DRUG POLICY RESEARCH CENTER
For More Information
Visit RAND at www.rand.org
Explore the RAND Drug Policy Research Center View document details
Support RAND
Purchase this document Browse Reports & Bookstore Make a charitable contribution
Limited Electronic Distribution Rights
This document and trademark(s) contained herein are protected by law as indicated in a notice appearing later in this work. This electronic representation of RAND intellectual property is provided for non- commercial use only. Unauthorized posting of RAND electronic documents to a non-RAND website is prohibited. RAND electronic documents are protected under copyright law. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. For
Skip all front matter: Jump to Page 1 6
The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.
This electronic document was made available from www.rand.org as a public service of the RAND Corporation.
CHILDREN AND FAMILIES EDUCATION AND THE ARTS ENERGY AND ENVIRONMENT
HEALTH AND HEALTH CARE INFRASTRUCTURE AND
TRANSPORTATION
INTERNATIONAL AFFAIRS
LAW AND BUSINESS
NATIONAL SECURITY
POPULATION AND AGING
PUBLIC SAFETY
SCIENCE AND TECHNOLOGY
TERRORISM AND
HOMELAND SECURITY
sional papers may include an informed perspective on a timely policy issue, a discussion
of new research methodologies, essays, a paper presented at a conference, a conference
summary, or a summary of work in progress. All RAND occasional papers undergo
rigorous peer review to ensure that they meet high standards for research quality and
objectivity.
The U.S. Drug Policy Landscape
Insights and Opportunities for Improving the View
Beau Kilmer, Jonathan P. Caulkins,
Rosalie Liccardo Pacula, Peter H. Reuter
The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors.
R ® is a registered trademark.
© Copyright 2012 RAND Corporation
Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes.
Unauthorized posting of RAND documents to a non-RAND website is prohibited. RAND documents are protected under copyright law. For information on reprint and linking permissions, please visit the RAND permissions page (http://www.rand.org/publications/
permissions.html).
Published 2012 by the RAND Corporation
1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665
RAND URL: http://www.rand.org
To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002;
Fax: (310) 451-6915; Email: order@rand.org
Library of Congress Control Number: 2012947920 ISBN 978-0-8330-7699-1
Health and RAND Infrastructure, Safety, and Environment.
Preface
Discussions about reducing the harms associated with drug use and antidrug policies are often politicized, infused with questionable data, and unproductive. In this occasional paper, researchers provide a nonpartisan primer on the topic that should be of interest to those who are new to the field of drug policy, as well as those who have been working in the trenches. This project was funded by the John D. and Catherine T. MacArthur Foundation, and the views presented here reflect only those of the authors.
This study was conducted under the auspices of the RAND Drug Policy Research Center.
The goal of the Drug Policy Research Center is to provide a firm, empirical foundation on which sound drug policies can be built, at the local and national levels. The center’s work is supported by foundations, government agencies, corporations, and individuals.
We are indebted to Nicholas M. Pace (RAND) and Harold Pollack (University of Chi- cago) for their constructive reviews. The paper also benefited from comments made by James Burgdorf (RAND), Keith Humphreys (Stanford University), and Sarah Lawrence (University of California, Berkeley).
Questions or comments about this paper should be sent to the project leader, Beau Kilmer
(Beau_Kilmer@rand.org). Information about the Drug Policy Research Center is available
online (http://www.rand.org/multi/dprc/). Inquiries about research projects should be made to
the center’s co-directors, Rosalie Liccardo Pacula (Rosalie_Pacula@rand.org) and Beau Kilmer
(Beau_Kilmer@rand.org).
