Is drug abuse a legal or public health issue?

Overview Prevalence of drug abuse Office of National Drug Control Policy (2004). The Economic Costs of Drug Abuse in the United States, 1992-2002. Washington, DC: Executive Office of the President (Publication No. 207303). Available at www.ncjrs.gov/ondcppubs/publications/pdf/economic_costs.pdf Estimates of the total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually. This includes approximately $181 billion for illicit drugs,1 $193 billion for tobacco,2 and $235 billion for alcohol.3 As staggering as these numbers are, they do not fully describe the breadth of destructive public health and safety implications of drug abuse and addiction, such as family disintegration, loss of employment, failure in school, domestic violence, and child abuse.

Criminal Justice populations - more than 25% of the estimated 1.5 million adults 18 or older on parole were current illicit drug users - Compared to those not on parole (8.7% illicit drug users) - Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011 NIDA analysis of treating criminal offenders - (my words) o Drug addiction is a disease o Recovery requires treatment and stability over time o Individually tailored treatment o Target factors at criminal behavior o Health of drug users as well as the community they are reintroduced into - (statistics) - A 2002 survey of jails found that 52 percent of incarcerated women and 44 percent of men met the criteria for alcohol or drug dependence (Karberg & James, 2005, www.ojp.gov/bjs/pub/pdf/sdatji02.pdf). Juvenile justice systems also report high levels of drug abuse. A survey of juvenile detainees in 2000 found that about 56 percent of the boys and 40 percent of the girls tested positive for drug use at the time of their arrest (National Institute of Justice, 2003, www.ojp.usdoj.gov/nij/). - The substance abusing offender may be encouraged or legally pressured to participate in drug abuse treatment. Even so, few drug abusing offenders actually receive treatment. The 1997 BJS survey showed that fewer than one-fifth of incarcerated offenders with drug problems had received treatment in prison (not including participation in self-help or drug education). - Untreated substance abusing offenders are more likely to relapse to drug abuse and return to criminal behavior. This can bring about re-arrest and reincarceration,

jeopardizing public health and public safety and taxing criminal justice system resources. Treatment offers the best alternative for interrupting the drug abuse/criminal justice cycle for offenders with drug abuse problems. Addiction http://www.drugabuse.gov/Infofacts/understand.html [ revised May 2011] - chronic, often relapsing brain disease that causes compulsive drug seeking and use.. - Drug addiction is a preventable disease. Results from NIDA-funded research have shown that
prevention programs involving families, schools, communities, and the media are effective in reducing drug abuse. Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. Thus, education and outreach are key in helping youth and the general public understand the risks of drug abuse. Teachers, parents, medical and public health professionals must keep sending the message that drug addiction can be prevented if one never abuses drugs.

Why? o Genetics Gender, ethnicity and presence of other mental disorders along with genes genes that people are born with in combination with environmental influences account for about half of their addiction vulneralabilty o Socioeconomic environment Peer pressure Stress Quality of parenting o Development (combination of environment and genetics) Starting early can progress to more serious abuse, and adolescents are larger risk takers in general

Why legal? Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011 - Risk to self/others o Driving 2010 10.6 million (4.2% of population aged 12 or older) reported driving under the influence of illicit drugs (4.2% in 2009, 4.2% in 2002) o Families o Violence - Criminality http://www.drugabuse.gov/Infofacts/CJtreatment.html o 3 types of drug related offenses Drug possession/sales Drug abuse related activites (stealing) Lifestyle of user (association with other offenders or illicit markets) Why public health?

Its a disease Blood-borne diseases o http://www.drugabuse.gov/Infofacts/DrugAbuse.html o HIV 1.1 million in US with HIV From 2005-2009, 64% of those with HIV/AIDs had used drugs but not IV, only 19% had never used an illicit drug 25% with HIV in 2009 reported use of alcohol or drugs at a level that warranted treatment o NIDA studies found that w/in 3 years of beginning injection drug use, most IDUs contract HCV, up to 90% of HIV infected IDUs may also have HCV

Current Drug Policies 1. United States http://www.whitehouse.gov/ondcp/policy-and-research a. 2011 National Drug Control Strategy i. drug use is a major public health threatdrug addiction is a preventable and treatable disease ii. Public health approach to reduce drug use, while maintain strong support for law enforcement iii. Focus on subsections 1. Active military and veterans a. 1 out of 8 active duty currently use illicit drugs 2. Women and families a. Admitting to drug abuse can lead to jail and lost custody of children 3. College students 4. Those in criminal justice system b. 7 core strategies i. Strengthening efforts to prevent drug use in our communities; ii. Seeking early intervention opportunities in health care; iii. Integrating treatment for substance use disorders into health care, and supporting recovery; iv. Breaking the cycle of drug use, crime, delinquency, and incarceration; v. Disrupting domestic drug trafficking and production; vi. Strengthening international partnerships; and vii. Improving information systems to better analyze, assess, and locally address drug use and its consequences. c. Impact of illicit drug use i. $193 billion in 2007 ii. Drug-induced deaths outnumber gunshot deaths iii. Children in foster care 50% to 75% of cases involved parental substance abuse d. Trends i. Prescription drug abuse ii. youth attitudes towards illicit drug use are softening

