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Assessing American Drug Policies

The two keynote speakers provided information, data, and perspectives about the role of race in the criminal justice system to serve as background for the rest of the workshop. They were tasked with helping participants better understand how drug policy and laws affect people and communities of color. Following the keynote addresses, a panel discussion for speakers and workshop attendees was held.

A FRAMEWORK FOR THINKING ABOUT SUBSTANCE USE AND DRUG CONTROL POLICY

Peter Reuter, an economist by training, presented a framework for thinking about drug problems and drug policies. He explained that in the United States, “We tend to talk about the ‘drug problem.’ In contrast, in Europe, they use the phrase ‘drugs problems.’” It is important, Reuter emphasized, to use the plural, particularly because among substance users there is a lot of substitution among the drugs used and because it is not a single problem. There are several different components to the problem of drugs. This has implications for different classes of interventions and indicates that there is no single policy intervention that will work against all drugs and all related problems. However, many of these interventions are effective for some components.

Reuter noted, “We are in a time of particular foment with respect to drug policy.” One aspect is the legalization of cannabis across the United States. Although cannabis itself is only a small part of the public health

problems resulting from drug use nationwide, the prevalence of frequent cannabis use is a moderately important public health issue.

He further stated that the prescription opioid problem has worsened an already existing problem with illegal opioids, and the problem of fentanyl (to be discussed later in this chapter) is making it even worse. At the same time, attitudes towards the use of criminal sanctions for selling and using drugs are changing. Reuter said this presents an opportunity to reform drug control policies, at least at the state level. And after 30 years of relying on a harsh approach to drug control, support has shifted to reducing the role of incarceration in drug control.

Components of Drug Use Problems and Policies

Reuter explained that there are four components of the drug problem in the United States, and each component has a specific policy to match (Figure 2-1). The first component described by Reuter is the initiation of drug use (typically cannabis) by young adults. These youth are more likely to drop out of school and less likely to participate in positive social networks than they would be if they did not use drugs. Although he did

not agree with the premise that cannabis is a gateway drug for the use of other substances, he did note that cannabis use among the young can be a gateway to other kinds of problems. In terms of policy, prevention programs are designed to reduce initiation by youth.

Second, there is a set of problems that are the result of drug use and drug dependence. Morbidity and mortality rates for users of cocaine, methamphetamines, and heroin are high when compared to nonusers. Part of the reason for the high mortality rates is that users inject drugs of unknown purity. Needle sharing offers other risks. Additionally, Reuter said, the continued use of these drugs over time exacerbates their criminal behaviors. Although he noted that in many cases, there was evidence of criminal activity prior to frequent drug use, there is “abundant research that shows that continued use over time exacerbates their criminality.” Policy efforts use treatment programs in an attempt to reduce abuse and dependence among drug users.

The third component is the markets for buying illicit drugs. Large illegal earnings are a particular problem in inner cities, he said, and particularly for communities of color in inner cities. Additionally, the markets for the distribution of illegal drugs are associated with a great deal of violence. Enforcement of drug control policies and laws is directly driven by the market for illicit drugs. The policy goal is to reduce the volume of drugs sold.

Fourth, Reuter noted that there are problems linked to the small number of source countries involved in the production and export of illegal drugs, such as Colombia and Mexico. Illicit drug use has clearly affected the development of both countries, he said. An additional complication is that the U.S. drug problem affects foreign relations with exporting countries. Policies to address source country control are largely aimed at reducing the production of illegal drugs and focus on eradication or alternative development.

Paradoxes

Reuter pointed out two paradoxes in drug control policies. First, he said that treatment success may have a positive effect on initiation. For example, crack cocaine had a very short epidemic period. Problems associated with crack use showed up early among crack cocaine users. However, the negative effects of using powder cocaine were much slower to become manifest, and this led to being less of a deterrent for powder cocaine users.

Many scholars have noted the racial bias in how cocaine versus crack is treated in the criminal justice system, said Reuter. Although the consumption of cocaine is different from crack (snorting or injecting versus

smoking), the two drugs are virtually chemically identical. According to the Drug Policy Alliance (2018):

However, there is a large sentencing disparity for cocaine versus crack. Initially, this disparity meant that the punishment for crack possession or sales was far greater than for possession or sales of cocaine. This law was changed in 2010, which helped close but did not eliminate the sentencing disparity, he said.

The second paradox described by Reuter is that the interdiction of drugs (seizing drugs and drug couriers as they cross into the United States) exacerbates the problem for the exporting country. So, for example, if cocaine is seized at the border on its way from Colombia, it worsens the problem in Colombia because it increases export demand. The desired effect is that seizing drugs makes it more expensive to obtain them, drug prices rise, and consumption in the U.S. declines. The second effect is that more cocaine, for example, has to be sent from Colombia to ensure that 1 kilogram arrives in the United States. However, this latter effect is larger than the first effect, meaning that the effects on the exporting country are stronger than for increased drug prices in the United States.

The Problem of Fentanyl

Reuter’s final comments focused on illicitly manufactured fentanyl, a synthetic opioid. Fentanyl emerged in 2014; although it existed before that, it was not a substantial contributor to overdose numbers. Fentanyl previously was used in surgical procedures. Reuter noted that fentanyl is estimated to be 50 times as powerful as heroin. It is also far less expensive than heroin. Fentanyl is now displacing heroin in some markets east of the Mississippi River, and west of the Mississippi it has entered stimulant markets as well. This shows up most notably in fatal overdose rates. The prevalence of opioid use has probably risen, but only fatal overdoses involving heroin have risen substantially, largely because they involve fentanyl. Increases in overdose deaths are often attributable to the use of other drugs, including fentanyl and other synthetic opioids.

