Like many of us, I have held lots of strong opinions about things in my life only for those opinions to be refined, altered, or even completely reversed by new knowledge. As a clinical scientist working in the addiction field for the past 25 years, I am asked a lot of questions about the complex issues of alcohol and other drug use and addiction. Unfortunately, the answers to these questions are often a potentially frustrating and annoyingly nuanced,
“Well, it depends on…” or,
“Yes, for some people, but….”
We all like and want straight, clear, and definitive answers. While alluring, however, such definitive answers are frequently inaccurate and misleading, based on a lack of knowledge and consideration of a larger context. As renowned journalist, Henry L. Mencken, once quipped,
“For every complex problem, there is a solution that is clear, simple, and wrong.”
Drugs and drug policy are issues that most people have an opinion about, evoking strong feelings and fiery debate, especially when talking about marijuana legalization. “For” or “against” arguments turn a complex problem with multiple imperfect solutions into binary, right or wrong arguments that ignore wider possible variations in legislation and policy.
If you haven’t wanted to think that deeply about different solutions to our long-lasting and ongoing “drug problem,” or have maintained fairly rigid opinions on drugs and want to keep these unperturbed, then I’d suggest you stop reading now. I am going to tell you about some different drug policy positions that you may not have pondered at all, or pondered for very long. Many of these positions even get confused in serious media reporting on these issues, generating even more confusion and misinformation.
On the plus side, knowledge of these different positions may lead you to impressing your friends with statements such as:
If it sounds appealing to be able to proffer some nuanced and enlightened tidbits to the coffee, dinner, or kitchen table conversation (or White House policy discussion) next time someone seems to have all the answers to the “drug problem,” read on, this article was written for you.
Most of us have heard the term “prohibition,” often associated with “alcohol prohibition.” Alcohol prohibition was enacted with the passing of the 18th amendment to the US Constitution and lasted for about fourteen years. The Volstead Act on which the initial amendment was based, banned the manufacture, sale, and distribution of all alcoholic beverages. Prohibition legislation was eventually repealed with the passing of the 21st amendment in 1933. This meant that alcohol was again legal. In most countries and the US, prohibition generally remains the primary policy position for psychoactive drugs that have the potential to be misused, cause intoxication, addiction, and induce harms.
We often end our thought process there. It’s either legal or it’s prohibited, right? But, let me introduce you to (or remind you of) some other terms and concepts that you may not have heard of or spent much time thinking about.
Decriminalization is often confused with legalization. They are very different. Decriminalization means that if you are caught in possession of small amounts of a drug for personal use, you do not incur a criminal penalty. It is still illegal to use the drug. The penalty, however, is typically nothing more than a modest fine, such as $100. Multiple states have now passed laws decriminalizing the possession and use of marijuana.
Often prior to passing decriminalization legislation, many states go through a period of “de facto decriminalization,” whereby no actual decriminalization law has been officially passed, but the existing criminal law prohibiting use is no longer enforced. It is an implicit recognition that decriminalization might be a potentially useful policy position, even if sufficient social and political will to enact it is currently absent.
Medicalization is a policy position taken for some psychoactive drugs. Notably, in the case of marijuana, its use for medical purposes has now become law in the majority of US states. Medicalization of marijuana is unusual in this regard because it is medically “recommended” rather than actually “prescribed,” due to a limited availability of rigorous empirical evidence on health benefits. If properly regulated and supported by clinical science for specific medical conditions, medicalization of a drug can help destigmatize use, and decrease pain and suffering related to those specific conditions. Because of safety concerns (e.g., in utero effects in pregnancy, drug-drug interactions, other medical contraindications), medicalization typically requires extensive testing to ensure users of the prescribed medication are not harmed by its use, and side-effects are minimized.
So, you have prohibition, de facto decriminalization, decriminalization & medicalization. Then there’s legalization, & that’s the end right?
While you might think legalization is simply a yes or no dichotomy, it is important to recognize that there are actually several forms that legalization can take, each accompanied by its own set of pros and cons.
One way drugs can be made legal for recreational use (e.g., marijuana), is to allow production, distribution, and sale, but forbid commercialization. This form of legalization bans product branding and advertising that are designed by industries to proactively increase sales, consumption, and profits. This is what happens currently with alcohol and did for a long time unabated for tobacco.
An alternative is to have local, state, or federal control over the production and sale of the drug. This would still make the drug completely legal, available, and accessible, and retain better control of quality and labeling of the drug’s psychoactive potency and ingredients.
