (including coerced treatment) on drug consumption; and (4) the effects of beliefs about confidentiality (or the lack of it) on participation in treatment. EFFECTS OF REGULATION ON LEGITIMATE MEDICAL USE AND SCIENTIFIC RESEARCH In 1970, Congress enacted the Controlled Substances Act (CSA), which places drugs in control schedules according to their abuse potential, ranging from Schedule I, including drugs (such as heroin and LSD) that have high abuse potential and no established medical use, to Schedule V, including drugs (such as nonprescription codeine elixirs) that have low abuse potential and are legally marketed as cough remedies. CSA controls the production and distribution of scheduled drugs by, among other things, requiring manufacturers and distributors to maintain records of their production and transportation, limiting refills of prescriptions, placing production quotas (limits) on such drugs, and requiring the use of special order forms to transfer these drugs to the retail level. Although enacted in an effort to curtail drug abuse, its legislative history makes it clear that CSA was not intended to interfere either with medical practice or with the availability of controlled substances for legitimate medical or scientific use. However, that has not been an easy balance to strike. The Drug Enforcement Administration (DEA) and most state drug control bodies generally favor more extensive regulations on any drugs with the potential for abuse, so that they can reduce drug diversion.1 Unfortunately, the measures they advocate, including government-issued multiple-copy prescription forms, elaborate measures for record keeping and for storing drugs, and stricter scheduling of substances, tend to increase the difficulty associated with prescribing such medications or making them available for scientific study. Many physicians and medical organizations perceive that these measures discourage physicians from prescribing the best drugs for conditions such as chronic pain, anxiety, attention deficit-hyperactivity disorder, epilepsy, obesity, 1   This is not to say that drug law enforcement officials are indifferent to the impact of controlled substance regulation on medical use. For example, the DEA Administrator recently ruled that the long-term prescribing of opioid analgesics for a patient with chronic nonmalignant pain is a legitimate medical use for these drugs and, if appropriately supervised, is not grounds for sanctions against the prescribing physician.

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Pathways of Addiction: Opportunities in Drug Abuse Research and narcolepsy. The medical and drug enforcement communities are therefore frequently at odds in debates on public policy, particularly during the development of legislation, and the gap between their perspectives has been growing wider (IOM, 1995a,b). Furthermore, federal and state regulatory obstacles act as a disincentive to the pharmaceutical industry in developing anti-addiction medications (Chapter 1; IOM, 1995b). As the controversy grows, the need for better data has become increasingly evident. Very little systematic research has been conducted on the actual effects of specific regulations or enforcement practices on either illicit drug use or medical use. To begin examining these issues, the National Institute on Drug Abuse (NIDA) recently conducted a technical review (Cooper et al., 1993). The resulting publication, Impact of Prescription Drug Diversion Control Systems on Medical Practice and Patient Care, presents preliminary evidence that drug control regulations have adverse effects on the treatment of a number of diseases. For example, DEA has been encouraging states to introduce multiple-copy prescription programs for certain controlled substances. When New York applied this regulation to the benzodiazepines, prescriptions of these drugs for anxiety and insomnia declined and were replaced, in some cases, by increased prescribing of outmoded and more dangerous sedative hypnotics (Weintraub et al., 1991). Introduction of multiple-copy prescriptions in Texas led to a halving in the number of prescriptions of controlled opioids for pain (Sigler et al., 1984). Drug control agencies assert that reductions in the number of prescriptions written for controlled substances indicate that multiple-copy prescription programs are a success. However, a reduction in the number of prescriptions does not automatically translate into a reduction in the illicit use and abuse of that drug, nor does it indicate that the prior level of prescriptions reflected overprescribing. On the contrary, reductions in the number of prescriptions may reflect a reluctance on the part of physicians to prescribe, and pharmacists to dispense or even stock, such drugs for legitimate medical use. The primary sources of amphetamines and similar psychostimulants appear to be illicit manufacturers rather than legitimate sources such as pharmacists and physicians (Angarola and Minsk, 1994). Existing research simply does not include enough direct measurement of prescribing patterns and patient outcomes to give a definitive picture of the risks or benefits of government-issued prescription programs. There are other examples of ways in which drug control regulations and enforcement practices appear to interfere with the physician's ability to treat patients, including the threat of criminal prosecution.2 A few 2   Under 21 C.F.R. section 291.505, failure "to abide by all the requirements" of the methadone regulations (which contain many specific provisions relating to inventory control as

