The Journal of the American Medical Association,

June 1, 1994, Volume 271, No. 21, pp. 1636-1639

Collateral Casualties Climb in the Drug War

by Andrew A. Skolnick

SINCE PRESIDENT Nixon declared war on drugs in 1972, the nation's primary remedy for illicit drug use has been an escalation of federal, state, and local law enforcement activities aimed at discouraging use by punishing both dealers and users. However, an increasing number of health, law, and other experts say the current policy is clearly failing and shows no sign of ever doing more good than harm.

Advocates for reform are calling for an objective cost-benefit analysis of current prohibition laws and of alternative approaches that place more emphasis on harm reduction than on the complete elimination of "recreational" illicit drug use.

Yet despite the nation's long, bitter and expensive war on drugs, much vital data remain uncollected - such as the total number of illegal-drug addicts killed by overdoses. "There appears to be an unwillingness among many national leaders to collect all the data needed for an objective analysis of the nation's drug policy,' says Baltimore (Md) Mayor Kurt Schmoke, a leading proponent of the decriminalization or the "medicalization" of illicit drugs. "So much of the nation's drug policy is driven by politics and emotions rather than any objective analysis of the most important data," he says.

While the total number of deaths in the United States from overdose or toxic reactions to illegal drugs is unknown, a recent study funded by the National Institute on Drug Abuse provides some idea of the problem's magnitude. The Drug Abuse Warning Network Survey of a nonrepresentational sample of hospital emergency department and medical examiner reports from 27 metropolitan areas found that 6001 people in 1991 suffered fatal reactions to illicit drugs. However, decriminalization advocates point out that many if not most of such deaths result from the use of contaminated drugs or drugs that have unexpectedly high potency. The vast majority of these deaths, they say, could be prevented by providing addicts with methadone or other replacement drugs in a clinical setting where health care and addiction therapy can be provided. An often-cited argument against de-criminalization is that it will increase the number of infants exposed prenatally to illegal drugs. Indeed, some infants born to heroin or cocaine addicts have a variety of physical and cognitive problems that may be related to drug abuse. However, the extent of this problem is not known.

Deanna S. Gomby, PhD, director of research and grants for child development, and Patricia H. Shiono, PhD, director of research and grants for epidemiology, at the Center for the Future of Children, Los Altos, Calif, estimate that 2% to 3% of newborns in the United States each year may be exposed prenatally to cocaine, compared with 73% exposed to alcohol and 38% exposed to the effects of maternal smoking (in their report The Future of Children. 1991;1:17-25). They say that 554,000 to 739,000 US newborns are exposed each year to cocaine, heroin or other illegal drugs.

Their estimate is somewhat higher than the 350,000 to 625,000 newborns estimated by the Institute of Medicine to have been exposed to illegal drugs, based on the National Institute on Drug Abuse's 1988 National Household Survey. However, these estimates are not a measure of the harm caused by prenatal exposure to these drugs. Prenatal exposure does not necessarily mean damage to the fetus, Gomby and Shiono write.

Media-generated hysteria over "crack babies" has led to the imprisonment of women who use cocaine during pregnancy. Many health care workers believe that the fear of prosecution and imprisonment discourages many of the women who most need prenatal care from seeking it (JAMA. 1990;261:30t 310). Ironically, properly controlled scientific studies suggest maternal cocaine use may pose less danger to a fetus than maternal cigarette smoking (JAMA, 1994; 271:576-577).

Legalization Spur to Crime?

Many addiction experts are not in favor of decriminalization.

Herbert D. Kleber, MD, executive vice-president and director of the Center on Addiction and Substance Abuse, Columbia University, New York, NY, argues that the current war on drugs has made substantial progress toward reducing drug use as that the current approach "is far preferable to proposals either to legalize drugs or to refrain from enforcing the laws prohibiting their use" (N Eng J Med. 1991;330:361-365).

