Informing America's Policy on Illegal Drugs What We Don't Know Keeps Hurting Us (2001) / Chapter Skim
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2 Determinants and Consequences of Drug Use
2 Determinants and Consequences of Drug Use
Pages 37-74
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DETERMINANTS OF DRUG USE A basic understanding of the determinants of drug use, especially of abuse and addiction, is a prerequisite to serious discussion of drug control policy. Different research disciplines, from neuroscience to economics to social psychology, offer distinct perspectives.
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Moreover, economists have generally not considered environmental, family, or peer influence on drug use. Conversely, social psychologists have studied individual, family, peer, neighborhood, and social risk factors for drug use but have generally neglected the economic costs of using drugs.
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Advances in the neuroscience of addiction are beginning to provide a strong scientific basis for drug abuse treatment and prevention programs as well as other drug control policies (Institute of Medicine, 1996~. Neuroscientists have long linked drug addiction with some disruption of the brain reward system (Olds and Milner, 1954; Wise, 1978; Cooper et al., 1996~.
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This cocaine-modulation of gene expression is linked to development of sensitivity to the drugs, possibly contributing to the drug dependence process (e.g., Kelz et al., 1999~. 3It would be unethical to expose cocaine-nave human subjects to crack cocaine and to powder cocaine in order to determine which form of cocaine is more "addictive," but the presently available evidence suggests most rapid and pronounced development of cocaine dependence symptoms when crack cocaine is smoked or when powder cocaine HC1 is injected intravenously (e.g., see Gossop et al., 1994; Hastukami and Fischman, 1996~.
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Produces dose-dependent relaxation, disinhibition, mild euphoria, inebriation, intoxication, CNS depression, liver damage. Significant tolerance and dependencewithdrawal following chronic use; intense craving, alcoholism.
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Demand functions and price elasticities must be understood to formulate effective drug policies. In particular, many antidrug policies are aimed at increasing the price that consumers must pay for a drug.
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. Why Estimating Demand Functions and Price Elasticities Is Difficult In the committee's judgment, the severe, unsolved conceptual and data-related problems involved in the estimation of demand functions for illegal drugs mean that no persuasive demand function for cocaine or other illegal drugs has yet been estimated.
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, the costs associated with any legal penalty that may be incurred if the consumer is arrested, and, possibly, psychological costs associated with committing an illegal act. The committee found no source of data on search costs and no demand model that attempts to incorporate these costs.5 Data are available on legal penalties for possessing illegal drugs (see Chapter 6 for further discussion of this issue)
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as a whole has been estimated by combining estimates of numbers of consumers, expenditure estimates obtained from arrested consumers interviewed by DUF (the predecessor of ADAM) , and price estimates obtained from STRIDE (Office of National Drug Control Policy, 1997~.
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It is therefore likely that different forms of cocaine have different demand functions and price elasticities. The committee is aware of no study that has estimated separate demand functions or price elasticities for different forms of cocaine.
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These and other risk factors are sometimes taken to be "candidate causes" of drug use suspected causal influences for which there may not be enough evidence to make a firm claim of causation. Other risk factors, in contrast, signal a reduced likelihood of a behavior or condition, such as drug use or drug dependence.
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From page 48... ...
Certain individuals may also be at higher risk of becoming drug users due to inherited traits. While not definitive, a mounting body of evidence suggests that the genetic pathways are related to the adverse conse9These characteristics, conditions, and processes are reviewed in detail elsewhere (Anthony and Helzer, 1995; Gottfredson, 2000; Gottfredson, et al., 1996; Hansen and O'Malley, 1996; Hawkins et al., 1992; 1995; Institute of Medicine, 1994, 1996, 1997)
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In addition to individual risk factors, social factors may also play an important role. Sociologists and social psychologists have long sought to determine how social interactions and environment more generally may affect drug use.
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Regarded as individual-level characteristics, these facets of temperament and personality help to determine an individual's repertoire of behavior, including social activities with peers and illegal drug use (e.g., see Kosten et al., 1994; True et al,. 1999; Kendler and Prescott, 1998a, 1998b)
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Once cocaine use begins, the cocaine-associated reinforcement may help draw the individual back to these environments, and the environmental circumstances again shape the probability and frequency of future return. A more recent line of evidence from the neuroscience research on postsynaptic signaling mechanisms provides an additional example of the transactions between nature and nurture.
