The Failure of Prohibition as a Drug Control Strategy: The Case of AIDS

Introduction

This is a conference on medicine and public health - not morality. But with more then 12,000,000 people already infected with HIV, and perhaps a million more being newly infected each year, the public health imperative assumes a moral significance of its own. While we await a cure or vaccine for AIDS, it is critical that we do all in our power to prevent its spread. This goal must be held up against other moral goals, such as the notion that people shouldn't use drugs.

There is no question that the global spread of AIDS is powerfully affected by the use of addictive drugs. But, unlike my colleague from Stockholm, I will argue that the policy of drug prohibition worsens the problem and that changes in this policy, toward a harm reduction approach, could both reduce the risk of AIDS and lead to a lower rate of addiction worldwide.

There are three components to my argument:

1. the central role of illicit drug use in the AIDS epidemic
2. the impact of drug policy on the prevalence and public health risks of drug use
3. the negative effect of prohibition on the development of new approaches to addiction based on harm reduction

Drug Use and AIDS

Illicit drug use and addiction are now the single most dynamic feature of the global AIDS epidemic, capable of igniting explosive regional spread of HIV infection. In the Bronx, where I have worked in public health and addiction treatment for nearly thirty years, we can see a striking example of this process.

The rapidity of the onset of HIV is, in this instance, fueled by the general neglect and poverty of the area when AIDS first struck, in the late 1970s. As of 1995, we have reported over 12,000 cases in a borough of 1.2 million. Other cities in the U.S. (e.g. Miami) and Europe (e.g. Edinburgh) have experienced similar outbreaks associated with IV drug use. In Southeast Asia, which once thought itself immune to AIDS, over 1 million new HIV infections have occurred in the past decade. There is strong evidence that the spread of IV drug use and prostitution were the engines driving this development. In Thailand between 1985-1995, over 60% of drug injectors were infected.

The long history of opiate addiction in that region of the world tells us that both cultural and commercial factors play a powerful role; the opium wars of the 19th century were as much about colonial economic advantage, as they were about human appetites or addiction. While millions were habitual users of opium well into the 20th century, early attempts to outlaw opium smoking were clearly associated with a shift towards heroin use and injecting.

Prohibition appears to accelerate the rapid expansion of international drug markets by creating a vast and profitable criminal economy. Since 1980, despite increased interdiction, worldwide heroin and cocaine production have tripled, with comparable increases in the prevalence of injection drug use and addiction. AIDS in the World estimates that there are now 3.4-5.5 million injecting drug users in 120 countries.

This dramatic expansion of drug markets occurred despite prohibition and threatens AIDS epidemics in many new areas - most recently the countries of the former Soviet Union. In combination with desperate economic conditions and widespread social instability, this lucrative trade in illicit drugs proves irresistible. As region after region develops illicit drug markets, the risk of HIV epidemics grows.

Drug Policy and Health Risk

Whereas my first argument relates to the fact that prohibition has failed to limit the prevalence of illicit drug use, the second component of my case is that prohibition policies adversely affect patterns of drug use in ways that increase individual and public health risk. By criminalizing addiction, prohibition makes drug use more dangerous - promoting more potent drugs and more risky forms of use. And, by stigmatizing and marginalizing the drug user, prohibition acts as a barrier to services - isolating him from education, prevention, and drug treatment.

The necessarily clandestine life of the criminal addict also fosters several specific patterns of behavior known to increase HIV transmission, most important among these the sharing of injection equipment and increased prostitution to get money for drugs. These phenomena had always been recognized as part of the culture of illicit drug use, but AIDS changed their significance.

Shared needles are a major vector of HIV transmission. But prosecution for possession of needles under drug paraphernalia laws, a cornerstone of drug enforcement, decreases their supply - in the U.S. there are 300,000 drug paraphernalia arrests/year.

Further, the failure to regulate and provide public health services for sex work is the norm - and the harsher enforcement, the more drug involvement and marginalization of prostitutes. In the U.S. war on drugs there has been a 400% increase in incarceration rates for women in the last 15 years - 90% of this related to drug use and prostitution.