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Pathways of Addiction: Opportunities in Drug Abuse Research additional examples include restricting the prescribing of opioids to patients with pain and a history of substance abuse (e.g., AIDS patients) (Joranson and Gilson, 1994a,b); as well as the cumbersome procedures, forms, and fees that must be fulfilled before a hospital or physician can use methadone to detoxify heroin-dependent patients (SAMHSA, 1992). The committee recommends additional research on the effects of controlled substance regulations on medical use and scientific research. Specifically, these studies should encompass the impact of such regulations and their enforcement on prescribing practices and patient outcomes in relation to conditions such as pain, anxiety, attention deficit disorder, obesity, and narcolepsy and on the availability of treatment and outcomes for patients with addictive disorders. EFFECTS OF SUPPLY REDUCTION ON CONSUMPTION Approximately 64 percent ($8.5 billion) of federal expenditures for drug control ($13.3 billion) in FY 1995 was allocated to law enforcement efforts to control the supply of drugs to illicit markets in the United States (ONDCP, 1996). Such "supply-reduction efforts" include (1) international efforts such as crop eradication, crop substitution, the negotiation of mutual legal-assistance treaties, and cooperative international enforcement efforts; (2) interdiction, for example, border inspections and patrols conducted by the U.S. Customs Service and the U.S. Immigration and Naturalization Service and the interdiction of ships and planes suspected of carrying contraband by the U.S. Coast Guard and the U.S. Armed Forces; (3) investigations, such as efforts by DEA, the Federal Bureau of Investigation (FBI), and U.S. attorneys to investigate and prosecute drug trafficking organizations; and (4) state and local drug enforcement efforts, for example, the enforcement activities of the nation's 4,000 municipal police departments directed at street-level traffickers and users (Moore, 1990). The primary goal of supply-reduction efforts is to decrease the availability and increase the cost of obtaining illicit drugs and thereby reduce their consumption and associated adverse consequences. There can be little doubt that a prohibitory system of drug control, if enforced, does suppress consumption and otherwise affect patterns of drug use, compared to a system under which these drugs are legally available for nonmedical use through authorized channels (Goldstein and Kalant, 1990).     well as clinical practice) can subject the service provider to criminal prosecution. In no other area of health care, with the possible exception of some abortion procedures, is the threat of criminal prosecution used as a tool for enforcing requirements of clinical practice.

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Pathways of Addiction: Opportunities in Drug Abuse Research What is less clear, however, is the extent to which particular strategies of supply reduction (such as interdiction and street-level enforcement) affect accessibility and price and, in turn, affect consumption (Moore, 1990). The total cost of illicit drugs includes both their dollar price and the nonmonetary costs of acquiring them (e.g., how long it takes to find them and how risky it is to purchase or sell them) (Moore, 1973). Those two elements of total cost are the mediating variables between enforcement and consumption. Due to the nature of illicit drug markets, the availability of drugs may be reduced more often by uncertainty than by actual physical scarcity. Dealer inventories and the presence of many suppliers in the market make it possible, albeit less convenient, to acquire drugs even when import, wholesale, or retail markets have been temporarily disrupted.3 Existing evidence is mixed as to whether specific enforcement-generated changes in the availability and cost of illicit drugs reduce consumption. Some studies have found no evidence that cocaine consumption responds to enforcement-induced price increases (Dinardo, 1993). Others, using Drug Abuse Warning Network (DAWN) data, have observed that the number of cocaine mentions for emergency room patients varies inversely with the price of cocaine at both national and city levels (ONDCP, 1992). Among economists it is now generally acknowledged that the demand for drugs is elastic, rising and falling in response to changes in price.4 Indeed, despite the addictiveness of nicotine, researchers have found that cigarette consumption exhibits surprisingly high elasticity (e.g., Wasserman et al., 1991; Peterson et al., 1992; Hu et al., 1994). Recent work suggests that the demand for both heroin and cocaine may also be highly elastic (Caulkins, 1995). Additional research is needed to establish the relationship between price and consumption and, particularly, to measure variations in elasticity among different categories of users and within different submarkets. For example, teenagers appear to be more sensitive than adults to tobacco price increases (IOM, 1994). If significant reductions in availability and increases in price do reduce consumption, it is important from a policymaking perspective to understand the extent to which alternative approaches to supply reduction and enforcement can reduce the availability and price of illicit drugs. Interdiction of drugs that have not yet reached retail markets, for ex- 3   An exception can occur with certain synthetic drugs (e.g., methaqualone) which can be produced only with sophisticated technology. 4   Elasticity is the percentage change in consumption in response to a 1 percent change in price. The demand for a drug is ''perfectly inelastic" if there is no change in the consumption of a drug in response to a change in its price.

