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A discussion about public welfare abuse and its negative impact

KleimanJonathan P. CaulkinsAngela HawkenBeau Kilmer The current research agenda has only limited capacity to shrink the damage caused by drug abuse. Some promising alternative approaches could lead to improved results. Drug abuse—of licit and illicit drugs alike—is a big medical and social problem and attracts a substantial amount of research attention.

But the most attractive and most easily fundable research topics are not always those with the most to contribute to improved social outcomes.

If the scientific effort paid more attention to the substantial opportunities for improved policies, its contribution to the public welfare might be greater. The current research agenda around drug policy concentrates on the biology, psychology, and sociology of drugtaking and on the existing repertoire of drug-control interventions.

But that repertoire has only limited capacity to shrink the damage that drug users do to themselves and others or the harms associated with drug dealing, drug enforcement, and drug-related incarceration; and the current research effort pays little attention to some innovative policies with substantial apparent promise of providing improved results.

At the same time, public opinion on marijuana has shifted so much that legalization has moved from the dreams of enthusiasts to the realm of practical possibility. Yet voters looking to science for guidance on the practicalities of legalization in various forms find little direct help. All of this suggests the potential of a research effort less focused on current approaches and more attentive to alternatives. The standard set of drug policies largely consists of: With respect to the currently illicit drugs, it is much harder to see how increasing or slightly modifying standard-issue efforts will measurably shrink the size of the problems.

The costs—fiscal, personal, and social—of keeping half a million drug offenders mostly dealers behind bars are suficiently great to raise the question of whether less comprehensive but more targeted drug enforcement might be the better course. Various forms of focused enforcement offer the promise of greatly reduced drug abuse, nondrug crime, and ncarceration.

These include testing and sanctions programs, nterventions to shrink flagrant retail drug markets, collecive deterrence directed at violent drug-dealing organizaions, and drug-law enforcement aimed at deterring and incapacitating unusually violent individual dealers.

Surely what we try to find out should bear some relationship to the practical choices we face. Below we list eight research questions that we think would be worth answering.

We have selected them primarily for policy relevance rather than for purely scientific interest. The fundamental policy question concerning any drug is whether to make it legal or prohibited. Although the choice s not merely binary, a fairly sharp line divides the specrum of options. Accepting that binary simplification, the choice becomes what kind of problem one prefers. Use and use-related probems will be more prevalent if the substance is legal. Prohibition will reduce, not eliminate, use and abuse, but with three principal costs: A discussion about public welfare abuse and its negative impact userelated harm could go up or down depending on the extent to which the reduction in use offsets the increase in harmfulness per unit of use.

The costs of prohibition are easier to observe than are its benefits in the form of averted use and use-related problems. We would like to know the long-run effect on consumption of changes in both price and the nonprice aspects of availability, including legal risks and stigma. There is now a literature estimating the price elasticity of demand for illegal drugs, but the estimates vary widely from one study to the next and many studies are based on surveys that may not give adequate weight to the heavy users who dominate consumption.

Moreover, legalization would probably involve price declines that go far beyond the support of historical data. Ye t those effects have never been quantitatively estimated for a change as profound as that from illegality to legality.

The decision not to enforce laws against small cannabis transactions in the Netherlands did not cause an explosion in use; whether and how much it increased consumption and whether the establishment of retail shops mattered remain controversial questions.

This ignorance about the effect on consumption hamstrings attempts to be objective and analytical when discussing the question of whether to legalize any of the currently illicit drugs, and if so, under what conditions. Polydrug use is the norm, particularly among frequent and compulsive users.

Most users do not fall in that category, but the minority who do account for the bulk of consumption and harms. The costs—fiscal, personal, and social—of keeping half a million drug offenders mostly dealers behind bars are sufficiently great to raise the question of whether less comprehensive but more targeted drug enforcement might be the better course.