Drug Policy and Addiction Treatment

Another important way in which drug prohibition and the criminalization of addiction has made drug use more dangerous; is its chilling effect on research into the development of more effective drug treatment approaches - especially if these are not consistent with strict abstinence models, e.g. substitution treatment using narcotic drugs.

The British medical profession's dedication to a humane substitution approach was first articulated in the influential Rolleston report of 1926, which re-affirmed the central role of medical management of incurable addiction. By providing substitute drugs which dealt with craving and withdrawal, (rather than insisting on abstinence) medicalization moved the opiate dependent individual from the streets to the care of a doctor.

But, in the U.S., the medical profession bridled at this approach - in part because it was held responsible for creating so much dependency and addiction in the late 19th and early 20th century through the over use of narcotic treatments, tonics, and other widely prescribed preparations. American medicine, still a weak profession then, did not oppose the moral crusade that arose to ban alcohol and, incidentally, the use of substitution drugs in treatment.

The model for today's global prohibition of drugs is this U.S. prohibition of alcohol (1920-1934), which made it illegal to obtain any form of alcohol for personal use. This set the stage for the establishment of a criminal culture which corrupted police and local governments and undermined respect for law. After 14 years, prohibition was an obvious failure. Even mothers organized opposition to it. But the moral entrepreneurs, who had produced this monster child, were implacable in their devotion to it:

Prohibition is an awful flop.
We like it.
It can't stop what it's meant to stop.
We like it.
It's left a trail of graft and slime,
It's filled our land with vice and crime,
It don't prohibit worth a dime,
Nevertheless, we're for it.

Overlooked in the glitter of the jazz-age, one of the tragic consequences of the prohibition mentality was that American medicine largely absented itself from serious engagement in the search for effective treatments for narcotic addiction. For over 40 years, our profession collaborated with increasingly harsh and cruel "treatment" enterprises - often involving forced abstinence in prison settings - something that is still widespread. It was not until the 1960s, with the pioneering work of Drs. Marie Nyswander and Vincent Dole on methadone, that American medicine re-entered the field.

Methadone is a long acting opiate well suited to oral administration and effective in the elimination of narcotic craving - the driving force behind heroin addiction. Between 1960 and 1975, the U.S. adopted methadone treatment on a massive scale - establishing treatment for over 100,000 patients in long-term maintenance, and many more in gradual detoxification using methadone.

But, by the 1980s, the maintenance approach, which did not seek total abstinence for those addicted to opiates (but did produce a 95% reduction in the use of heroin), ran afoul of the "war on drugs." "Like giving alcohol to alcoholics" some doctors said in their antagonism to substitute therapies and their profound ignorance of the underlying physiological realities of addiction.

Perhaps it is important to remind ourselves at this time that addiction is not a moral problem - but a disorder rooted in the characteristics of neurotransmission and brain physiology. As Alan Leshner, Director of the U.S. National Institute on Drug Abuse, recently said: "While using drugs is a choice, addiction is not." And though drugs have been with us for millennia, never before in history has our scientific understanding of addiction been so complete.

We have now identified the specific neurotransmitters, major receptor types and sites, exact localities in the brain, and the linkage of these to all the important phenomenon of drug action and addiction. We now know that the brain produces endogenous substances closely linked to the metabolic end products of addictive drugs (e.g. opiates, cocaine, cannabis, alcohol). And that the common neuro physiological locus of tolerance, withdrawal, and craving for all addictive drugs implicates the serotonin/dopamine pathways of the mid-brain - a crucial nexus for emotional and repetitive behaviors - strongly linked to the subtle nuances of personality, affect, and to compulsive behavior. The development of new pharmaco-therapies for depression (such as Prozac) are based on this research.

Still, the moral approach to addiction perseveres - blind to these biological realities, denying effective medical treatment to the vast majority of drug dependent individuals, and consigning the addict to an endless quest for the chemicals he needs to restore his neurophysiological equilibrium. All the while insisting that he undergo moral rehabilitation in their place.