Contents
Preface . . . . iii
Figures . . . . vii
Summary . . . . ix
Abbreviations . . . . xiii
ChAPter One Introduction . . . . 1
ChAPter twO The Drug Policy Landscape in the United States . . . . 3
Drug Use . . . . 3
Designer Drugs . . . . 5
Drug Problems . . . . 6
The Economic Burden of Drug Use . . . . 6
Observation 1: Prescription Drugs Account for an Increasing Share of the Nation’s Drug Problem . . . . 7
Observation 2: Cocaine Accounts for a Decreasing Share of the Nation’s Drug Problem . . . . 8
Observation 3: U.S. Demand for Drugs is Fueling Violence and Corruption in Mexico and Central America . . . . 9
Drug Policy in the United States . . . . 10
Government Spending on Drug Policy . . . . 10
Domestic Law Enforcement . . . . 10
Interdiction . . . . 11
International Efforts . . . . 12
Prevention . . . . 12
Treatment . . . . 13
Recent Change 1: The Patient Protection and Affordable Care Act (ACA) . . . . 13
Recent Change 2: Federal Response to Medical Marijuana . . . . 14
ChAPter three efficacy of U.S. Drug Policies and Programs . . . . 17
Supply Reduction . . . . 17
Management of Market-Related Harms . . . . 19
Treatment . . . . 20
Other Interventions with Dependent Users . . . . 22
Prevention . . . . 23
Topics Meriting Additional Attention . . . . 24
ChAPter FOUr The Drug Policy research Funding Landscape . . . . 25
Government Agencies . . . . 25
National Institutes of Health (NIH) . . . . 25
Substance Abuse and Mental Health Services Administration (SAMHSA) . . . . 26
U.S. Veterans Health Administration (VHA) . . . . 26
White House Office of National Drug Control Policy (ONDCP) . . . . 26
U.S. Department of Justice (DOJ) Office of Justice Programs (OJP) . . . . 27
Other Government Agencies . . . . 27
Foundations . . . . 27
The Robert Wood Johnson Foundation (RWJF) . . . . 28
Open Society Foundations . . . . 29
Other Foundations . . . . 29
Corporations and Individuals . . . . 30
Summary of the Funding Landscape . . . . 30
ChAPter FIve Opportunities to Influence the Drug Policy Field . . . . 33
Opportunity 1: Sponsor Young Scholars and Strengthen the Infrastructure of the Field . . . . 33
Opportunity 2: Accelerate the Diffusion of Good Ideas and Reliable Information to Decisionmakers . . . . 34
Opportunity 3: Replicate and Evaluate Cutting-Edge Programs in an Expedited Fashion . . . . 34
Opportunity 4: Support Nonpartisan Research on Marijuana Policy . . . . 35
Opportunity 5: Investigate Ways to Reduce Drug-Related Violence in Mexico and Central America . . . . 36
Opportunity 6: Improve Understanding of the Markets for Diverted Pharmaceuticals . . . . 36
Opportunity 7: Help Build and Sustain Comprehensive Community Prevention Efforts . . . . 37
Opportunity 8: Develop More Sensible Sentencing Policies That Reduce the Excessive Levels of Incarceration for Drug Offenses and Address the Extreme Racial Disparities . . . . 37
ChAPter SIx Concluding Thoughts . . . . 39
Bibliography . . . . 41
Figures
2.1. Trends in Past-Month Use in the Household Population, 2002–2010 . . . . 4
2.2. Past-Year Use of Intoxicating Substances Among High School Seniors, 2011 . . . . 5
2.3. Number of Drug Poisoning Deaths Involving Opioid Analgesics and Other Drugs: United States, 1999–2008 . . . . 7
2.4. Age Distribution of Adult Crack Cocaine Treatment Admissions, 1992 and 2008 . . . . 8
2.5. Proposed 2012 Federal Budget for Drug Control: $26 Billion . . . . 10
2.6. Number of People in Prisons and Jails for Drug Offenses, 1980 and 2010 . . . . 11
Summary
Three topics dominate discussions of drug policy in the United States: legalizing marijuana for medical and nonmedical purposes, the violence in Mexico, and the increase in prescription drug abuse. While these issues now capture policymaker and media attention, other important drug-related problems and questions, such as the extraordinarily high levels of incarceration for drug offenses, still need to be considered.
This paper provides a nonpartisan primer on drug use and drug policy in the United States. It aims to bring those new to drug policy up to speed and to suggest where researchers and potential research funders could focus their efforts to make strong contributions to the field.
Overview of Drug Use and Drug Policies in the United States
More than 40 million Americans use cocaine, heroin, marijuana, methamphetamine, halluci- nogens, or prescription drugs for nonmedical purposes each year, with roughly half consuming only marijuana. In the last five years, marijuana use—particularly daily use—has increased, and cocaine use has declined. As homicides associated with flagrant street markets for crack have declined, there has been a sharp rise in deaths associated with prescription drugs. A more recent policy challenge involves new substances, often referred to as designer drugs or “legal highs,” because they are—at least initially—not covered by existing prohibitions.
The Obama administration estimated that federal spending on drug control would reach about $26 billion in 2012, divided into prevention, treatment, domestic law enforcement, international law enforcement, and interdiction; the proportion of spending allocated to pre- vention and treatment has increased since 2008 but remains below one-half. Large amounts of money are also spent by states (e.g., corrections, treatment), local governments (e.g., policing, school-based prevention), and the private sector (e.g., funding media-based prevention cam- paigns) on policies and programs related to drug use. It is likely that state and local govern- ments spend more on drug control than does the federal government, and that this spending is even more enforcement-oriented than the federal drug budget.
This paper discusses two recent and important changes to U.S. drug policy at the fed-
eral level. The first is the passage of the Patient Protection and Affordable Care Act, which is
expected to expand insurance coverage to tens of millions of individuals who do not have it
now. This will help extend prevention and early intervention services, provide incentives for
coordinating primary care, and enhance community-based treatment options. Another change
is the federal response to medical marijuana, which is evolving. Federal authorities have never
made a priority of targeting patients or their caregivers for simply possessing medical mari- juana. What has changed over time has been the federal response to those supplying medical marijuana. Over the last two years, federal prosecutors have stepped up their efforts to shut down dispensaries.