Kleber, who as deputy director of the Office of National Drug Control Policy was a general in President Rush's escalated war on drugs, which promoted the policy of "zero tolerance," says legalizing illicit drugs would lead inevitably to a sharp rise in use. Cocaine use would increase from the current 2 million users to between 18 million (the estimated number of problem drinkers) and 50 million (the estimated number of smokers), he says. Moreover, in the New England Journal article cited above, Kleber writes, "Crime would not decrease if drugs were legalized. If the cost of drugs were low, addicts would tend to spend more time using them and less time working, so they would continue to need to commit crimes in order to acquire money. If the total number of addicts rose sharply as availability increased, crime would also increase."

While acknowledging that marijuana does not induce violent or criminal behavior, as cocaine and alcohol are said to do, legalizing that drug, he says, will do nothing to reduce crime in the streets.

Kleber concedes that mandatory minimum sentencing laws may require revision in order "to deter or control the true `drug kingpins' and to make better use of limited prison facilities." He also calls for increased funding for drug addiction prevention and treatment programs.

Disease Follows War

Although the morbidity and mortality that directly result from illicit drug use in the United States have not been adequately measured, there are a good deal of data on the morbidity and mortality that result from prohibition. Epidemics of disease always follow in the footsteps of wars. The war on drugs is no exception. The difficulty users of intravenously administered illegal drugs have in obtaining clean needles has stymied efforts to control the spread of drug abuse associated hepatitis, AIDS, and tuberculosis (TB). Other infections are mounting as well, as is the number of children and adults who have been killed in battles over drug-dealing turfs, in crimes committed by addicts to pay for the next fix, and in shootouts between drug dealers and law enforcement officials. In addition to rising body counts, the war's toll includes the rending of the social fabric of the nation's inner cities, especially in black and Hispanic communities that have become the main focus of law enforcement activities.

Despite the severe punishment users of illicit drugs face if caught, illicit drug use is widespread in the United States. According to the National Institute on Drug Abuse's 1992 National Household Survey, more than one in three Americans (36.2%) have used illegal drugs at least once in their lifetime, nearly 28 million Americans (11.1%) used them in the previous year, and almost 14 million Americans (5.5%) used them during the past month.

While choice of drugs may vary, illicit drug use is comparable among blacks, whites, and Hispanics. Nevertheless, although blacks and Hispanics make up approximately 20% of the US population, they make up nearly 75% of the men and women in jails and prisons for drug violations, says Jerome Miller, PhD, founder and director of the National Center on Institutions and Alternatives, a group in Alexandria, Va, that does research and consultant work in criminal and juvenile justice.

With nearly five in every 1,000 Americans behind bars on any given day, the United States has the dubious distinction of incarcerating a higher percentage of its citizens than any country in the world. Thanks in large part to the country's war on drugs, US prison and jail populations are 2-1/2 times larger than they were in 1980. That growth has outpaced all attempts to house and care for the inmates. Each week the United States must add nearly 1,000 prison beds for its rapidly growing inmate population.

According to US Bureau of Justice statistics, on December 31, 1993, there were 883,656 inmates (50,493 women) in state and federal prisons. An additions 441,781 adults, including 39,834 women were in local jails on June 30, 1992. In 1980, federal and state prisons held only 329,821 inmates.

More than 20% of men in prisons are there for drug violations. One in three women in prison were sentenced for drug crimes, up from one in eight in 1983. The incarceration of these women, in particular, has had an enormous impact or their families. According to a 1939 survey of inmates of 424 local jails across the nation, two thirds of incarcerate women were mothers of children younger than 18 years, and two thirds of the mothers said their children were in their custody at the time of their arrest.

According to the Drug Policy Foundation, Washington, DC, from 1980 to 1992 federal and state government spent approximately $150 billion on law enforcement efforts in the war against illegal drugs. An additional $150 billion is likely to be spent between 1992 and 1997. In 1980, the federal government spent $1 billion on the war. The proposed federal drug control budget for 1995 is $13.2 billion. State and local governments will spend $16.5 billion more says press officer David Fratello.

