A drug policy for our times
Three erroneous assumptions
The lessons of science
Other adverse effects
Limited power to control drug use
The Lessons of history
Curtailing the illicit supply
Author: G.G. NAHAS, H. C. FRICK, T GLEATON , K SCHUCHARD, O MOULTON
Pages: 3 to 14
Creation Date: 1986/01/01
H. C. FRICK
College of Physicians and Surgeons of Columbia University, New York, United States of AmericaInstitut national de la sante et de la recherche medicale (INSERM), paris, FranceParents Research Institute for Drug Education (PRIDE), Atlanta, Georgia, United States of America
Three erroneous assumptions have influenced illicit drug abuse control policy. The first states that dependence-producing drugs are not different from many other substances consumed by people. This assumption underestimates the inherent neuro-behavioural properties of dependence-producing drugs that lead their users to adopt a compulsive pattern of daily consumption that is damaging to health. The second assumption states that even a young person may learn to use these drugs in a reasonable and responsible fashion, taking advantage of their redeeming qualities and avoiding their damaging effects. This assumption overestimates the ability of the human neocortex (new brain) to override the chemical stimuli induced by dependence-producing drugs in the pleasure and reward centres, which seem to be located in the limbic system of the old primitive brain. The third assumption states that social acceptance and commercial availability of illicit drugs would eliminate the social costs associated with their illegal traffic, which breeds crime and corruption. This assumption ignores historical precedents and the results of epidemiological surveys that demonstrate the damaging effects that social acceptance of these drugs and their widespread use may have on the individual and society.
Surveys of drug consumers indicate that the percentage of addicts is significantly related to the dependence-producing potential of the drug used. In a population where alcohol is commonly consumed, 7-9 per cent of the consumers drink in amounts that are damaging to health. In a population where cannabis is socially accepted and easily available, more than half of cannabis consumers use the drugs in doses damaging to health. Approximately 90-95 per cent of cocaine or heroin users consume their drug of choice on a daily basis. Therefore, the dependence-producing potential of cannabis and that of cocaine or heroin would be, respectively, 7 and 14 times greater than the dependence potential of alcohol.
* This article is an abridged version of "A drug policy for our times -1985. A position paper of the Parents' Research Institute for Drug Education".
Current illicit drug control policy should be based on scientific evidence and successful historical precedents, some of which are summarized in this article. This policy should concurrently aim at curtailing the supply of illicit drugs and reducing their demand.
In the report on its February 1985 session, the Commission on Narcotic Drugs stated that illicit drug traffic and drug abuse markedly increased in most parts of the world. Compared with 1982, the amount of heroin seized in the world in 1983 increased by 91.9 per cent, cocaine by 229.9 per cent, cannabis resin (hashish) by 57.3 per cent, cannabis herb (marijuana) by 25.() per cent and liquid cannabis by 25.1 per cent [ 1] . These figures may be regarded as a barometer indicating an increasing availability of drugs in the world, particularly in countries which offer lucrative markets and an ever-expanding drug demand, with consumers numbering in the millions.
Over the past 50 years, strict drug control policies have been successfully implemented in certain countries, such as China, Japan [ 2] and Singapore [ 3] , where national consensus has supported a social taboo against the illicit use of drugs designated by the Single Convention on Narcotic Drugs, 1961, and the 1972 Protocol amending that Convention [ 4] and the Convention on Psychotropic Substances 1971 [ 5] . Such policies, for example, have enabled Singapore to reverse upward trends in heroin addiction in that country.
Drug policies in Western countries have been influenced by the views of social scientists who have formulated a permissive theory of drug addiction based on the following three erroneous assumptions.
The first erroneous assumption of this theory states that illicit dependence-producing drugs are not different from many other substances consumed by people. This assumption underestimates the neurobehavioral properties of dependence-producing drugs- According to the permissive theory of drug addiction, the dangers to mental and physical health caused by illicit drug use have been greatly exaggerated; these drugs, acting primarily on the mind, which can control their use, should be regarded as being like any other substances. According to one author, there is little difference between heroin and sugar; both are white crystal- line powders that produce addiction [ 6] . The same author argues that there is little difference between chocolate and morphine. Similarly, it is claimed that marijuana is a "soft" drug and that its sale should be legalized or at least decriminalized [ 7] - [ 10] , which, in effect, would increase its social acceptance and consumption. Cocaine is considered with benign neglect. ,Two professors of psychiatry wrote in 1983 [ 11] that cocaine was no more addictive than peanuts. An organization created by major foundations in the United States of America to study drug abuse prevention methods claimed in 1980 that cocaine use produced few adverse effects and did not lead to dependence [ 12] . The authors supporting the permissive point of view minimize the long-term damaging physical and mental effect of addictive drugs when they are used frequently [ 10] , [ 13] , [ 14] .