The Efficacy of U.S. Drug Policies and Programs
It has been customary to distinguish four or five categories (“pillars”) of interventions: domes- tic law enforcement, international supply-side reduction efforts, treatment, prevention, and (outside of the United States) harm reduction. However, this traditional categorization fails in two important respects. First, it imagines that law enforcement is synonymous with supply control, but law enforcement agencies do more than try to reduce drug supply. Second, signifi- cant harms revolve around drug markets, and law enforcement is the lead agency for address- ing those. Given these issues, this paper distinguishes between supply reduction, management of market harms, treatment, other interventions with dependent users, and prevention.
Based on the available evidence, we highlight a number of long-standing topics merit- ing additional attention, such as being more strategic about the use of incarceration for easily replaced functionaries, expanding nontraditional approaches to dealing with dependence, and improving understanding of the dynamics of drug epidemics to evaluate whether there are
“global” lessons or differential experiences.
What Is the Drug Policy Research Funding Landscape, and Where Are the Gaps?
The bulk of drug-related research is sponsored by the National Institutes of Health and, in particular, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. Other government agencies include the Substance Abuse and Mental Health Services Administration, the U.S. Veterans Health Administration, the White House Office of National Drug Control Policy, and the U.S. Department of Justice Office of Justice Programs.
For various reasons, little of that funding addresses strategic policy choices.
As a result, foundations have played a major role in drug policy research. The Robert Wood Johnson Foundation remains the largest source of nongovernment support for objective research in the area of drug policy, but its support has decreased since the end of its Substance Abuse Policy Research Program (SAPRP) in 2009. The Open Society Foundations have also been a significant contributor, with an emphasis on projects that support human rights, harm reduction, and the liberalization of drug laws.
Much of the focus has been on biomedical research, with little-to-no funding for big-
picture research—either comprehensive evaluations that look at successful ideas and strategies
or novel promising approaches, grounded in the understanding that drug problems do not
affect every city, every family, or every nation in the same way. Moreover, there are diminishing
returns in the areas that have been traditionally studied, compared with the low-hanging fruit
that remains in areas that have been neglected. Indeed, largely missing from the landscape is
analysis and evaluation of the drug control strategy that has dominated government budgets
and rhetoric for decades: law enforcement, both domestic and international. With the end of
Summary xi
SAPRP in 2009, there is a need for a new, sustained source for funding of science that objec- tively and systematically considers overarching policy objectives and/or politically unpopular alternatives.
What Are the Opportunities to Influence the Drug Policy Field?
Comparing the needs, old and new, to the current funding patterns, suggests eight salient opportunities to improve understanding of drug problems and drug policies:
1. Sponsor young scholars and strengthen the infrastructure of the field.
2. Accelerate the diffusion of good ideas and reliable information to decisionmakers.
3. Replicate and evaluate cutting-edge programs in an expedited fashion.
4. Support nonpartisan research on marijuana policy.
5. Investigate ways to reduce drug-related violence in Mexico and Central America.
6. Improve understanding of the markets for diverted pharmaceuticals.
7. Help build and sustain comprehensive community prevention efforts.
8. Develop more sensible sentencing policies that reduce the excessive levels of incarcera- tion for drug offenses and address the extreme racial disparities.
This paper offers specific suggestions for researchers and potential research funders in
Abbreviations
ACA Patient Protection and Affordable Care Act BJA Bureau of Justice Assistance
CESAR Center for Substance Abuse Research CND Commission on Narcotic Drugs CSA Controlled Substances Act
CSAP Center for Substance Abuse Prevention CSAT Center for Substance Abuse Treatment DMI Drug Market Intervention
DOJ U.S. Department of Justice DTO drug trafficking organization
FY fiscal year
HOPE Hawaii’s Opportunity Probation for Everyone ISSDP International Society for the Study of Drug Policy MHPAEA Mental Health Parity and Addiction Equity Act of 2008
MTF Monitoring the Future
NASADAD National Association of State Alcohol/Drug Abuse Directors NIAAA National Institute on Alcohol Abuse and Alcoholism
NIDA National Institute on Drug Abuse NIH National Institutes of Health NIJ National Institute of Justice
NORML National Organization for the Reform of Marijuana Laws NSDUH National Survey on Drug Use and Health
OJJDP Office of Juvenile Justice and Delinquency Prevention
OJP Office of Justice Programs
ONDCP Office of National Drug Control Policy
OTC over-the-counter
RWJF Robert Wood Johnson Foundation
SAMHSA Substance Abuse and Mental Health Services Administration SAPRP Substance Abuse Policy Research Program
SBIRT Screening, Brief Intervention, and Referral to Treatment TEDS Treatment Episode Data Set
UNODC United Nations Office on Drugs and Crime
VHA Veterans Health Administration
ChaPTer One
Introduction
Three issues currently dominate drug policy discussions in the United States:
• Marijuana. In an increasing number of states, voters are being asked about whether to replace marijuana prohibition with legal production and sale for general, not just medi- cal, purposes. 1 There is also discussion about the intensification of federal enforcement against medical marijuana suppliers (e.g., Onishi, 2012).