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Pathways of Addiction: Opportunities in Drug Abuse Research 1995). At the community level, the deterrent effects of legal sanctions and other social controls on drug use and drug dealing are confounded. Several studies have shown, for example, that incomes from illicit drug dealing were significantly higher than legal wages in inner cities (see Fagan, 1995, for a review). In areas of high unemployment, an active economic incentive also shapes the opportunities for social status and roles, and provides a source of social control that reinforces illegal activity. Thus, strong institutionalized drug markets themselves become sources of social control that compete with legal norms and sanctions. In addition, the social and economic isolation of neighborhoods with active drug markets can disrupt the intergenerational job networks that in the past eased the entry of unskilled workers into stable (although low-wage) jobs. A research agenda is needed to assess the effects of legal controls on drug use and dealing. Furthermore, there is a need to understand how the informal social controls that compete with punishment costs influence compliance with the law. Such factors are likely to explain neighborhood variation in the effects of legal controls on drug use and may suggest effective community-based prevention intervention efforts. Therapeutic Leverage Apprehension of drug users provides an opportunity to reduce drug use (and future offending) through treatment, by using the threat of sanctions as a form of leverage for inducing satisfactory compliance with therapeutic requirements (see Chapter 8). In 1973, the National Commission on Marihuana and Drug Abuse concluded that the primary utility of criminal sanctions for consumption-related drug offenses lies in their use as means of therapeutic leverage (NCMDA, 1973). The commission endorsed a multistage linkage between the criminal justice system and community-based treatment systems, under which favorable dispositions would be conditioned on participation in treatment.8 During the ensuing decade, the White House Special Action Office for Drug Abuse Prevention (SAODAP) and NIDA joined hands with the Department of Justice to implement this strategy through a variety of initiatives, the most important of which was Treatment Alternatives for Street Crime (TASC). Although federal funding for TASC and related initiatives was reduced during the 1980s, most states retained their TASC programs, albeit on a 8   The commission also endorsed a parallel structure of short-term community-based civil commitment, as an alternative to criminal justice intervention, together with model legislation to implement this approach (Bonnie and Sonnenreich, 1975).

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Pathways of Addiction: Opportunities in Drug Abuse Research reduced scale. In 1991, there were 178 TASC programs in 32 states (Weinman, 1992). In recent years, new initiatives linking criminal justice intervention to drug abuse treatment have begun to emerge, largely on an ad hoc basis. One important example is the proliferation of so-called drug courts—a generic term for several different types of initiatives designed to cope with the growing number of drug cases. These initiatives include distinctive case management systems and/or pretrial diversion programs. Many of the new drug courts hear evidence and adjudicate guilt, whereas others serve as special "plea bargaining" forums. Some drug courts handle only first offenders; others have no such limitations. Since all of the drug court initiatives are relatively new, outcome data are limited, and their efficacy remains open to question. The renascent interest in drug treatment-criminal justice linkages heightens the need for rigorous studies of the therapeutic utility (and cost-effectiveness) of these coercive legal strategies: To what extent, and under what circumstances, does coerced treatment through the criminal justice system achieve beneficial effects as compared with voluntary treatment, with nontherapeutic criminal justice intervention, or with no intervention at all? Legal strategies to coerce drug users into treatment have been used both at the "front end" in diversionary programs and among parole and probation populations. As noted in Chapter 8, however, experimental designs are rare, and it is difficult to disentangle the effects of treatment from the effects of coercion. Also, many studies have been concerned primarily with treatment retention or length of stay, rather than treatment outcome or posttreatment involvement in drug use or criminal behavior. Future research regarding the effects of coerced treatment for drug abuse should compare outcomes (drug use and criminal behavior) for treatment groups under criminal justice supervision with the behavior of groups of matched offenders subjected to similar criminal justice supervision without treatment and of matched drug treatment clients who are not under criminal justice supervision. These studies should focus on coerced treatment at both the front and the back ends of the criminal process and should pay special attention to variations in offender characteristics (e.g., criminal and treatment histories) that bear on risk of recidivism and the risk of relapse. Use of coerced treatment for women offenders, especially those with children, also deserves attention. Many treatment programs are ill equipped to respond to the unique needs of this population, and the effects on treatment and legal outcomes should be evaluated. Special attention should be paid to the behavioral contingencies used in various criminal justice linkage programs (see generally Winick, 1991). Three important variables in the dynamics of "soft" coercion are whether