The second assumption states that even a young person may learn to use dependence-producing drugs in a reasonable and responsible manner, benefiting from their redeeming qualities and avoiding their damaging effects. This assumption overestimates man's ability to control the use of dependence-producing drugs. According to this assumption, modern man has become "sovereign over his own body and mind" with inherent rights, and any effort by society to prevent him from using the drug of his choice is an invasion of privacy and an infringement of individual freedom [ 15] , [ 16] . A person's reason, it is assumed, will ultimately prevail over his or her craving for pleasure-inducing drugs, and most individuals should be able to control their use of drugs, including opium and cocaine, without abusing them. According to this assumption, children should be taught how to develop "good relationships with drugs,, or how to "get intoxicated without getting into trouble,,; and those who get into trouble will be treated by a "drug abuse specialist" [ 6] . The same authors also claim that drug-dependent people have a psychological profile that triggers their addiction. This, in fact, has never been scientifically proven. All individuals, especially youth, are susceptible to the addictive power of dependence-producing drugs. Other authors have stated that drug addicts are the victims of a repressive policy that must be reversed in order to deal more effectively with drug addiction [ 7] , [ 12] , [ 13] , [ 16] . History clearly indicates that the opposite is true. With regard to the outcome of treatment and the recovery of confirmed addicts, many drug abuse professionals have expressed an over-optimistic view, as if treatment always leads to a cure.
The third erroneous assumption states that social acceptance and commercial availability of illicit drugs would eliminate the social costs associated with their illegal trade- This assumption underestimates the social and individual costs that would result from the legalization of the use of illicit dependence-producing drugs. According to this assumption, the prohibition of drugs in a free society does not work, as proven by attempts to prohibit alcohol in the United States; prohibition only compounds the problem by breeding crime, corruption and more addiction.
Instead, people should learn "chemical survival" [ 17] , that is to say, how to live with drugs, how to use them for pleasure in a responsible fashion, without abusing them [ 18] . But none of the authors supporting this point of view has ever projected the individual and social damage that would be caused by the legalization and commercial availability of illicit drugs. By most conservative estimates, such damage would be infinitely greater than that associated with the present use of alcohol and tobacco [ 1] , [ 2] , [ 19] , [ 20]
All these erroneous assumptions have been widely disseminated for two decades through the media and have inspired hundreds of books and articles. They have also permeated popular thinking and encouraged a greater tolerance towards the use of dependence-producing drugs, which has resulted in greater social acceptance and Consumption of such drugs [ 21] , [ 22] .
As a result, the world is experiencing an epidemic of drug abuse of unprecedented magnitude that is threatening the fabric of democratic societies. It is time to reassess all of the erroneous assumptions of the permissive theory of drug dependence in order to chart a new course based on current scientific knowledge. Indeed, there is no sound basis for the assumptions just enumerated- It is time to formulate an effective policy of drug dependence prevention on the basis of psychopharmacological, epidemiological and historical evidence.
The results of scientific research show that the following four main properties distinguish dependence-producing drugs from other substances: a pleasurable feeling produced by drug use; neuropsychotoxicity leading to inability to interpret reality; abstinence; and tolerance-
The use of dependence-producing drugs produces a pleasurable feeling because of their properties to interact with the pleasure and reward mechanisms of the brain [ 23] - [ 25] . As a result, a person who has used one of these drugs has a tendency to take it again in order to obtain the initial pleasurable sensation. Drug use also dissipates unpleasant feelings, decreases anxiety, produces detachment from the world and alters the state of consciousness [ 26] . .
The use of dependence-producing drugs produces a temporary impairment of the brain functions (neuropsychotoxicity) or an inability to interpret the outside world as it really is. An intoxicated brain cannot process the millions of signals that keep an individual alert and functional in his environment [ 21] , [ 24] . Such intoxication impairs psychological and psychomotor performance. Some dependence-producing drugs , such as nicotine , caffeine and alcohol, if taken in small doses , do not induce neuropsychotoxicity. Their use among adults has been tolerated in many societies , despite their inherent potential to induce drug dependence. All these societies emphasize , however, that the use of tobacco and alcohol should be restricted to adults and controlled by law , and that intoxication with alcohol is a deviant behaviour that is in many instances penalized.
While the use of a dependence-producing drug provides a pleasurable feeling, abstinence from its use results in an unpleasant and often painful reaction known as the withdrawal syndrome. Therefore, a drug-dependent person is caught between the urge to take a drug for pleasure and the desire to avoid the unpleasantness and difficulties that occur when he is no longer under its influence. Withdrawal symptoms are characteristic of all dependence-producing drugs , including tobacco , which is a highly addictive substance .