• Mexico. It is difficult to escape the gruesome pictures and stories about criminal violence in Mexico, which is fueled in large part by U.S. demand for illegal drugs. This drug violence has spilled into Central America, where homicide rates are even higher than in Mexico (U.S. State Department, 2011).
• Prescription drug abuse. Prescription drug use is an increasing cause of morbidity and mortality in the United States (Warner et al., 2009; 2011). Prescription drugs, such as Oxycontin, pose new challenges since much of the thinking about drug policy is oriented toward illegally produced substances.
The sheer diversity of these three topics highlights the complexities surrounding drug policy in the United States. While these three issues receive considerable attention from deci- sionmakers and the media, other important drug-related problems and questions still need to be considered. This paper arose from a question about how a funder could contribute to improving drug policy and thereby ameliorating drug-related and drug policy–related harms;
indeed, Chapter Five takes up that issue directly. However, funding recommendations must be grounded in a clear understanding of the overall drug policy landscape and of the drug prob- lem itself. Communicating that “big picture” is the goal of the first four chapters, which should be of interest to a wide readership.
This paper does not directly tackle the issues surrounding alcohol and tobacco. While some of the ideas and approaches discussed here are also relevant for reducing alcohol and tobacco consumption and related costs, there are enough issues specific to illegal drugs to merit a separate document addressing only them. Moreover, while most users of illegal drugs also consume alcohol, effective responses to many drug policy issues do not require an understand- ing of that relationship.
This paper begins with an overview of drug problems and policies in the United States, including the nonmedical use of prescription drugs. Chapter Three discusses the efficacy of
1 In 2010, California’s ballot initiative to legalize marijuana received 46 percent of the vote. As of August 2012, legaliza-
tion will be on the November 2012 ballot in Colorado, Oregon, and Washington state.
U.S. drug policies and programs, including the long-standing issues that deserve additional
attention. Chapter Four lists the major funders who support research related to substance use
and describes their priorities. By highlighting the issues that receive the bulk of funding today,
this discussion identifies where gaps remain. Comparing these needs, old and new, with cur-
rent funding patterns, Chapter Five identifies promising opportunities to improve understand-
ing of drug problems and drug policies in the United States.
ChaPTer TwO
The Drug Policy Landscape in the United States
This chapter provides an overview of drug use, consequences, and drug control policies in the United States. It is far from exhaustive; the goal is to survey the most salient issues, with a spe- cial focus on those that are new or emerging.
Drug Use
The United States has experienced four major epidemics of illegal drug use: heroin (circa 1968–
1973), powder cocaine (circa 1975–1985), crack cocaine (circa 1982–1988), and methamphet- amine (circa 1990–2000) (Pollack, Sevigny, and Reuter, 2011). An epidemic is characterized by a very sharp increase in initiation of use of the drug, followed later by a similarly sharp downturn as the dangers of the drug become better known. Even after the initiation begins to decline, drug demand continues to rise for a while as some of those who experimented go on to become addicted and, so, consume in greater quantities; eventually prevalence and demand will decline, albeit rather slowly.
More than 40 million Americans use cocaine, heroin, marijuana, methamphetamine, hallucinogens, or prescription drugs for nonmedical purposes each year, with roughly half consuming only marijuana (Substance Abuse and Mental Health Services Administration [SAMHSA], National Survey on Drug Use and Health [NSDUH], 2011; Office of National Drug Control Policy [ONDCP], 2012c). The federal government spends tens of millions of dollars each year conducting nationally representative household and student surveys about substance use (NSDUH and Monitoring the Future [MTF], respectively). These studies pro- vide information about the more popular substances and less-intensive patterns of use, such as marijuana and nonmedical use of prescription drugs. They are less useful for estimating the number of cocaine, heroin, and methamphetamine users; this is because the modal age of ini- tiation for those drugs is later and a greater share of heavy hard drug users do not show up in or respond to these surveys (Abt Associates, 2001; ONDCP, 2012c). Nevertheless, these data can help policymakers and the public understand the magnitudes and trends in use among the general population for some substances.