On the plus side of the legalization without commercialization position, people who wanted to use the drug recreationally could do so by obtaining and using it without fear of recrimination, which would eradicate criminality, incarceration, and black markets. It would also lessen the stigmatization of addicted users, lessening a known barrier to seeking treatment. On the downside, because psychoactive drugs, including marijuana, do cause acute psychological impairments when people use the drug, as well as addiction (about 9% of marijuana users meet medical criteria for addiction), the increased accessibility, de-stigmatization, and decreased price that comes with legalization, would result in more users and therefore more potential hazards and harms in the population (e.g., drugged driving) as well as addiction cases.
Alternatively, one could legalize the drug(s) but allow at least some modicum of commercialization. For instance, restrictions could be placed on how much and to whom the newly legalized products are advertised. A drug like marijuana for example, could be made legal for recreational use, but its commercial advertising in certain venues and at certain times when children and adolescents are likely to be exposed to the advertisements, is restricted. Other restrictions could also be put in place while still legalizing the drug. These could include such things as having a minimum age for use (e.g. being at least age 21), ensuring quality control in production, and listing of ingredients including the nature and potency of its psychoactive content; limiting the number of licensed sales outlets in a given area; prohibiting use under certain conditions, such as when driving a car; and having a minimum price per unit at which the drug could be sold. Many such restrictions are placed on the sale of alcohol, for example. It should be remembered however, that just because there are laws in place to limit potential public health and safety harms from an uptick in use, it does not mean necessarily that such laws will be adequately enforced once a drug is legalized.
At the other end of the spectrum from prohibition, and at the far end of the legalization continuum, one can have unmitigated free market commercialization. This allows free reign for industry to brand and advertise as much as they want and for it to be sold with few, if any, restrictions. To think about how valuable advertising and branding is, think about buying cigarettes sold in a plain white box with nothing on the outside; or buying wine, beer, or liquor, in ordinary transparent glass containers with just a simple white label on the outside stating, “Wine” or “Vodka.” Not quite the same allure. Industry goes to great expense to attractively shape, tint, color, and even emboss the glass, create gilt-edged high-color labels, gold foil wrappings, and launch multi-million-dollar professional advertising campaigns in an attempt to create an image that attracts, seduces, and increases sales and profits.
Winston Churchill once said, “Democracy is the worst form of government, apart from all the rest.” Similarly, each of these policy positions comes with its own set of positive and negative consequences. As I alluded to earlier, we may not be able to completely eliminate “the drug problem,” but merely choose which types of problems we are going to have.
Moving from prohibition toward de facto decriminalization and actual decriminalization can reduce criminality and incarceration for individual users of the drug, but does not eliminate the cartels and criminal activity associated with the drug’s manufacture, distribution, and sales.
It would reduce both the negatives of prohibition, while also minimizing the public health and safety harms that come at a population level with the increased availability, accessibility, and reduced price. This allows people who want to buy and use the drug to do so without the drug being “pushed” on the population through advertising and branding.
On the other hand, unrestricted commercialization, while eliminating the criminal activity and increasing associated industry jobs and tax revenues, is likely to substantially increase drug sales and consumption, as well as public health and safety harms in the population as more people use it. Thus, any potential tax revenue gains from sales can be offset by economic losses related to lowered workforce productivity (e.g., more people take days off work to recover from the effects of use) as well as health care costs. It should also be noted that despite being legal, economic costs due to law enforcement and criminal justice could still also contribute to economic burden due to violations of the laws accompanying legalization (e.g., drugged driving convictions; sales to minors).
There are many vested interests and pressures on policy makers. Ultimately in a civilized society, good policy preserves individual freedoms, while respecting the rights of others likely to be affected. In the case of psychoactive drugs, such as marijuana, there is an added layer because while people make a free choice to use a drug initially, a proportion of users suffer from a radically impaired ability to continue to make that rational choice- they become addicted, and may suffer from additional illnesses, such as depression, caused by the drug. Addiction dramatically impairs quality of life, and with some drugs such as alcohol and opioids, can foreshorten the human lifespan by decades.
So, with regard to the complexities of the ‘drug problem,’ whenever you hear someone proffer their simple solution by starting their first sentence with, “Listen, all you gotta do is…,” you know they may be suffering from a case of the ‘clear-and-simple,’ but ultimately ‘wrong’ solution, described by Henry Mencken. It is far more complex and obstinate than that.
Now, go and impress your friends with this nuanced drug policy information… and while you are at it, maybe educate them too.