For a drug user, fentanyl is extremely difficult to titrate. It only takes a couple of milligrams, which is difficult to measure, said Reuter. This is likely what causes the overdose deaths; it is, simply, the unfortunate result of mistakes in the titration of the dose.

Fentanyl is mingled in the cocaine supply. He said that seizures of fentanyl from Mexico have primarily been in the form of counterfeit prescription opioids. Fentanyl, then, is appearing in different parts of the drug distribution system.

Reuter used Estonia as an example of a place where fentanyl has taken over the opioid market and heroin has been effectively driven out. Estonia, with a population of 1.3 million, has had a drug market dominated by fentanyl since 2005. The country has a very high overdose rate compared to the rest of Europe.

British Columbia, Canada, is the other jurisdiction most affected by fentanyl. Reuter noted that there is at least one 2016 study showing that fentanyl is close to driving heroin out of the opioids market. The study, in its analysis of heroin samples, found that 90 percent contained fentanyl (Vancouver Coastal Health, 2016).

Reuter explained that fentanyl has many benefits for sellers in the illegal opioids market. It is substantially less expensive, and it is more easily concealed, and thus is much more attractive to traffickers and dealers. China is thought to have been the primary source of fentanyl entering the United States (BBC News, 2018). Following legal changes in China, there has been a change in trade. Now, most fentanyl entering this country comes through Mexico, where drug trafficking organizations use precursors from China to produce the drug.

In his closing remarks, Reuter said that this country has seen a “relentless 8 percent annual increase” over the past 40-year period in overdose deaths from illegal drugs. Yet, he added, “We have no sense of the fundamental law that is driving this. It seems that for now, fentanyl will be driving the increase for the next few years.”

THE ROLE OF RACE AND ETHNICITY IN THE WAR ON DRUGS

The second keynote speaker, Kassandra Frederique, is the New York State director at the Drug Policy Alliance, a national organization that works to reduce the criminalization of drug use and drug sales. She made her perspective explicit from the beginning of her talk: “There are so many people who choose to use drugs, and criminalizing the use and sales of drugs doesn’t actually help.”

She went on to note that even though the war on drugs has existed for decades, somehow there is still a disproportionate effect of policies arising from the war on drugs on people of color. Frederique acknowledged that there are other factors, including socioeconomic status and gender, but race still has a disproportionate effect. From a historical perspective, said Frederique, drug laws have always targeted people of color. For example, she said, marijuana was made illegal because it was used by Latinos in the

Southwest, and heroin was used by African American jazz musicians. She shared a headline from the New York Times (Huntington Williams, 1914):

Similarly, sociologist Troy Duster published research indicating that drug laws are created and enforced not because of the pharmacology of the drug; they are created in direct response to the dominant users (Duster, 1971). In short, Frederique said, there is “a systematic infrastructure to criminalize people based on substances.”

She said that the war on drugs and the focus on people of color have led to skyrocketing incarceration rates. Today, people of color are still being incarcerated at numbers far greater than White people for marijuana possession, crack cocaine, heroin, and opiates. She also noted that there is still a strong belief in the model of the “accidental addict,” the White individual who “made one mistake.”

Social class is also at play here, Frederique continued. She shared a quote from the former governor of Maine, Paul LePage, who said that drug traffickers have names like “D-Money, Smoothie, Shifty” and that “half the time, they impregnate a young White girl before they leave” (NBC News, 2016). Given that the population of Maine is overwhelmingly made up of White people, it seems clear that race and social class influenced the governor’s comments, she said.

Like Reuter, Frederique concluded her comments with a discussion of fentanyl. She noted that the increase in deaths attributable to fentanyl among White people has opened an opportunity to discuss the war on drugs, commenting that once an issue becomes a problem for the White community, there is more attention paid to that issue.

DISCUSSION

The first question, posed by Octavio Martinez of the Hogg Foundation for Mental Health, asked about the potential solution of legalizing drugs. Reuter made three points in response. First, there are no data whatsoever on how legalization would potentially affect drug use and drug addiction. Second, it is not clear how legalization would affect crime and health outcomes. And third, the costs and benefits of legalization would be distributed unevenly across populations. Reuter said, “There’s no question but that the burden of the current policies is borne disproportionately by populations of color.”

Frederique added, “We cannot have a comprehensive drug regulation conversation without having a comprehensive conversation about

the social determinants of health.” In any discussion of legalization, the conversations about economic participation and race must be included.

Another participant, Eve Higginbotham of the University of Pennsylvania, asked about the role of military health in the history of the war on drugs, noting that many men of color were drafted during the Vietnam War. Mental illness must also be included. How can the U.S. Department of Defense play a role here? Frederique responded that the Department of Defense could experiment with social policies because it has the resources to do so.

Higginbotham also asked about the role of the judicial system, saying, “We have a very conservative court system.” Frederique responded that efforts should be made to target the lower courts; the focus of strategies should be hyperlocal.

Francisco Garcia of the Pima County Health Department in Arizona commented that in his home county most drug use is polysubstance. In response, Reuter explained that this indicates the limits of relying on supply-side approaches; drug suppliers primarily specialize in selling one drug while users simply switch from one drug to another drug. Those users who die are primarily accidental deaths, and about half are methamphetamine connected (the other half are opioid related). Garcia said that the drug policy tools that are being created today focus on opioids. Frederique added that public health interventions such as safe injection sites tend to focus on IV drug users rather than those who use stimulants.

Eric Sterling of the Criminal Justice Policy Foundation asked about the challenges of dealing with the stigma around drug use and the place of the recovery movement in changing public policies. Frederique noted that with the recovery movement’s focus on anonymity, it is a positive thing to move away from anonymity. It is a big tent, she said, and success will not look the same for everyone. What is needed, then, is a myriad of opportunities to address drug use.

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