The foundation and other critics see similarities between the drug war and the Vietnam war, in which costs escalated and the body counts mounted while the nation's other problems became increasingly underfunded and defenders of the war periodically claimed to see the `light at the end of the tunnel."

Perhaps the side effect of the drug war that has caused the greatest public concern is the nation's climbing murder rate, attributable in large part to drug-related crime in inner-city areas. Like many critics of current policy, Mayor Schmoke blames much of the violence in Baltimore and other American cities on the "failed national drug strategy," which he and others say has made the illicit drug trade enormously profitable. "Drug traffickers kill to protect or seize drug turf, and addicts commit crimes to get money for drugs," he says. "Almost half the murders in Baltimore in 1992 were drug related."

According to the Federal Bureau of Investigation, 5.7% of the 22,510 homicides that occurred in the United States in 1992 involved motives related to an illegal drug transaction. However, this number does not include victims of crimes committed to obtain money for illegal drugs or those killed in battles over drug-dealing turf. Local studies show that a much higher percentage of murders may be drug related. A study of all homicides involving victim' younger than 18 years in Fulton County Georgia, between 1988 and 1992 (for which a motive was determined), showed that 121 (21%) were connected to illegal drug activity (MMWR MorS MoM Wkly Rep. 1994;43:251-261). Another study showed that 434 (20%) of all homicides in Los Angeles, Calif, between January 1986 and August 1988 involved illegal drugs (AJDC. 1992;146:683887)

The decriminalization of illegal drug could greatly reduce the forces that drive both violent crimes and crimes against property, Schmoke says.

Baltimore, he says, is a perfect example of how and why the national drug strategy is failing. With 48,000 heroin and cocaine users and only 5,300 treatment slots, the only therapy most addicts receive is arrest and incarceration. "We made 18,000 drug-related arrests last year. Fifty-five percent of the cases handled by the Baltimore state's attorney's office are drug offenses." The national situation is not much better. According to federal figures, there are more than 2.77 million Americans in need of treatment for addiction to illicit drugs, but only 600,000 slots in the nation's treatment facilities.

Breading Ground for HIV and TB

Although the public's fears seem to be centered on drug-related violence, the number of deaths caused by diseases spread by shared hypodermic needles is many times greater and growing every year. The news media continue to focus on the hundreds killed in drug wars but give little attention to the tens of thousands dying of diseases spread by IV drug use each year.

According to the Centers for Disease Control and Prevention's October 1993 Hw/MDS Surveillance Report, from October 1992 through September 1993, 26,033 people (19,142 men and 6,391 women) developed AIDS attributable to needles shared during IV drug use. Another 3,576 (1102 men and 2474 women) developed AIDS through heterosexual contact with IV drug users. In addition, 397 children of IV drug-using mothers or fathers were diagnosed as having AIDS. All totaled, 30,006 cases of AIDS, or 30.3% of all new AIDS cases in 1992, were caused by contaminated hypodermic needles.

Despite this great toll in death and the enormous strain on public health services, many political leaders still strongly oppose needle exchange programs, even though studies show that the programs are effective in reducing the spread of human immunodeficiency virus (HIV) infection. Nine states still have laws that prevent addicts from obtaining sterile hypodermic needles.

Opponents of needle exchange programs argue that providing addicts with sterile needles condones their illegal behavior. However, advocates for these programs say that at least some of this resistance reflects an underlying belief that illicit drug users should pay for their crime with their lives and that their deaths will deter others from using such drugs.

More than one champion of the "zero-tolerance" policy has publicly described drug users as deserving the worst of fates. In 1938, former First Lady Nancy Reagan told the press that "if you're a casual drug user, you are an accomplice to murder." Former Los Angeles police a chief Daryl Gates went further by advising the US Senate Judiciary Committee that "casual drug users" should be "taken out and shot."