For example, driving up the price of one drug, say cocaine, might reduce its use, but victory celebrations should be tempered if the reduction stemmed from users switching to methamphetamine or heroin. On the other hand, school based drug-prevention efforts may generate greater benefits through effects on alcohol and tobacco abuse than via their effects on illegal drug use.

Comparing them to other drug-control interventions, such as mandatory minimum sentences for drug dealers, in terms of ability to control illegal drugs alone is a mistake; those school-based prevention interventions are not just illicit-drug—control programs.

But policy is largely made one substance at a time. Drugs are added to schedules of prohibited substances based on their potential for abuse and a discussion about public welfare abuse and its negative impact use as medicine. Ye t it makes little practical sense to allow powder cocaine while banning crack, because anyone with baking soda and a microwave oven can convert powder to crack.

Considerations of substitution or complementarity ought to arise in making policy toward some of the so-called designer drugs.

  • Variants of Ceasefire have been implemented across the country, some with impressive results;
  • But to date there has been no systematic experimentation to test how variations in program parameters lead to variations in results;
  • Would adding other services to the mix improve outcomes?
  • And many of the factual questions are too hard to be solved with the current state of the art;
  • With respect to the currently illicit drugs, it is much harder to see how increasing or slightly modifying standard-issue efforts will measurably shrink the size of the problems.

Mephedrone looks relatively good if most of its users would otherwise have been abusing methamphetamine; it looks terrible if in fact it acts as a stepping stone to methamphetamine use. But no one knows which is the case. Marijuana legalization is in play in a way it has not been since the 1970s. Various authors have produced social-welfare analyses of marijuana legalization, toting up the benefits of reduced enforcement costs and the costs of greater need for treatment, accounting for potential tax revenues and the like.

Yet the marijuana-specific gains and losses from legalization would be swamped by the uncertainties concerning its effects on alcohol consumption. There is conflicting evidence as to whether marijuana and alcohol are complements or substitutes; no one can rule out even larger increases or decreases in alcohol use as a result of marijuana legalization, especially in the long run.

Marijuana legalization might also influence heavy use of cocaine or cigarette smoking. But again, no one knows whether that effect would be to drive cocaine or cigarette use up or down, let alone by how much. That suggests both caution in drawing policy conclusions and aggressive efforts to learn more about cross-elasticities among drugs prone to abuse.

Many county, state, and federal initiatives target drug use among criminal offenders. Ye t most do little to curtail drug use or crime.

An exception is the drug courts process; some implementations of that idea have been shown to reduce drug use and other illegal behavior. Unfortunately, the resource intensity of drug courts limits their potential scope. The requirement that every participant must appear regularly before a judge for a status hearing means that a drug court judge can oversee fewer than 100 offenders at any time.

Like drug courts, HOPE provides swift and certain sanctions for probation violations, including drug use. HOPE starts with a formal warning that any violation of probation conditions will lead to an immediate but brief stay in jail.

  • For instance, some studies have argued depression, physical health problems and limited education are the most common barriers to improving the conditions of drug-using welfare recipients;
  • The stunning finding is that, properly deployed, very small incentives for example, vouchers for everyday items can induce much greater behavioral change than can conventional treatment methods alone;
  • So, have they worked?
  • Furthermore, as with HOPE, there remains a need to better understand for whom the program works, how long the effects last, the mechanism s by which it works, and whether it can be effective in a more urban environment;
  • Like drug courts, HOPE provides swift and certain sanctions for probation violations, including drug use.

Probationers are then subject to regular random drug testing: A positive drug test leads to an immediate arrest and a brief jail stay usually a few days but in some jurisdictions as little as a few hours in a holding cell. Probationers appear before the judge only if they have violated a rule; in contrast, a drug court judge participates in every status review.

A similar program in Tarrant County, Texas encompassing Arlington and Fort Worthappears to produce similar results, although this has not yet been verified by an RCT, as has a smaller-scale program verified by an RCT among parolees in Seattle.