The impact of this prejudice against the therapeutic use of narcotics can be seen in other areas of medicine, e.g. on analgesia (under-medicating for pain) and in palliative care of the terminally ill. But its source is generally not traced back to our policy of prohibition and the effect that it has on physicians willingness and training to use these drugs to treat drug dependency - as can be seen in the case of Mexico, where the USDEA has actively blocked that country's physicians' access to morphine.

So, although there is overwhelming and abundant evidence of its efficacy and safety, methadone is still denied to most opiate addicts in the world. And, although there is clear evidence that methadone reduces AIDS risk, of the 2,000,000 opiate addicts in the U.S. and Europe, fewer than 15% have access to methadone.

It took over 20 years after the British experience for the Swiss to begin their landmark program of injectable heroin maintenance for longer term addicts who had previously failed in treatment with methadone. Today over 900 patients visit twenty-four clinic sites throughout Switzerland, up to five times a day. The preliminary evaluation by Dr. Ambrose Uchtenhagen of the Swiss Federal Health Ministry (with over 1000 person years of data) indicates over 80% one year retention in treatment, sharp reductions in arrests and criminal activity, greater involvement with non- drug using family and friends - and all this while injecting a median of 135mg of pharmaceutical heroin each day.

In Germany, until very recently, doctors were barred by law from using methadone in addiction treatment - so they developed a system of maintenance using oral codeine syrup. Today over 35,000 German addicts are now in this treatment with positive results. But this approach, based in general medicine is under attack and may be curtailed. Drs. Elias and Ullmer and their colleagues in general medicine have organized to oppose these restrictions, but face a powerful and hostile psychiatric profession that insists addiction is primarily psychopathology.

In Belgium, as of 1992 (the 10th year of the AIDS epidemic in Europe), there were only a few hundred patients in methadone treatment (and this largely because of Dr. Peter Piots' early advocacy on behalf of AIDS prevention and care). But, the general physicians union in Belgium, successfully mounted a legal challenge to restraints on the use of methadone. Dr. Marc Reisinger of Bruxelles reports that today there are 6500 in methadone treatment and a growing network of local practitioners involved in addiction treatment.

Likewise in France, which had only 50 patients in methadone treatment as late as 1993, the medical human rights community led by Medicins du Monde and Mutualitie Francais - a powerful and progressive social and health insurance organization, fought successfully to expand the methadone program. Today, there are more than 3000 patients in care. Harm reduction thinking also led Australia to increase the availability of methadone treatment tenfold - largely through general practice.

These developments have pushed the boundaries of medical practice and addiction treatment forward in a score of countries - demonstrating significant therapeutic advantages for many patients and decisive reductions in the spread of HIV/AIDS. But no thanks to prohibition policies, which have fought them and still fight them at every turn.

Thus, in addition to increasing the prevalence of addictive drug use by expanding global markets and relentlessly driving the drug user to the most dangerous forms of use at the margins of society, drug prohibition policies have inhibited the development and utilization of alternative drug treatment strategies, which are not premised on abstinence but do reduce the spread of AIDS.

Harm Reduction: A New Aproach

Harm reduction approaches are based on the basic public health principals of reducing population morbidity and mortality and have proven effective in stopping the spread of AIDS in several nations (Great Britain, Australia, Nepal) and slowing it in others (Thailand and parts of the U.S.).

The harm reduction approach resonates clearly with steps taken to deal with other drugs - especially alcohol. In countries that tolerate and regulate alcohol use (rather than prohibiting it) harm reduction strategies now include standard unit labeling, low alcohol beverages, designated driver programs, and coordinated national media campaigns, backed up by road testing for blood alcohol level with strict enforcement. Harm reduction has demonstrated its effectiveness in Australia, which developed a National Drug Strategy for all drugs (licit and illicit) and was receptive early to harm reduction programs, lowering alcohol-related auto fatalities by 40-50% within a few years.