Reuse of hypodermic needles by addicts also results in an unknown number of cases of hepatitis B, bacteremia, and other infections. Some of these diseases are also transmitted to sexual partners, children, and others in the community. Disease spread by contaminated needles is clearly a major public health problem that is not adequately addressed by the current national drug control policy.

By incarcerating large numbers of drug users, the nation has been housing men and women at high risk of HIV infection and TB in greatly overcrowded facilities, in an environment that encourages the spread of these diseases. Inmates infected with HIV and TB are at high risk for developing active TB and spreading it in prison and when they are released, in the community. Overtaxed medical staffs at correctional facilities are not able to detect and treat many of the infectious cases (JAMA.1992;2G8:3177-3178).

The rates of TB in some jails and prisons have skyrocketed. In 19%, the case rate in the general population was 13.7 per 100,000. Case rates in correctional facilities have been as high as 400 to 500 per 100,000.

Decimating Black Communities

"The drug war takes most of its collateral casualties from the inner cities," says Ethan Nadelmann, PhD, assistant professor at Princeton (NJ) University's Woodrow Wilson School of Public and International Affairs. "Drug prohibition has created a permanent under-class of unemployable inner-city youths whose lives have become hopelessly interwoven with drug crime and who in turn are becoming parents to another generation of dysfunctional children."

The war on drugs has virtually decimated many black communities and has led to increasing poverty, alienation, and violent antisocial behavior, says Miller of the National Center on Institutions and Alternatives. Miller, who is author of Search and Destroy: African-American Males and the Criminal Justice System (New York, NY: Cambridge University Press. In press), says his center's figures show that 75% to 30% of black men will be arrested at least once by the time they reach 35 years of age.

"Those who spend time in correctional facilities are compelled to adopt the values and violent tactics necessary to survive in these facilities," Miller says- "They then bring these antisocial survival tactics back out to the streets.

"The war on drugs is causing far more destruction than the use of illicit drugs ever could." Miller blames much of the inner-city violence on some of the drug control strategies used by police. "The widespread use of stiff sentences to force drug users and minor dealers to inform on others has helped escalate the violence," he says. "Gang-related murders have become the way young men are expected to establish membership in the group and convince fellow gang members that they're not snitches who will ever rat on them."

According to a General Accounting Office (GAO) report, only 1% of the estimated 27,000 federal inmates who have moderate-to-severe substance abuse problems receive adequate treatment. In state prisons, the GAO found that less than 20% of inmates with drug problems received any type of treatment (GAO. Drug Treatment: State Prisons Face Challenges in Providing Services. Washington, DC: GAO; 1991).

According to a 1999 and 1990 American Jail Association survey, less than 20% of jails reported having drug treatment programs involving paid staff and 75% provided no group therapy, drug education, transition planning, or referral to community drug treatment agencies.

In 1992, the American Bar Association Ad Hoc Committee on Drugs concluded that mandatory minimum sentences require expenditures "disproportionate to any deterrent or rehabilitative effect they might have." The committee found that there is no proof that incarcerating large numbers of drug offenders with stiffer prison sentences is reducing criminal behavior. Indeed, it concluded, the burden of "warehousing" more and more prisoners is preventing correctional facilities from providing drug offenders with drug treatment, education, and job-training programs that might benefit them.

A joint position paper by the American College of Physicians, the National Commission on Correctional Health Care, and the American Correctional Health Services Association (Ann Intern Med. 1992; 117:71-77) concludes: "Clearly, Mandatory sentencing practices and the National Drug Control Strategy have overwhelmed correctional facilities to the point of crisis, without substantially alleviating the national problem of drug abuse or drug-related crime . . . . As health professionals, we are seeing the human costs of putting more and more people behind bars.

"Given its enormous human and financial cost, the National Drug Control Strategy, with its emphasis on incarceration, must be reconsidered. Its effectiveness in managing and preventing drug abuse must be evaluated, and alternative approaches that put less emphasis on criminal sanctions and more on prevention and treatment must be considered."

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