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Pathways of Addiction: Opportunities in Drug Abuse Research participation in the program is contractual (the defendant can decline to participate) or mandatory; the nature of the prescribed conditions (e.g., frequency of appointments and of urine testing); and the nature of the sanctions for violating the specified conditions. An important innovation in recent years has been frequent testing combined with the use of graduated sanctions, a scheme that utilizes escalating, though not catastrophic, penalties in response to predictable relapses. Examples of graduated sanctions used in the Washington, D.C., pretrial release program include three days in the jury box observing drug court, three days in jail, seven days in residential detoxification, or seven days in jail (Carver, 1996). Another important feature of the new generation of programs is the use of inducements to elicit voluntary participation, even within the coercive context of criminal justice control. Lessons about the subjective aspects of coercion can be drawn from recent research on coercion in mental health treatment, which tends to show that, even in objectively coercive situations, people feel less "coerced" if they feel that they have had a "voice" and that they have been treated fairly (Lidz et al., 1995; Monahan et al., 1996). Careful study of the dynamics of therapeutic leverage represents an important new frontier in drug abuse research. The committee recommends a strategic research initiative to determine the conditions under which threatened criminal sanctions deter drug use and the ways in which criminal sanctions can be used most effectively, in the context of other social controls and in conjunction with other initiatives such as treatment programs, to maximize their beneficial effects while minimizing their deleterious effects. CONFIDENTIALITY AND FEAR OF PUNISHMENT In 1972, in response to the increasing incidence of drug abuse in the United States, Congress passed the Drug Abuse Office and Treatment Act of 1972 (86 U.S. Stat. 65; 21 U.S. Code 1175, 1972). The act was intended to increase the number of drug users who would willingly seek treatment by guaranteeing the confidentiality of the clinical records of all drug patients in federal drug treatment programs, based on the assumption that a guarantee of confidentiality is a necessary prerequisite to the success of any voluntary drug treatment program. The act also was intended as a minimum requisite for confidentiality in drug treatment programs; it was expected that state laws governing confidentiality would go beyond the federal model. In fact, however, the rules governing confidentiality in federal drug treatment programs offer a greater degree of protection than do the laws of many states that govern confidentiality in state drug treat-

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Pathways of Addiction: Opportunities in Drug Abuse Research ment programs and in the physician-patient or therapist—client relationship. Little research has been conducted to assess the effect that a guarantee of confidentiality, or the real or perceived lack thereof, has on the treatment-seeking behavior of drug users. The research that has been conducted has focused primarily on pregnant women and adolescents, who often are not protected by confidentiality laws at the state level. As discussed in more detail below, anecdotal reports and existing research indicate that laws denying confidentiality to pregnant women and adolescents may have unintended deleterious health effects. Additional research on the effects of various laws governing confidentiality would enable policymakers to make informed judgments when considering such laws. Moreover, research on the effects of confidentiality, and fear of disclosure, on treatment-seeking behavior has been given heightened importance in the era of managed care with its erosion of confidentiality on many levels. Pregnant Women As state courts and legislatures have become more aware of the risks of drug use during pregnancy, they have responded with a variety of both rehabilitative and punitive measures. Many courts have permitted the prosecution of women, under general child abuse and neglect statutes, if they have been found to use drugs while pregnant. State legislatures have enacted a variety of laws, ranging from statutes mandating the creation of counseling programs for pregnant drug abusers, to those requiring physicians (under certain circumstances) to test women and/or their newborns for the presence of controlled substances and to report positive test results to appropriate state agencies. There also has been an increasing trend toward imposing criminal sanctions on women who use drugs while pregnant. Proponents of these requirements and sanctions argue that such measures will deter women from using drugs while they are pregnant and will prompt pregnant drug abusers to seek drug treatment. Opponents, including many representatives of the medical profession, counter that such measures will cause pregnant drug abusers to avoid prenatal or medical care in order to avoid detection of their drug use. In addition, researchers protest that mandatory reporting laws, requiring them to report pregnant women who admit drug use, often prevent them from gathering any meaningful data from that population. Little empirical evidence exists regarding the effects of mandatory reporting laws and the imposition of civil and criminal penalties on pregnant drug abusers (Berlin et al., 1991; Poland et al., 1993). To assist policymakers and the courts