In the area of injecting drug use linked to AIDS prevention, needle and syringe exchange programs are one of the hallmarks of harm reduction innovation. Australia's timely initiation of needle exchange and its rapid tenfold expansion of methadone treatment (largely through the private sector) has kept the HIV rate among its addicts <2% since 1988. Dr. Alex Wodak estimates that over 2,000 lives have been saved among a population of 50,000 injectors. A similar success rate for this preventive approach in the U.S. (with 1 million injectors) and for Europe (with 800,000) would have yielded tens of thousands of preventable HIV infections in the past decade. <p />But, as with their resistance to drug substitution therapies, the U.S. Federal health authorities have been unyielding in their opposition to needle exchanges programs (NEP). They have, by law, banned the use of Federal funds for NEPS (banning even research about NEPs until 1991). And, succumbing to the demagogic American politicization of addiction, its causes, and possible cures, Federal public health officials have cravenly tolerated the status quo, at a cost of thousands of preventable HIV infections.

Despite scores of studies demonstrating needle exchanges safety and efficacy, and despite the clear and repeated recommendation of two National AIDS Commissions, The National Academy of Science's Institute of Medicine, and leading U.S. government experts calling for an end to the ban on needle exchange funding, U.S. Federal health authorities still refuse to acknowledge harm reduction programs because (they say) "they give the wrong message." What message do public officials imagine they are sending when California Governor, Pete Wilson, declares "is it worth reducing the risk of infection of intravenous drug users at the potentially far greater cost of undermining all our other preventive drug efforts?", or when New Jersey Governor Christine Todd Whitman (a figure of national political prominence) even rejects the possibility of a pro- needle exchange recommendation of her own State AIDS Advisory Board - saying that even though "there are scientific reasons to develop needle exchange (to prevent AIDS), that I do not view the matter solely in terms of science."

But, those of us in medicine and public health must view needle exchange in terms of science, for these are the only criteria and the only terms on which we have any legitimacy and rightful authority. If we fail to assert that responsibility to public health, we are no better than the derelict doctor who neglects or mistreats his or her individual patient. My colleague, Dr. Peter Lurie of the University of California, San Francisco and I, will present a paper at this conference estimating the toll of the U.S. decision to restrict NEPs - a landmark failure of public health in our nation. And all driven by the politics of prohibition.

In the case of my own country the stakes are very high - our large population, its diversity and the uneven burden of HIV/AIDS faithfully reiterates all of our social, economic, and political problems. How could it be otherwise? As we withdraw support of social programs and create a lethal ecology of poverty, deterioration, and despair from which people seek escape in mind- numbing drugs, it appears to be worsening.

And, instead of working for social improvement and preventing drug abuse by building housing and schools, we are building prisons. Over 3.5 million Americans are in the control of the criminal justice system - 1.4 million behind bars. The rate of incarceration in the U.S. is now the highest in the world - 500/100,000 and most of this is associated with the prosecution of drug users. Over 35% of all Black young men are now in the control of this system, which some have called the "incarceration state."

Conclusion

Enforcing drug prohibition by criminalizing the addict inevitably means an assault on basic human rights and individual dignity. In systematic violation of the UN Declaration on Human Rights, national programs of massive prosecution and incarceration of addicts destabilize those communities most vulnerable to drugs and do damage to many social and civic institutions vital to order and public health.

In public health we seek pragmatic solutions which produce demonstrable and reproducible gains - measured in reduced rates of morbidity and mortality: The only measures we can accept as professionals dedicated to saving lives and reducing suffering due to disease. While there are certainly moral and ethical dilemmas associated with the use of drugs, these pale by comparison to the moral significance of the social conditions of poverty and despair - which are the major determinants of destructive drug use. Regardless of our moral or political beliefs, when we don the authority and prestige of medicine and science, we assume a responsibility to scrupulously adhere to the truth about the health consequences of our policies. Our response to addiction based on prohibition, is a clear and present public health danger - a failed policy that must change.