THE WAR ON DRUGS

See Richard Smith's Editorial:

The war on drugs... Prohibition isn't working - some legalisation might help

Legalisation maybe necessary

EDITOR - I agree with Richard Smith that some drugs may have to be legalised.[i] I remember that, when working at Columbia University, New York, in 1954 I heard Dr Robert Loeb, the head of medicine, deploring the news that the police intended to crack down on illicit drug dealing in Harlem. He had watched prohibition result in alcohol dependence and gangsterism in the United States. When prohibition ended, dependence on alcohol still remained but the gangsterism associated with the drink trade stopped. Loeb predicted that the more the police enforced the law on the illicit drug trade the more profitable the trade would become and the more vicious and rapacious would be the gangsters who would move into Harlem. I think that the experience in the United States since then has more than confirmed his prediction.

The situation in Britain may not yet be as bad as it was in New York in the 1950s, but I believe that we should now be examining ways to eliminate the profit from illicit drug trading; it is the profit that attracts dealers, who play a major part in encouraging young people to use drugs. To eliminate this profit I believe we will have to legalise the use of these "pleasure" drugs, with cannabis to be treated as tobacco is now and hard drugs like morphine, heroin, and cocaine:to be available from specified pharmacies. We would still have serious problems of dependence but not, I think, on the huge scale of our current problems with alcohol; but crime would be reduced and the pushers would be eliminated because the enormous profits would no longer exist.

Other advantages would be that the purity of the drugs could be ensured and that people wishing to purchase hard drugs could be better informed of the dangers and dissuaded more effectively than is the case at present. The disadvantages include, firstly, that the end result would not be perfect: I do not like people taking hard drugs, but the situation would be better than it is at present and much better than it will be if we do nothing. A second disadvantage is that it is difficult for one country in Europe to act alone. The Dutch, who tried to relax implementation of their drug laws, had an influx of drug users from other countries. Britain has some advantages in being an island. A third disadvantage is that there are some drugs such as LSD (lysergide) - and no doubt others yet to be discovered-that are so dangerous that they should remain illegal.

0 L WADE Emeritus professor of therapeutics

Medical School University of Birmingham Birmingham B15 2TF

i. Smith R. The war on drugs. BMJ 1995;311:1655-6. (23 - 30 December.)

Editorial contained specious arguments

EDITOR - I find it reprehensible that the editor of the BMJ has decided to support the lobby for the legalisation of drugs.[i] His specious arguments will be interpreted as the view of the medical profession as a whole precisely because they have come from the editor of the journal.

Prohibition is not "working," but it was never meant to be the measure that would solve society's dependence on drugs, only a way of making it more difficult to become dependent. The trouble with using quotes from writers who know nothing of the incalculable suffering caused by drug misuse is that they may obscure the reasons why people become users in the first place: it is a grave error to assume that people use drugs simply because their life is "monotonous" or "poor." As doctors we should be helping to direct society into finding ways to make its life richer rather than to seek temporary escapism with its added long term misery.

Richard Smith says that legalisation would promote education on how to avoid drugs. Does this mean that we cannot educate people at present? The criminalisation that stems from misuse of drugs will not disappear if we legalise them - it is the misuse itself that causes the criminal acts. Perhaps Smith thinks that the occasional "joint" causes people to turn into muggers, ram raiders, or burglars. Legalisation of tobacco has not resulted in a decline in its use and the resultant long term effects. The fact that seizures of drugs have increased and that a lot of people have experimented with drugs is no evidence that legalisation will improve the health of the nation. The police force has opted not to prosecute people found in possession of small quantities of cannabis, but this cannot be taken as proof that the police and the society they work for approve. It is unclear from the editorial which drugs Smith would seek to legalise: he uses the example of the Netherlands in relation to cannabis, but neither doctors nor the judicial system would claim that misuse of cannabis is a major health or criminal problem. The effects of cannabis on attention and concentration, however, are recognised,[ii] and its consequences in those who drive or operate heavy machinery can be imagined Smith fails to deliver a balanced view of the pros and cons of legalising drugs. Such opinions are more fairly expressed in the journal's letters pages or when presented with an opposing argument on an adjacent page.

THOMAS F G ESMONDE Senior registrar in neurology

3 Sharman Close Stranmills Belfast BT9 5GF

i. Smith R. The war on drugs. BMJ 1995;311:1655-6. (23 - 30 December.)

ii. Grinspoon L, Bakalar JB. Marihuana. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance abuse: a comprehensive guide. 2nd ed. Baltimore, MA: Williams and Wilkins, 1992.

An international discussion is desirable

EDITOR - Richard Smith states that wars on drugs are doomed to fail and asks whether it is time to consider "going Dutch," referring to the fact that the Netherlands is more willing than other countries to experiment with decriminalisation.[i] What considerations must be taken into account in the debate on the availability of hard drugs in the Netherlands?