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Pathways of Addiction: Opportunities in Drug Abuse Research in developing effective approaches for the reduction of drug use during pregnancy, studies should be undertaken to examine the attitudes and actions of women both before and after a variety of laws are implemented so as to better understand the impact of such laws on drug use and prenatal care. Adolescents Adolescents also may be deterred from seeking treatment for drug use due to a lack of confidentiality in the physician-patient relationship. Although many states currently allow for confidential medical evaluation and treatment of minors for alcohol and other drug abuse problems, the extent to which physicians confidentiality is respected is unclear (Marks et al., 1990). Moreover, researchers have found that uncertainty about confidentiality may cause adolescents to suppress relevant information or to delay or avoid medical visits (Resnick et al., 1980; Cheng et al., 1993). There is also evidence that some pediatricians are not comfortable providing care to adolescents for such problems (Marks et al., 1990). Additional studies of adolescent confidentiality and its effect on care-seeking behavior would provide an important guide to policymakers and health care service providers who are trying to encourage adolescents to enter drug abuse treatment. The committee urges research on confidentiality and disclosure laws to determine their impact on treatment-seeking behaviors among adolescents and pregnant women. CONCLUSION AND RECOMMENDATION In this chapter, the committee has presented a menu of policy-relevant issues pertaining to the effects of drug control and has identified four specific topics for future research. In the course of its deliberation on these questions, the committee noted, with considerable uneasiness, that some readers of this report might regard the very raising of these questions, and the use of a ''public health" framework, as a declaration of dissent from current policies. This is not the committee's intention. Its aim is simply to include the public health effects of drug control within the field of drug abuse research and, thereby, to strengthen the empirical foundation of drug policymaking. The committee recognizes that drug policy debate has become highly polarized. Committee members are convinced, however, that the empirical issues bearing on drug policy can be usefully organized within a public health framework, that the use of this framework is compatible with

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Pathways of Addiction: Opportunities in Drug Abuse Research the entire range of positions on drug policy, and that it represents a commitment to none of them. The committee is also convinced that a common understanding of the current state of knowledge and of the questions that should be addressed would clarify the areas of dispute and thereby promote rational and informed debate. The committee encourages NIDA, the National Institute of Justice (NIJ), and other public and private sponsors of drug abuse research to incorporate policy-relevant studies of drug control within a comprehensive scientific agenda. The committee is aware that this recommendation raises important questions about the relative priority of drug control research and the proper locus of responsibility for funding it. NIDA's current budget could not feasibly be stretched to include a broad new realm of investigation, and the NIJ budget is not now adequate to fund a rigorous new initiative. For the present, the committee recommends that NIDA, the Department of Justice, and other public and private agencies review the substantive suggestions made in this chapter and consider the most sensible ways to encourage and support research on the public health effects of drug control. REFERENCES Angarola RT, Minsk AG, 1994. Regulation of psychostimulants: How much is too much? In: Schwartz HI, ed. Psychiatric Practice Under Fire: The Influence of Government, the Media and Special Interests on Somatic Therapies. Washington, DC: American Psychiatric Press. Belenko S. 1993. Crack and the Evolution of Anti-Drug Policy. Greenwich CT: Greenwood Press. Belenko S, Nickerson G, Rubinstein T. 1990. Crack and the New York City Courts: A Study of Judicial Responses and Attitudes. Final Report, Grant No. SJI-88-14X-E-050. New York: State Justice Institute. Belenko S, Fagan J, Chin K. 1991. Criminal justice responses to crack. Journal of Research in Crime and Delinquency 28(1):55-74. Berk RA, Campbell A, Klap R, Western B. 1992. The deterrent effect of arrest in incidents of domestic violence: A Bayesian analysis of four field experiments. American Sociological Review. 57:698-708. Berlin F, Malin M, Dean S. 1991. Effects of statutes requiring psychiatrists to report suspected sexual abuse of children. American Journal of Psychiatriy 148(4):449-453. BJS (Bureau of Justice Statistics). 1993. Prisoners in 1992. BJS Bulletin NCJ-141874. Washington, DC: U.S. Department of Justice. BJS (Bureau of Justice Statistics). 1994. Fact Sheet: Drug Data Summary. NCJ-148213. Washington, DC: U.S. Department of Justice. Blumstein A, Cohen J, Martin SE, Tonry ME. 1983. Research on Sentencing: The Search for Reform, Vol. 1. Washington DC: National Academy Press. Bonnie RJ. 1977. Decriminalizing the marijuana user: A drafter's guide. University of Michigan Journal of Law Reform 11:3-50.

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