Approaches to Limiting the Problems from Drug

Most human societies have known of and used psychoactive drugs, and most also have made efforts to limit the use of one or more drugs, customarily if not legislatively. Historically, the main aim of those restrictions was to diminish threats to the social order or to increase the labor supply. Public health concerns sometimes were expressed in attempts to justify restrictions—for instance, in the efforts of James I of England to stem tobacco smoking (Austin)—but such concerns were rarely decisive. The restrictions on the spirits market adopted in Britain as a response to the extreme alcoholization of eighteenth-century London (depicted in Hogarth's famous print of "Gin Lane") are an early example of limits substantially motivated by concern about public health (Warner; Dillon). Only in recent decades have public health concerns become a major element in discussions of drug policies, although those concerns often are subordinated in the case of legal drugs to fiscal and economic considerations and in the case of illicit drugs to moral and lifestyle issues.

Health hazards from psychoactive drugs occur in two main ways: in connection with particular occasions of use and in connection with the patterning of use over time. Thus, an overdose from barbiturates, a traffic casualty from drunk driving, and an HIV infection from sharing a needle to inject heroin are all consequences associated with a particular occasion of use, whereas lung cancer from tobacco smoking, liver cirrhosis from alcohol use, and (by definition) addiction all reflect a history of heavy use (Room, 1985). As is discussed below, measures to prevent event-related problems often differ from and even conflict with measures to prevent cumulative, condition-related problems. For alcohol the ethical situation with regard to public health measures is complicated by the possibility of a protective effect of drinking on heart disease that must be balanced against the undoubted negative health effects (Room, 2001c; Rehm et al.).

Efforts to limit problems from drug use can be seen as oriented to controlling whether a drug is used at all; influencing the amount, context, and pattern of use; or preventing harmful consequences of use (Bruun; Moore and Gerstein).

PROHIBITING USE TO ALL OR SOME. Efforts to impose a general prohibition on the use of a drug for all the members of a society have a lengthy history, although those efforts frequently have failed (Austin). Perhaps the most sustained effort has been the prohibition on alcoholic beverages in Islamic societies. In general, religious taboos on drug use tend to have had more lasting effect than have state prohibitions. Prohibiting the sale or use of a drug that some might choose to use and enjoy involves a degree of intervention in the marketplace and in private behavior that is unusual in modern democratic states. If there are people who use a drug without problems, the prohibition on their use of that drug must be justified as benefiting others who would have or would cause problems if they used it. In societies with a strong tradition of individual liberties and consumer sovereignty discomfort with the use of this line of argument to support prohibition commonly is resolved by presumptions that users sooner or later will become addicted and that users without problems do not really exist.

A common form of prohibition of use in village and tribal societies has been sumptuary rules restricting use to particular status groups, most commonly the most powerful segments of the society. Depending on the culture, a variety of arguments are offered for the inability of lower-status groups to handle drug use appropriately. Because psychoactive drugs offer visions of an alternative reality (Stauffer) and may be associated with disinhibition, dominant groups may fear challenges to their power if subordinates have access to drugs (Morgan). The universalist ethic of modern states has made explicit sumptuary restrictions untenable, with the substantial exception of prohibitions on use by children. Even the provisions, still common in U.S. state laws, that the names of habitual drunkards be posted and that those listed be refused service of alcoholic drinks are largely unenforced because of their perceived interference with individual liberties.

A third form of modified prohibition of use that often is employed in modern societies is limitation to medicinal use. The individual's supply of such medications is controlled by state-licensed professionals who are backed up by a state system of market controls. National controls on psychopharmaceuticals are backed up by an unusual and elaborate international control structure (Bruun et al.; Room and Paglia). In principle, prescription and use of these drugs are limited to therapeutic purposes. For psychoactive drugs, which commonly are prescribed to relieve negative affective states or mental distress, the definition of therapeutic use often is quite wide, and a substantial proportion of the resources of the health system in industrial societies is absorbed in superintending the provision of psychoactive drugs.

Except for methadone as a remedy for heroin addiction and nicotine as a remedy for tobacco smoking, it generally is considered illegitimate to prescribe a drug to help a person maintain a habitual pattern of use without withdrawal or other distress. Use for pleasure or for the sake of the psychoactive experience is considered nontherapeutic, and so the functions of drugs that are considered psychopharmaceuticals always are described in terms of the relief of distress rather than the provision of pleasure. To some extent the medical prescription system in a modern state serves as a covert form of control by status differentiation, according to the prejudices of the prescriber; for instance, older and more respectable adults find it easier than do the younger and more disreputable to obtain a prescription for a psychopharmaceutical.

INFLUENCING THE PATTERN OF USE. An enormous variety of formal and informal strategies have been used to influence the amount, pattern, and context of the use of drugs. Among the potential aims of those strategies is the public health goal of reducing the prevalence of hazardous use.

Controlling availability. One class of such strategies attempts to reduce drug-related problems by controlling the market in drugs by means of taxes, general restrictions on availability, or user-specific restrictions (Room, 2000; Babor et al.). Public health considerations are one reason among several that governments tax legally available drugs such as alcohol and tobacco. Those taxes often constitute a substantial portion of the price to the consumer. Raising taxes does diminish levels of use among heavier as well as lighter users, although demand usually diminishes proportionately less than the increase in price; that is, demand is relatively inelastic. Thus, short of levels that create an opening for a substantial illicit market, raising taxes on drugs tends both to have positive public health effects and to increase government revenues.