Many people argue that hard drugs should be freely available. One argument for this is on grounds of "fairness": why is alcohol freely available and heroin not? But other aspects must also be considered. An argument against prohibition is that it makes international criminal organisations flourish; their activities and economic power are so great that the Dutch government believes that they could constitute a threat to the country's democratic system.' Another argument hinges on the crimes committed against property by a number of drug users and the annoyance and nuisance that users cause m some city areas. Fourthly, prohibition leads to considerable health problems for the users themselves. They spend a lot of time on drug related activities, which results in an unstable pattern of daily activities. Furthermore, there is no possibility of monitoring the quality of the drugs and the devices used. So prohibition has many drawbacks.

Smith wonders whether free availability might be the solution. The expected effects of free availability must, however, be put into perspective. Crimes against property would not be completely abolished because not every user would renounce crime. Another consideration is that a "go it alone" policy could harm international relations. Furthermore, drug tourism would probably increase. Another, less widely discussed problem emerges when comparison with alcohol is made. Increased availability of alcohol may result in higher consumption, which in turn may result in more problems related to alcohol. The same is conceivable for hard drugs: problems related to illegal use would be reduced if drugs were freely available, but other problems - for example, at work or with driving - might increase. So free availability has many drawbacks too.

Partial legalisation would help, but to what extent? Methods of controlled supply to limited groups of users are now being discussed in the Netherlands. More specifically, an experiment is being planned in which heavy users will be prescribed heroin on prescription.[ii, iii] Such experiments are useful, but important questions remain unanswered. For instance, what will the government's response be if the results of these experiments are positive: an extension of the initiatives?

In all cases an international discussion is desirable.

HENK F L GARRETSEN Professor of addiction

Addiction Research Institute Erasmus University 3062 NM Rotterdam Netherlands

FRED STURMANS Professor of epidemiology

Municipal Health Service Rotterdam P0 Box 70032 3000 LP Rotterdam

Legalisation would have to be accompanied by personal responsibility

EDITOR - Richard Smith argues for the legalisation of those psychoactive substances whose distribution or possession is currently a crime.[i] The argument is presented in terms of the impossibility of stopping people from wanting to take illicit drugs, the failure of prohibitionist policies, the desirability of a reduction in the costs of enforcement, the possibility of education about drugs, the attraction of purer preparations of drugs being manufactured by large companies, and the right of individuals to do what they like so long as no harm is done to others.

All drugs, including alcohol and tobacco, harm the user. But it is the country as a whole that foots the bill for the care of people with illnesses caused by the consumption of drugs. Without this cost the taxes we pay would be considerably less. Drug users could well argue that they, too, contribute to the national coffers and that their taxes help to pay for the treatment of other people's illnesses. The issue here is one of proportion.

The use of every drug also entails harm to others: passive smoking causes disability and death in non-smokers, dependence on alcohol disrupts family life, a considerable proportion of road traffic and other accidents are related to alcohol, and people with drug induced psychoses have killed or seriously injured others. Dependent users desperate for supplies of their drugs commit serious crimes, including murder. We are a long way from the situation in which what drug users do in private does no harm to others.

If currently illicit psychoactive substances were legalised we would not incur the costs of enforcement, prosecution, and imprisonment but we would still have the personal and financial costs of the care of people with drug induced disorders, prosecution for crimes committed under the influence of drugs, and serious harm to others. Decriminalisation would therefore have to be accompanied by a clear statement of drug users' personal responsibility for the consequences of their self poisoning.

The government has no right to prevent people from consuming anything, but it has a responsibility to inform everyone of the harmful effects of what is consumed. Drug and alcohol treatment and rehabilitation services will always be available to those who seek help, but it has to be made abundantly clear that any harm caused to others in the search for, or use of, drugs must be punished.

IKECHUKWU OBIALO AZUONYE Consultant psychiatrist

Psychiatric Intensive Care Unit St Bernard's Wing West London Healthcare NHS Trust Southall Middlesex UB1 3EU

i. Smith R. The war on drugs. BMJ 1995;311:1655-6. (23 - 30 December.)

Harm minimisation is a way of lessening effects of more harmful drugs

EDITOR - I hope that Richard Smith's editorial on the prohibition of drugs and the potential solutions provided by (partial) legislation[i] will stimulate the debate in Britain, which has been extraordinarily slow to evolve. While this delay has been partially due to political gagging and the reluctance of academics to take sides in a controversial area of policy, another problem exists, which is exemplified by the editorial-namely, confusion over the drugs that may or may not be dangerous and the tendency to refer to drug abuse, use, and misuse as if they all concerned the same substance. As a recent contribution in a national newspaper identified, in one word (drugs) we include all illicit substances and the treatments and cures for many diseases.[ii]

To take the debate forward, research needs to provide separate information about those drugs that may be less harmful, especially cannabis, and to remove them from the debate about more harmful and less well understood drugs. A similar division needs to be acknowledged between the harmful effect of substances themselves and of the circumstances of their administration or mode of use. Smoking heroin must be infinitely less harmful than injecting it. At various times the Edinburgh drug addiction study has identified that in Edinburgh more than 500/5 of people who inject heroin have HI"' infection, over 60% have evidence of past infection with hepatitis B virus, and (most recently and most significantly for the future) 70% have antibodies to hepatitis C virus.