Continued consumption of a dependence-producing drug produces tolerance of the effects of such use, which leads to an increase in dosage of the drug in order to obtain the desired initial effects. Tolerance accentuates the problems of drug supply and the need for frequent readministration.
The combined factors of pleasure and reward , the dream-like state of neuropsychotoxicity, withdrawal symptoms and tolerance lead to drugseeking behaviour and compulsive daily self-administration. Addiction is characterized by a major preoccupation with securing the drug and a strong tendency to relapse after discontinuing drug use. Medical science shows that the regular use of dependence-producing drugs is associated with a high incidence of mental or physical ailments. This also holds true for cannabis, which should no longer be called a soft drug because it impairs the lungs, the brain and the immune and reproductive systems [ 27] - [ 29] . The science of epidemiology shows that the consumption of illicit addictive drugs tends to spread in an epidemic manner when social circumstances are conducive to their use. Drug abuse epidemics are particularly contagious because the individual victim actively seeks out the drug, whereas the individual in an epidemic of infectious disease tries to avoid the infectious agent [ 30] .
Clinical studies indicate that a person has limited power to control the intake of a dependence-producing drug once he has started using it; one of the main properties of a dependence-producing drug is that its use interferes with brain mechanisms associated with pleasure and reward, which seem to be centred in the limbic system (old primitive brain). Nature has endowed the brain with these pleasure and reward mechanisms to favour behaviours that foster the dominant activities of nutrition and reproduction, which are essential for the survival of the individual and the species. .The functional purpose of these pleasure and reward centres, which is so crucial for the survival of an individual in a demanding technological society [ 25] , [ 31] , is impaired by the use of dependence-producing drugs.
Throughout history, people have had a profound craving for the rapid induction of pleasure and a dream-like state via chemical stimulation of the brain. This is particularly true of a young person, who is very vulnerable to the use of dependence-producing drugs; his brain functions are in the process of integration and development, and the dominant pleasure mechanisms tend to orient his behaviour towards immediate fulfilment of the desire for fun. Only through training and drilling the "new brain" (neo-cortex) , which covers the old brain, will a child or adolescent become willing to forgo immediate satisfaction in order to obtain long-lasting rewards. That is what education is all about.
Because of the very nature of the human brain, people have a natural propensity to consume pleasurable dependence-producing drugs- It is now clear that the use of these drugs abridges the freedom of an individual by enslaving him in a damaging habit that he can no longer control. Clinical surveys of the treatment and rehabilitation of drug addicts show that, whatever method is used, the return of a confirmed addict to a drug-free life is a long and difficult process, with often disappointing results; the success rate may not exceed 50 per cent [ 2] , [ 20] , [ 32] [ -34] .
Records of history show that in societies where dependence-producing drugs are socially acceptable and easily obtainable, they are widely consumed, and their usage is associated with a high incidence of damage to the individuals involved and their societies.
In 1858, the legal trade of opium was imposed on China. By 1900, 75 million Chinese were addicted to the drug. It took a national revival and 50 years of coercive measures for the country to become free of opium. In the 1920s, the unrestricted commercial availability of cocaine and heroin in Egypt resulted in epidemic abuse of these drugs, which was also curtailed following restrictive measures.
Epidemiological surveys have documented in a statistical fashion the relationship between alcohol consumption and the occurrence of alcoholism [ 10] . The French mathematician Ledermann, after extensive investigation of the distribution of consumption of alcohol in France and other countries, reported that the more consumers of alcohol there were in society, the more alcoholics and problems associated with alcoholism there were [ 10] . This observation seems to derive from common sense, but Ledermann gave it a mathematical formulation by describing the lognormal distribution of alcohol consumption and the covariance between mean and excessive consumption. His general conclusion was that in order to decrease the incidence of alcoholism and alcohol-related damage ,one had to attempt to decrease the overall consumption of alcohol in a given population. For instance, one effective way of decreasing the number of casualties among 18-year olds in alcohol-related road accidents is to raise the legal drinking age to 21 years, which, in essence, decreases the overall consumption of alcohol in that vulnerable age group.
Ledermann also observed that in a given population, within a given time period, the percentage of consumers of alcohol who had drunk excessively corresponded to 7 -9 per cent of the drinking population, which in France represented 2 million alcoholics and in the United States over 12 million.
A similar analysis may be applied to the consumption of cannabis in a population of cannabis smokers that is also log normally distributed. In the population of adolescents who reported smoking marijuana during 1978, 18 per cent of these cannabis consumers used the drug daily [ 35] ,though cannabis, being an illicit drug, was not as available as alcohol. Other surveys of cannabis consumption were conducted in three Jamaican villages where the drug was easily obtainable and socially acceptable. In those villages, 50 per cent of the villagers who smoked cannabis were intoxicated by cannabis daily; they smoked an equivalent of 10 joints a day, which amounted to 100 mg of tetrahydrocannabinol [ 36] .