Figure 2.1 presents trends in the number of NSDUH respondents who report being “cur-
rent” users (i.e., use in the month preceding the survey). The number of respondents reporting
past-month use of marijuana was stable from 2002 to 2007, but it increased by 20 percent from
2007 to 2010. Perhaps more importantly, the total number of marijuana use days by respon-
dents using on a near-daily basis (20+ times in the past month) rose 38 percent between 2007
and 2010 (Kilmer et al., in progress; not shown here). There is little systematic research on what
is driving this increase; not surprisingly, there is a heated debate about the role that medical marijuana has played in increasing availability and reducing the stigma associated with use (e.g., Harper, Strumpf, and Kaufman, 2012; Wall et al., 2012).
There was also an important change in cocaine use during the 2000s, but in the other direction. The number of past-month cocaine users in the household survey decreased by almost 40 percent from 2006 to 2010, and this decrease is consistent with other findings in the literature (Pollack et al., 2011). A change in the survey question pertaining to metham- phetamine makes it difficult to examine methamphetamine trends before 2007, but it is well established that the drug was primarily concentrated in the western United States for decades and started spreading eastward in the 1990s and 2000s (National Institute on Drug Abuse Community Epidemiology Work Group Meeting, 2005). NSDUH’s hallucinogens category, which includes ecstasy, PCP, LSD, and other illegal psychedelics, fluctuated around 1 million past-month users throughout the decade. Heroin use is so infrequently reported in the house- hold survey that we did not include it in the figure.
The use of prescription drugs for nonmedical purposes is nothing new. Indeed, cocaine was originally prescribed for a number of ailments in the 1880s, and methaqualone (Quaaludes) was used to treat insomnia in the 1960s before becoming a recreational drug in the 1970s.
Compared to the 2002–2005 period, there was roughly a 10-percent increase in past-month use of pain relievers and tranquilizers for nonmedical purposes in the latter half of the decade (Figure 2.1). However, prevalence trends may not capture the entire story. Overdose deaths have increased dramatically, and more than 15 percent of high school seniors reported using a prescription drug without a doctor telling them to use it in 2011—making this category the third most popular intoxicating substance for youth behind alcohol and marijuana (Figure 2.2).
Figure 2.1
Trends in Past-Month Use in the Household Population, 2002–2010 (in thousands)
SOURCES: SAMHSA, NSDUH, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, and 2011.
NOTES: These figures do not account for misreporting or those not covered by the sampling frame. Data from before 2002 are not reported because of changes to the survey. The psychotherapeutics category includes the nonmedical use of any prescription-type pain reliever, tranquilizer, sedative, or stimulant—including
methamphetamine. It does not include over-the-counter drugs. There was also a change to the methamphetamine question in 2007, so data prior to that are not shown for the methamphetamine, stimulant, and
psychotherapeutics categories.
RAND OP393-2.1
16,000
12,000 8,000 6,000 4,000 2,000 18,000
2002 2007 2008 2009
Year 2006 2005 2004
2003
Population
0 2010
14,000
Marijuana
Psychotherapeutics
Pain relievers
Cocaine
Tranquilizers
Hallucinogens
Methamphetamine
Stimulants, including
methamphetamine
The Drug Policy Landscape in the United States 5
Marijuana use accounts for the majority of those who are classified through surveys of the general population as meeting clinical criteria for illegal drug abuse or dependence (4.4 million in 2010; SAMHSA, NSDUH, 2011). 1 That said, the consequences of marijuana dependence appear to be substantially less for both the individual and society when compared with the consequences of dependence on alcohol and on the more expensive drugs—cocaine (crack or powder), heroin, and methamphetamine (Room et al., 2010). The combined number of people meeting clinical criteria for abuse and dependence on illicit drugs other than marijuana is only 2.6 million, as detected by NSDUH, and is probably no more than 6 million when factoring in populations underrepresented in a household survey (ONDCP, 2012c).
Designer Drugs
A more recent policy challenge involves new substances, often referred to as designer drugs or
“legal highs,” since they are at least initially not covered by existing prohibitions (Winstock and Ramsey, 2010). Controlled Substances Acts (CSAs) around the world prohibit a specific list of substances and, in many countries, kindred chemicals. In countries with CSAs that lack language extending the ban to kindred molecules, chemists can cook up tiny variations—
altering just an atom or two on an out-of-the-way corner of the molecule—that are not techni- cally banned but that have similar intoxicating effects. The U.S. language is rather inclusive, covering not just specific chemical variants but all chemicals that are substantially similar in
Figure 2.2
Past-Year Use of Intoxicating Substances Among High School Seniors, 2011
SOURCE: Johnston et al., 2012.
NOTE: OTC = over-the-counter.
RAND OP393-2-2
60 50 40 30 20 10 70
Alcohol
Methamphetamine Cocaine
OTC cold medicines Salvia
Synthetic marijuana Prescription drugs
Marijuana Heroin
Been drunk
Per centage
0
composition and effect. That may be one reason designer drugs tend to be more prominent in some European countries than in the United States.