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Without longitudinal data, the problem of causal interpretation of risk factors is likely to remain unresolved. CONSEQUENCES OF DRUG USE Concerns about the consequences of drug use for users and nonusers are central to U.S.
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reports published by the White House over the past decade, which provide an annual list of specific national goals for drug policy. For many years, the list consisted entirely or almost exclusively of goals pertaining to reductions in the prevalence of drug use.
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Some of these measures are problematic because they require respondents to draw potentially invalid causal attributions about the link between their drug use and various conditions e.g., attributing certain health states to drug use as opposed to a co-occurring illness, or attributing antisocial behaviors to drug use when they might have occurred in its absence. Even when the items don't require such inferences, their placement in the 10Other federally funded sources not listed in the table provide additional data the emergency department and medical examiner data of the Drug Abuse Warning Network (DAWN)
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They may facilitate budgetary planning and serve a rhetorical role in mobilizing public support for drug policy, but they provide little insight into the dynamics of the drug problem or its responsiveness to alternative strategies and tactics of policy intervention. Dose-Response Relationships Some alternate methodologies for improving understanding of drug use consequences are available.
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. Cumulative risks are often difficult for casual users to observe; by definition, such evidence takes longer to accumulate, and heavy users are often socially isolated from casual users.
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For example, to the extent that morbidity and mortality are sometimes lagged consequences of drug use or consequences of cumulative rather than incidental use, data on emergency room visits and drug-related deaths are potentially misleading as proxies for otherwise underestimated hard drug prevalence. Fourth, a better understanding of dose-response relationships might support more effective decision making about the allocation and targeting of drug policy instruments and resources (e.g., arrests, prison space, treatment slots, prevention efforts)
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Using a variety of indirect sources of evidence since direct data was not available and a simple epidemiological model of the flow of individuals between nonuse, casual use, and heavy use, Everingham and Rydell estimated that while cocaine prevalence declined between 1983 and 1990, the total quantity of cocaine consumption remained fairly stable. According to their estimates, 22 percent of the current users of cocaine accounted for 70 percent of the total cocaine consumed in 1990.
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Others argue that there may be greater aggregate benefit from reducing consumption among casual users; they pose fewer risks individually, but they typically outnumber heavy users by a wide margin.l2 12In the public health literature, this latter notion is referred to as the "prevention paradox"; see Rose (1992~. A strong version was proposed by Ledermann (1956)
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It will be more effective to target heavy users when the dose-response curve rises slowly at low doses and when the statistical distribution of consumption is heavily skewed. Thus the ability to create accurate dose-response curves promises benefits for reduced consumption of illegal drugs.
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. Thus, if reductions in average harm bring about increases in total use, there is no guarantee that a drop in average harm will produce a decline in total harm.
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It is likely that many of the harmful consequences of drug use would be significantly reduced under a regulated policy of legal access to drugs but not all harms. And even if average harm declined overall, there is no guarantee that net or total harm would decline as a result.
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1997 Setting goals for drug policy: Harm reduction or use reduction? Addiction 92:11431150.
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1999 Toward the Development of a Typology of Illegal Drug Markets. Unpublished paper prepared for Committee on Data and Research for Policy on Illegal Drugs.
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Prepared for the Office of National Drug Control Policy and the U.S.
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Livermore 1998 The Economic Costs of Alcohol and Drug Abuse in the United States, 1992. Rockville, MD: National Institute on Drug Abuse.
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1999 "Economic cost" measurements, damage minimization and drug abuse control policy. Addiction 94:638-641.
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Schelling 1996 Assessing alternative drug control regimes. Journal of Policy Analysis and Management 15:1-23.
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Office of National Drug Control Policy 1999 The Price of Illicit Drugs: 1981 through the Second Quarter of 1998. Washington, DC: Abt Associates.
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Everingham 1994 Controlling Cocaine. Report prepared for the Office of National Drug Control Policy and the U.S.
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Kupfer, eds. 1995 Genetic influences in drug abuse.
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