The results of a survey carried out among a population of coca leaf chewers in the Bolivian Andes, where this habit is an inherent part of the local culture, are even more striking. Out of the population that chewed the coca leaf, 90 per cent used it daily in large amounts, the equivalent of 300- 500 mg of cocaine a day, which is an intoxicating dose [ 37] . It is common knowledge that heroin users have to consume their drug every day [ 3] , [ 8] .
These results indicate that in a population of drug consumers the percentage of addicts is significantly related to the dependence-producing potential of the drug used ; this potential is measured by the degree to which the drug used is capable of leading its user to a compulsive consumption of the drug that is associated with damage to health. The dependence-producing potential of illicit drugs is higher than that of alcohol [ 38] . In societies where alcohol is commonly consumed, 7 -9 per cent of alcohol consumers are excessive drinkers who consume amounts damaging to their health. Surveys of populations in which cannabis is socially acceptable and easily obtainable show that more than half of the cannabis users consume it in doses damaging to their health. Among cocaine or heroin consumers, approximately 90 - 95 per cent of users consume their drug of choice on a daily basis. Therefore, the dependence-producing potential of cannabis and that of cocaine or heroin would be, respectively, 7 and 14 times greater than the dependence-producing potential of alcohol.
In the light of the foregoing analysis it is possible to formulate a drug policy that takes into account :
The evident failure of the assumptions and permissive policies of the 1970s;
The updated analysis of scientific, medical and historical records ;
The examples of nations that have successfully controlled drug abuse epidemics.
Such a policy should concurrently emphasize measures aimed at curtailing the illicit supply of dependence-producing drugs and reducing the demand for such drugs.
The illicit supply of drugs can be curtailed by strictly enforcing the existing legal provisions for illicit drug control.
The international legislation that has been adopted over the past century, aimed at limiting the use of cocaine, opiates, cannabis and other dependence-producing drugs to medical and scientific purposes, must be enforced. The enforcement of laws against illicit drugs might seem excessively repressive to an occasional drug user, but it has been amply demonstrated that thousands of users are also small drug traffickers, so-called "ant traffickers" , who illegally distribute their drug of choice, often making it impossible to distinguish drug users from drug traffickers. The policy of cannabis "decriminalization" in the 1970s, which clearly failed, showed that a society cannot effectively enforce criminal law on a half-legal, and half-illegal basis.
To be effective, a national programme of law enforcement must involve close co-operation with its counterparts in other countries and with international programmes. The reduction of the illicit drug supply at its source is essential; it requires co-operation with drug enforcement agencies in countries in which the illicit drugs are produced. Effectively fighting the multi-billion dollar business of the illegal international drug trafficking organizations, which corrupt and destabilize the social fabric of the affected nations, has become a monumental task. Historically, the United States has been committed to this fight by implementing the international treaties against illicit drug traffic. It is now quite clear, however, that curtailing the illicit supply of drugs must be coupled with a programme of drug demand reduction in order to reverse the current trend in illicit drug abuse.
The illicit demand for dependence-producing drugs can be reduced by programmes for primary prevention, as well as for treatment and rehabilitation.
Primary prevention can best be achieved by a programme for public education that presents without equivocation the damaging effects of dependence-producing drugs on the individual and society. The programme should be broadly based on history, science and literature, with a clear and consistent message. It should be integrated into the school curriculum and taught by all teachers. The anecdotal and misleading drug literature that abounds in bookstores and libraries should be matched by publications that are based on current scientific knowledge. The co-operation of the media should be sought so that the national consensus on such a vital issue will be clear to all. It should be mentioned, however, that primary prevention has a limited effect on the confirmed addict, who has to undergo treatment and prolonged rehabilitation in order to live a drug-free life.
Drug-free in-patient programmes for the rehabilitation of confirmed addicts based on the model of therapeutic communities [ 34] will have to be expanded. There are millions of drug-addicted people. The number of drug addicts must be decreased with the help of effective treatment and rehabilitation programmes if the demand for illicit drugs is to be curtailed. Early intervention is to be emphasized. In some instances, compulsory referral of addicts to a treatment and rehabilitation programme should be considered.
This blueprint for illicit drug control policy is based on the pharmacological and epidemiological studies of dependence-producing drugs, as well as on examples of successful control of illicit drugs. The recommended policy relies on both common sense and ethical standards that are fundamentally opposed to the slavery of the mind imposed by the consumption of dependence-producing drugs. For these reasons, the policy has the overwhelming support of young people in the United States, their families and their counterparts throughout the world, who are determined to build a better tomorrow.
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