Marijuana is, as always, an exception. Marijuana is a plant that contains scores of psycho- active chemicals (called cannabinoids). The federal CSA banned the plant, not the individual chemicals within it. Thus, preparations containing closely related cannabinoids, such as spice and K2, were not initially covered because they were not kin to a listed chemical. The 2011 MTF student survey inquired about synthetic marijuana, and Figure 2.2 shows that more than 11 percent of high school seniors reported using it in the past year (Johnston et al., 2012).
In July 2012, President Obama signed the Synthetic Drug Abuse Prevention Act of 2012 into law, which bans many compounds found in synthetic marijuana and synthetic cathinones (e.g., “bath salts”) at the federal level. In an email announcing the law, ONDCP encouraged
“states that have not already done so to incorporate these substances into their state drug schedules to ensure that state law enforcement agencies have full authority to act against these substances” (ONDCP, 2012e).
Drug Problems
Both drug use and the policies intended to reduce it can create harm. A comprehensive analysis of these consequences is beyond the scope of this paper; instead, we summarize a recent, albeit limited, study of these consequences and make three observations about the changing nature of these costs (National Drug Intelligence Center, 2011). 2
The Economic Burden of Drug Use
“Cost-of-illness” studies calculate the economic burden of disease. For more than 30 years they have been conducted in the United States to measure the consequences of drug use on the economy. Critics rightfully note that many, perhaps even most, of these costs may be more directly attributable to the policies—not just the consumption (e.g., lost productivity due to incarceration for a drug arrest).
Still, some find the cost-of-illness estimates to be helpful for understanding the magni- tude of certain factors and the main drivers. The most recent estimate puts the economic cost of illegal drug use under current policies in the United States at $193 billion in 2007 (National Drug Intelligence Center, 2011). 3 Costs were classified into three categories: crime ($61 bil- lion), health ($11 billion), and productivity ($120 billion). The latter includes missed work and
“presenteeism” (being less productive while on the job), as well as wages lost due to incarcera- tion and homicide. These costs do include the nonmedical use of prescription drugs and are not broken down by specific drug.
Drug markets generate large illegal revenues, which are an important negative conse- quence (especially when the money goes to violent actors). For marijuana alone, it is estimated
2 Analysis could also address the benefits that users derive from consuming psychoactive substances. (Just as many people enjoy consuming alcohol; others enjoy consuming marijuana or cocaine.) Given the issues surrounding dependence and the fact that many heavy substance users would prefer to use less, we do not think it is appropriate simply to equate total expenditures with the benefits derived from consumption; however, this is an issue worthy of future research. The academic literature on the nonmedical benefits associated with using illegal drugs is strikingly thin (Caulkins et al., 2012).
3 As a point of comparison, the cost of excessive alcohol use was $223.5 billion in 2006 (Bouchery et al., 2011).
The Drug Policy Landscape in the United States 7
that in recent years total retail sales in the United States have been between $15 billion and
$30 billion (Kilmer and Pacula, 2009; Caulkins et al., 2012). A recently released report from ONDCP (2012c) estimates that retail spending on cocaine, heroin, and methamphetamine in 2006 was in the ballpark of $70 billion. Indeed, the drug trade involves very large dollar amounts, and the fact that some view participation in the trade as an attractive economic option constitutes an important element of the nation’s drug problem.
Observation 1: Prescription Drugs Account for an Increasing Share of the Nation’s Drug Problem
What is striking about the current wave of prescription drug use is the surge in negative conse- quences. The Centers for Disease Control and Prevention (2010a) reports that emergency room visits “for nonmedical use of opioid analgesics increased 111 percent during 2004–2008 (from 144,600 to 305,900 visits) and increased 29 percent during 2007–2008.” Further, among cases in which the drug can be specified, poisoning deaths involving prescription opiates alone now exceed the number of deaths from all other drugs combined (Warner et al., 2011, shown in Figure 2.3).
Needless to say, the nearly 15,000 opioid analgesic deaths per year represent a significant health problem; 4 however, thus far the prescription drug trade has not been associated much with large illegal markets and violence. Rogue doctors and freewheeling pain clinics (“pill mills”) have received serious attention from law enforcement agencies, but they operate in a dif-
4 Indeed, this is close to the total number of homicides reported each year in the United States (FBI, 2011; Kochanek et Figure 2.3
Number of Drug Poisoning Deaths Involving Opioid Analgesics and Other Drugs: United States, 1999–2008
a
Opioid analgesics include natural and semisynthetic opioid analgesics (for example, morphine, hydrocodone, and oxycodone) and synthetic opioid analgesics (for example, methadone and fentanyl).
Some deaths in which the drug was poorly specified or unspecified may involve opioid analgesics.
SOURCE: Warner et al., 2011.
NOTE: Drug categories are mutually exclusive.