1. less likely to perceive drug use as risky or to disapprove of those who use drugs

2. United States a. b. $35b per year i. Half a million dealers and drug users are in prisons ii. Should focus on violence surrounding drugs, not issue of lower level dealers iii. Criminal punishment of marijuana does not appear to be justified iv. Rehab centers such as methadone clinics deserve greater financial support and less regulation 1. Boyum, D. & Reuter, P. An analytic assessment of U.S. Drug Policy. The AEI Press March 2005

3. United Kingdom
a. Bringing evidence and analysis together to inform UK drug policy. 2007. UK Drug Policy Commission b. Problem i. Highest level of dependent drug use in Europe ii. 1,644 drug related deaths in 2005, 2nd highest in Europe iii. Suggested correlation between high number of offenses in order to fund drug use (1/5 on heroin) iv. Size of drug market ~>5 billion pounds, social cost in Englad in Wales approximate over 13 billion c. Policy i. 1997 UK Drug strategy (did it renew?) 1. Aimed to reduce harm a. Stabilized drug users b. Cocaine and crack use has increased 2. Increase drug users entering treatment a. 1998 85k entered b. 2004 181k c. Believed to lead to reductions 3. Although drug use has stabilized the benefits to individuals is believed to have minimal effect on the overall social impact of drug abuse (those left untreated, relapse rates, effectiveness of treatment, new users) 4. Needle exchanges and methadone programs a. Prevented HIV spread b. Did not reduce hep C 5. Cannabis was reclassified (???) which had people worried use would increase, but it has declined since 2001 6. Prison sentences

a. Courts gave ~3x prison time in 2004 compared to 10 years earlier 7. Effect on drug prices a. Prices declined, with no indication that stronger enforcement has driven prices up 8. Overall a. little evidence from the UK, or any other country, that drug policy influences either the number of drug users or the share of users who are dependent (p. 10) b. Focus on reducing crime (corroborate with US paper) 4. Portugal a. Current system effective from 2001 in response to high indcidence of HIV/AIDs, 45% of AIDS came from IV drug users b. Strategies i. IV drug users 1. Clean needles, a condom and alcohol from pharmacies since 93 2. Change attitudes towards users ii. Free healthcare for drug users (treatment for dependence) iii. Substitution drug treatment 1. 2000- 6,040 substitute treatment patients 2. 2008 25,808 in 2008 iv. Decriminalization 1. Illegal to possess or use 2. No longer criminal, personal use was defined being up to 10 days supply a. http://www.emcdda.europa.eu/publications/drug-policyprofiles/portugal 3. Focus aggressively on therapy or community service compared to fines 4. Criminal penalties still enforced against drug growers, dealers and traffickers c. Effects http://www.scribd.com/fullscreen/13784156 i. Public Health 1. Drug overdoses from 400 (2000) to 290 (2006) annually 2. New HIV cases from 1,400 (2000) to 400 (2006) 3. Drug use rates have not increased and are now among the lowest in the EU 4. STDs and deaths have declined attributed to treatment programs ii. Public Perception 1. very few political factions are agitating for a repeal of 2001 law 2. Political consensus in favor 5. Netherlands a. Goals i. Prevent recreational use

http://apps.who.int/medicinedocs/pdf/whozip46e/whozip46e.pdf Summary The aim of the research was to use a set of standardized indicators to assess the achievement of the NDP and to use the political mapping technique to better analyse the process of policy formulation and implementation. 1. Positive link between NDP and economic development (does not apply for all the aspects of the policy) 2. Lack of local industry allows easier implementation of NDP 3. Geographical locations of countries has an impact: i.e. easier to control import/export of drugs on an island 4. Radical changes in NDP are easier in cases of new regimes/political turmoil, whereas in stable areas a graded approach would be better 5. Technical soundness and/or economic rationality of a policy did not always imply that the policy was politically viable Prevalence and Correlates of Drug Use and Dependence in the United States Results From the National Comorbidity Survey Lynn A. Warner, MPP; Ronald C. Kessler, PhD; Michael Hughes, PhD; James C. Anthony, PhD; Christopher B. Nelson, MPH Arch Gen Psychiatry. 1995;52(3):219-229. http://archpsyc.ama-assn.org/cgi/content/abstract/52/3/219 Purpose: analyze lifetime use and previouys year use - Males more likely to report lifetime and 12 month dependence - Drug use and dependence more common in those born after WWII http://www.drugabuse.gov/Infofacts/treatmeth.html

NIDA InfoFacts: Treatment Approaches for Drug Addiction

Addiction is a complex but treatable disease that affects brain function and behavior. No single treatment is appropriate for everyone. Treatment needs to be readily available. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. Remaining in treatment for an adequate period of time is critical. Counselingindividual and/or groupand other behavioral therapies are the most commonly used forms of drug abuse treatment. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. Many drugaddicted individuals also have other mental disorders. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change longterm drug abuse. Treatment does not need to be voluntary to be effective. Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted riskreduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

Prevention http://www.drugabuse.gov/Infofacts/lessons.html