Governments often also control the conditions of availability, particularly for alcohol. Through a system of retail licenses or a government monopoly of sales, limits are placed on the hours and conditions of sale. Changes in those limits sometimes have been found to affect patterns of consumption and of alcohol-related problems (Babor et al.). However, with the strengthening of the ideology of consumer sovereignty—legal goods should be readily available, with purchases limited only by the consumer's means—controls on availability tend to have been loosened in the contemporary period (Makela et al.).

A generally stronger and more direct effect on hazardous alcohol consumption has been found to result from measures that ration or restrict the availability of alcohol for specific purchasers (Babor et al.). A general ration limit for all purchasers restricts heavy consumption or at least raises the effective price, but such measures strongly conflict with the ideology of consumer sovereignty and are thus politically impracticable nearly everywhere. As was noted above, proscriptions or limits on sales to named heavy users also have fallen out of favor because they are considered infringements on individual liberty.

Controlling the circumstances of use. Another class of strategies aims to deter drinking or drug use in particularly hazardous circumstances, usually through the use of criminal sanctions. The prototypical situation is driving after drinking. Because alcohol consumption impairs the ability to drive a vehicle, most countries treat driving with a blood-alcohol level above a set limit as a criminal offense, and enforcement of those laws often absorbs a substantial proportion of the criminal justice system's resources. Popular movements as well as policy makers have expended much energy, particularly in the United States and other Anglophone and Scandinavian countries, in seeking a redefinition of drunk driving as a serious crime rather than a "folk crime" (Gusfield). This type of situational limit or prohibition has been extended to other skill-related tasks and also has been applied to driving after using other psychoactive drugs, particularly illicit drugs. A related development has sought to eliminate illicit drug use in working populations and alcohol use in the workplace by means of random urine testing ofworkers, with job loss as the sanction (Zimmer and Jacobs).

The ethics of this measure, which was pushed strongly by the U.S. government in the 1980s, are controversial, particularly because the tests detect illicit drug use that has not necessarily affected work performance (Macdonald and Roman). Random blood-alcohol tests of drivers to deter drinking before driving also have proved controversial: They are effective, well accepted, and widely applied in Australia (Homel et al.; Peek-Asa); legally permissible but not intensively applied in the United States; and viewed as an impermissible infringement on individual liberty and privacy in many countries.

Education and persuasion about use. A third class of strategies seeks to educate people or persuade them not to engage in hazardous drug use. Because such strategies are seen as the least coercive, at least for those beyond school age, they are used very widely and commonly despite the frequent lack of clear evidence on their effectiveness (Paglia and Room). Education of schoolchildren about the hazards of drug use is very widespread, indeed nearly ubiquitous, in the United States. Most countries also have made at least a token effort at public information campaigns about the hazards of tobacco smoking, and poster and slogan campaigns against drinking before driving and illicit drug use are also widespread. Other public information campaigns on alcohol have promoted limits on drinking (e.g., suggestions of safe levels in Britain and Australia) or campaigned against drinking in various hazardous circumstances.

Often these public information campaigns compete for attention in a media environment saturated with advertising on behalf of use from tobacco or alcohol companies. In the last two decades of the twentieth century some governments imposed substantial restrictions on tobacco and, to a lesser extent, alcohol advertising, for example, banning advertisements on electronic media, and mandated warning labels in advertisements or on product packages. These restrictions often have precipitated court fights about the constitutional permissibility of restrictions on the freedom of "commercial speech."

REDUCING THE HARM FROM USE. The strategies considered above are directed primarily at influencing the fact or pattern of use. They thus fall into the category of either supply reduction or demand reduction, to use terminology commonly applied to the use of illicit drugs. Since the late 1980s substantial attention has been directed toward a third option: harm reduction, or strategies that reduce the problems associated with drug use without necessarily reducing drug use (O'Hare et al.; Heather et al.). Attention to this class of strategies has a somewhat longer history for alcohol (Room, 1975). Usually these strategies focus on the physical or social environment of drug use, seeking physical, temporal, or cultural insulation of the drug use from harm. Thus, needle exchanges are intended to remove the risk of HIV infection from injection drug use, and seat belts and air bags insulate drivers who drink and those around them from the possibility of becoming casualties.

The debate over harm reduction strategies for illicit drugs has raised classic ethical issues for public health. Some argue that insulating the behavior from harm will encourage and thus increase the prevalence of the undesirable behavior.

A further consideration is the effectiveness of the insulation provided. Thus, efforts to provide a safer tobacco cigarette largely have been undercut by compensatory changes in puffing and inhaling by smokers. At an empirical level it seems that insulating drug use from harm does not necessarily increase the prevalence of drug use (Yoast et al.). Even if it did, an old public health tradition that is epitomized by the operation of venereal disease clinics would argue that reducing the immediate risk of harm has a higher ethical priority than affecting the prevalence of disapproved behaviors.

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