RAND OP393-2.3
14,000 12,000 10,000 8,000 6,000 4,000 2,000 16,000
1999 2004 2005 2006 2007
Year 2003 2002
2001 2000
Number of deaths
0
2008 Any opioid analgesic
aSpecified drug(s) other than opioid analgesic
Only nonspecified drug(s)
ferent fashion than street drug markets. Thus, the methods for reducing the prescription drug problem will likely be different from those traditionally used when targeting wholly illegal drugs. The policy and political challenges will also be distinct.
Observation 2: Cocaine Accounts for a Decreasing Share of the Nation’s Drug Problem
The nation’s population of problematic cocaine users now consists largely of those who began using the drug a long time ago. Figure 2.4 illustrates that phenomenon for those seeking treat- ment for crack cocaine use (SAMHSA, Treatment Episode Data Set [TEDS], 1993, 2009).
Whereas the modal age group in 1992 was 26 to 30, accounting for nearly one-third of the total, that age group accounted for a little more than one-tenth of treatment-seekers in 2008.
In contrast, the age group 41 to 45 was the modal group in 2008, accounting for 21 percent of treatment-seekers, compared with only about 5 percent in 1992.
This aging has many consequences, both good and bad, for society. The age-crime curve is particularly pronounced for violence (e.g., Sampson, Morenoff, and Raudenbush, 2005), meaning that aggregate offense rates drop sharply as a birth cohort ages. So, older consumers (who may also sell) may be less likely to settle conflicts with violence than their younger and more impulsive counterparts. On the other hand, older users, with long histories of addic- tion and physical problems, are more likely to overdose or suffer serious medical problems as a result of continued use (e.g., Kerr et al., 2007). Their longer criminal records also make them more likely to receive long prison sentences when convicted; in fact, the aging of the American prison population is heavily driven by the increasing number of older drug-involved inmates (Pollack et al., 2011). Thus, the nature of the American drug problem has changed substan- tially over the last 20 years; it is now less of a crime problem (drug market violence) and more of a health problem (higher rates of morbidity and mortality) and a criminal justice problem (burdensome rates of incarceration).
Figure 2.4
Age Distribution of Adult Crack Cocaine Treatment Admissions, 1992 and 2008
SOURCES: SAMHSA, TEDS, 1993, 2009.
RAND OP393-2.4
30 25 20 15 10 5 35
18–20 36–40 41–45 46–50 51–55
Age 31–35
26–30 56+
21–25
Per centage
0
1992 TEDS
(N = 182,835)
2008 TEDS
(N = 163,419)
The Drug Policy Landscape in the United States 9
While cocaine markets in inner cities were once a major source of violence and disorder, this has become less of a concern in many, but not all, communities in recent years (Fryer et al., 2010). The reduction in markets’ visibility and destructiveness probably reflects the combina- tion of several factors, including changes in technology (e.g., arranged purchases by cell phone and texting). Nonetheless, the remaining flagrant markets can still make it difficult to attract businesses and other investment to inner-city communities.
Observation 3: U.S. Demand for Drugs is Fueling Violence and Corruption in Mexico and Central America
The levels of drug-related violence and corruption in Mexico are staggering. Since 2006, there have been approximately 50,000 organized crime killings in Mexico (Molzahn, Ríos, and Shirk, 2012). While Mexico’s homicide rate is still lower than in many Central American countries, the current wave of violence, is shocking. Despite a large reduction in murders in Juárez in 2011, the murder rate hovered around 150 per 100,000 population, making it not only the most dangerous city in Mexico, but also one of the most dangerous cities in the world (Consejo Ciudadano para la Seguridad Publica y Justicia Penal A.C., 2012). This is in sharp contrast with neighboring El Paso, Texas, which is one of the safest large cities in the United States (about three homicides per 100,000 population; Valdez, 2012).
For decades, Mexican drug trafficking organizations (DTOs) primarily smuggled mari- juana and Mexican-grown heroin. Until the 1990s, most cocaine shipped from Colombia entered the United States through the Caribbean. However, after increased enforcement pres- sure in that region, cocaine traffickers began hiring Mexican smugglers to get cocaine into the United States (see, e.g., Beittel, 2011). Over time, the Mexican DTOs played a bigger role in the cocaine trade, and this generated enormous revenues (Kilmer et al., 2010a).
Even a decade ago, there were only a few large DTOs involved in the trade, and rela- tions among them were relatively nonviolent. Violence did become more common after the election of President Fox in 2000 (the first non–Partido Revolucionario Institucional [Institu- tional Revolutionary Party] president in 70 years), and, in 2006, President Calderon stepped up efforts to crack down on the DTOs. This had two major effects: (1) It increased violence against law enforcement officers and others seeking to diminish the trade, and (2) it splintered the DTOs, thereby increasing the number of organizations fighting over product and smug- gling routes. The DTOs were able to intimidate and/or pay off many law enforcement officials, and it is still common to hear of entire departments being fired for corruption (Associated Press, 2011). There are efforts under way to reduce corruption and revamp the legal process, but this will take years. Indeed, in January 2012, the Mexican Public Safety Secretary projected that while the increase in drug-related homicides was slowing (there was only an 11-percent increase in 2011 over 2010), it could be another five years before the violence significantly decreases (Archibold, 2012).