The last result is the most striking; get-tough automatic-incarceration policies can reduce incarceration rather than increasing it, if the emphasis is on certainty and celerity rather than severity. But to date there has been no systematic experimentation to test how variations in program parameters lead to variations in results. No one is mandated to undergo treatment except after repeated failures. The results suggest that this is an effective design, but is it optimal?

Would some sanction short of jail for the first violation—a curfew, home confinement, or community service—work as well? Are escalating penalties necessary and if so, what is the optimal pattern of escalation? Is there a subset of offenders who ought to be mandated to treatment immediately rather than waiting for failures to accumulate?

Should cannabis be included in the list of drugs tested for, as it is in Hawaii, or excluded?

Drug testing in Florida

Would adding other services to the mix improve outcomes? How can HOPE be integrated with existing treatment-diversion programs and drug courts? How can HOPE principles best be applied to parole, pretrial release, and juvenile offenders? Answering these questions would require measuring the results of systematic variation in program conditions.

There is no strong reason to think that the optimal program design will be the same in every jurisdiction or for every offender population. Under current law, state governments effectively give every adult a license to purchase and consume alcohol in unlimited quantities.

  • By focusing enforcement on those identified as the most violent, police can create both Darwinian and incentive pressures to reduce the overall violence level;
  • There is also evidence that formal treatment, both psychological and pharmacological, can yield improvements in outcomes for those who accept it;
  • But no one knows which is the case.

Judges in some jurisdictions can temporarily revoke that license for those with an alcohol-related offense by prohibiting drinking and going to bars as conditions of bail or probation. However, because alcohol passes through the body quickly, a typical random-but-infrequent testing regiment would miss most violations, making the revocation toothless. As a condition of bail, repeat drunk drivers who were ordered to abstain from alcohol were now subject to twice-a-day breathalyzer tests, every day.

Those testing positive or missing the test were immediately subject to a short stay in jail, typically a night or two. What started as a five-county pilot program expanded throughout the state, and judges began applying the program to offenders with all types of alcohol-related criminal behavior, not just drunk driving.

Some jurisdictions even started using continuous alcohol-monitoring bracelets, which can remotely test for alcohol consumption every 30 minutes.

That is not because the offenders have no interest in drinking. About half of the participants miss or fail at least one test, but very few do so more than once or twice. Furthermore, as with HOPE, there remains a need to better understand for whom the program works, how long the effects last, the mechanism s by which it works, and whether it can be effective in a more urban environment.

This approach would probably face legal and political challenges, but that should not discourage serious analysis of the idea. There is also strong evidence that increasing the excise tax on alcohol could reduce alcohol-related crime. There is also evidence that formal treatment, both psychological and pharmacological, can yield improvements in outcomes for those who accept it. There is also strong evidence that increasing the excise linked.

Among people with drug problems who are also crimtax on alcohol could reduce alcohol-related crime.

Eight Questions for Drug Policy Research

Duke Uni- inally active, criminal activity tends to rise and fall with drug versity economist Philip Cook estimates that doubling the consumption. There is also evidence that formal shrink illicit drug markets, producing benefits everywhere, treatment, both psychological and pharmacological, can yield from inner-city neighborhoods wracked by flagrant drug improvements in outcomes for those who accept it. The serious criminal activity and other harms associated with those substances are further highly concentrated among a minority of their users.

Many people commit a little bit of crime or use hard drugs a handful of times, but relatively few make a habit of either one. Despite their relatively small numbers, those frequent users and their suppliers account for a large share of all drug-related crime and violence. Moreover, the two sets of behaviors are causally linked. Among people with drug problems who are also criminally active, criminal activity tends to rise and fall with drug consumption.

Reductions in crime constitute a major benefit of providing drug treatment for the offender population, or of imposing HOPE-style community supervision. Reducing drug use among active offenders could also shrink illicit drug markets, producing benefits everywhere, from inner-city neighborhoods wracked by flagrant drug dealing to source and transit countries such as Colombia and Mexico.