Mexican DTOs are increasing their presence in Guatemala, Honduras, and El Salvador,
exporting violence and corruption to countries already known for violence and weak institu-
tions (The Economist, 2011). The U.S. State Department reports that the security situation con-
tinues to deteriorate in Guatemala, with the major Mexican DTOs having a larger presence
while the country is decreasing spending on courts and law enforcement (U.S. State Depart-
ment, 2011). El Salvador and Honduras are just as badly affected. This suggests once again
industry geographically (which does not imply that it has a major impact on the total market volume).
Drug Policy in the United States
This section provides an overview of drug policies and programs in the United States; their efficacy is discussed in Chapter Three. This section concludes with discussions of two recent changes in federal efforts: health insurance and medical marijuana.
Government Spending on Drug Policy
A common, albeit imperfect, lens for describing U.S. drug policy is the federal drug control budget. In 2012, the Obama administration estimated that it would spend approximately
$26 billion on drug control (Figure 2.5), with less than half going to prevention and treatment (ONDCP, 2012a); however, the ratio of spending on prevention and treatment to law enforce- ment has increased over time (ONDCP, 2000, 2012a).
Of course, this figure would be much more useful if it looked beyond the federal budget and incorporated data on the large amounts of money spent by states (e.g., corrections, treat- ment), local communities (e.g., policing, school-based prevention), and the private sector (e.g., funding media-based prevention campaigns) on policies and programs related to drug use.
The National Association of State Alcohol/Drug Abuse Directors (NASADAD) has compiled information at various times from the state alcohol and drug program agencies on state spend- ing for prevention and treatment programs. For the most recent year available (fiscal year [FY]
1999), NASADAD reported that the federal government only accounted for about 40 percent of expenditures on state-supported alcohol and other drug services (NASADAD, 2001).
Domestic Law Enforcement
After property crimes, drug offenses constitute the largest category for arrests in the United States, edging out driving under the influence (FBI, 2011). Almost half of the 1.6 million drug
Figure 2.5
Proposed 2012 Federal Budget for Drug Control:
$26 Billion
SOURCE: ONDCP, 2012a.
RAND OP393-2.5
Prevention International
Interdiction
Domestic law enforcement
Treatment
$9.0
$1.7
$9.5
$3.9
$2.1
The Drug Policy Landscape in the United States 11
arrests in 2010 were for possession of marijuana. Low-level marijuana possession arrests result in few sentences of incarceration (Sevigny and Caulkins, 2004; ONDCP, 2009), though some arrestees do spend time in local jails before trial (Reuter et al., 2001). Most individuals behind bars for drugs were involved in distributing drugs, and the Sentencing Project (2012) estimates that the total number of persons incarcerated for drug offenses increased from approximately 40,000 in 1980 to more than 500,000 in 2010 (Figure 2.6).
While this increase and the absolute numbers are striking, the massive racial and ethnic disparities in the incarceration rates merit special attention. There were 64 white sentenced prisoners under state jurisdiction for a drug offense for every 100,000 whites aged 18–59 in 2009; the comparable rates for Hispanics and blacks were 150 and 523 per 100,000. 5 These disparities are not unique to the state sentencing. For example, the lengthy fight to reduce the disparity in quantities for powder cocaine versus crack cocaine that trigger federal mandatory minimum prison sentences only reduced the difference from 100 to 1 to 18 to 1. Still, this was seen as important for helping to reduce some of the racial disparity since blacks are much more likely than whites and Hispanics to be charged with selling crack cocaine as opposed to powder cocaine (Mauer, 2011).
Interdiction
Interdiction refers to efforts to seize drugs, couriers, or vessels between source countries and the United States, including just as they enter the country. Accounting for expenditures on inter- diction is complicated, since many interdiction assets serve multiple functions, not just drug
5 Guerino et al. (2011, Appendix Table 16B) reports the number of sentenced prisoners under state jurisdiction for a drug offense on December 31, 2009, by race and ethnicity. The figures for non-Hispanic whites, Hispanics, and non-Hispanic blacks were 73,900, 41,400, and 122,600, respectively. Corresponding figures from U.S. Census Bureau (2010) for the number of individuals in these groups aged 18–59 in 2009 were 114,727,000, 27,634,000, and 23,429,000. This last figure
Figure 2.6
Number of People in Prisons and Jails for Drug Offenses, 1980 and 2010
SOURCE: The Sentencing Project, 2012. Used with permission.
RAND OP393-2.6
250,000 200,000
19,000
4,700
97,500
17,200
167,000 242,200