With better research into drugs of misuse it might become clear that in many instances the drug itself is not particularly toxic but the circumstances of its use and the mode of its administration can be lethal. If cannabis is taken out of the debate then the concept of harm minimisation or risk reduction might be seen as the way to lessen the dangerous effects of opiates, amphetamines, and other drugs. If it were possible to remove the effects of poverty and unemployment then the damage done by drugs would be seen in an even clearer perspective. If the resources given to law enforcement and the costs of custodial and other sentences were channelled into community services (medical and other support) then the drugs war might disappear completely.

J R ROBERTSON Medical practitioner

Edinburgh Drug Addiction Study Edinburgh EH4 4PL

i. Smith R. The war on drugs. BMJ 1995;311:1655-6. (23 - 30 December.) ii. Popham P. A modern vision of heaven and hell. Independent 1995 Dec 26.

Legalisation would be likely to result in increased use

EDITOR - I strongly disagree with the numerous assertions by Richard Smith that legalising or decriminalising drugs is the answer to the drug problem.[i] The first major misconception is that legalisation or decriminalisation would result in an overall decrease in the problems associated with drug use. As DuPont and I pointed out in our detailed consideration of drug policy, any reduction in the intensity of drug policy is likely to result in an increase in drug use and associated problems.[ii] An excellent example of this is the drastic difference in the use of marijuana compared with the use of alcohol and tobacco among adolescents. These drugs are all illegal for young people, yet the legal drugs are far more heavily used.

Dutch drug policy is an excellent example of misguided drug policy. While Smith's editorial discusses drug use in the Netherlands until 1985, drug use among Dutch males aged 12-18 increased 277% from 1984 to 1992, and the number of users of marijuana rose 50% from 1991 to 1993.[iii] Crime has increased drastically, with shootings increasing by 40%, car thefts by 62%, and robberies by 69%.[iv] That is understandable, since in the United States about half of violent climes are committed under the influence of drugs.[v]

The reality that we face in the United States and elsewhere is that we have only partially fought a drug war. We need to bolster efforts to prevent drug use and to broaden the availability of treatment. In addition, we should put teeth into prohibition and imprisonment. Drug dealers deal their drugs with minimal fear of imprisonment. Federal inmates imprisoned for trafficking in marijuana possessed on average 3.6 tonnes, while those imprisoned for trafficking in cocaine possessed on average 83 kg. We should consider even more stringent penalties for high level dealers and move towards pressuring casual users to refuse drugs through the use of drug testing and intervention.

Lastly, all of us need to sing from the same hymnal. Internationally, so many people are heading in so many directions that the public does not know whom to follow. It is particularly important that prestigious medical journals do not lead the public down a harmful road by proposing legalisation or decriminalisation.

ERIC A VOTH Chairman

International Drug Strategy Institute 901 Garfield Topeka ES 66606 USA

i. Smith R. The war on drugs. BMJ 1995;311:1655-6. (23 - 30 December.) ii. DuPont RL, Voth EA. Drug legalisation, harm reduction, and drug policy. Ann Intern Med 1995;123:461-5. iii. Zwart WM, Mensink C. Alcohol, tabak, drugs en gokken in ciffers. Rotterdam: National Institute for Alcohol and Drugs, 1993. iv. Criminal Investigation Department. Recherche 1993: centrale recherche informatie 1993 report. Rotterdam: CID, 1993. v. US Department of Justice, Bureau of Justice Statistics. The costs of illegal drug use. In: Drugs, crime, and the criminal justice system. Washington, DC: US Department of Justice, Bureau of Justice Statistics, 1992:126-7. (NCJ-133652.)

The aim should be a drug free society

EDITOR - The image of drug use in the Netherlands depicted in Richard Smith's editorial does not reflect the true situation.[i] The note on Dutch drug policy recently sent to parliament by the Dutch government estimated the number of regular users of cannabis as being 675 000-that is, 4.5% of our population of 15 million.[ii]

In 1980 there were a few dozen so called coffee shops, where the sale of cannabis is tolerated under certain conditions. Today, according to the government's note, the number of coffee shops and illegal "sale points" is estimated at over 2,000. The note states that the sale of cannabis in many municipalities has expanded enormously in the 1980s and '90s and that the number of coffee shops and the resulting nuisance have increased. Initially these shops were situated in a few large towns, but now they are spread throughout the country.

According to an investigation by the National Institute for Alcohol and Drugs, which is sponsored by the government, from 1984 to 1992 the use of cannabis among 12-19 year old pupils almost trebled (lifetime prevalence from 4.8% to 13.6%, use in the past month from 2.3% to 6.5%).[iii] Walburg, the director of the Jellinek Centre (an institute in Amsterdam that helps drug users) has said that the growing number of coffee shops has lowered the threshold for experimenting with hard drugs and that the increase in young heroin users is now alarming.[iv]

We must certainly look for the best way to deal with the drug problem. As all illicit drugs are harmful we should set ourselves a target for a drug free society. This may seem utopian, but it is the - only way. Toleration is not merciful, but prevention and cure are. A good drug policy should have four aspects, two related to prevention and two related to relief. Firstly, good information should be given to parents, schools, and children and should include the dangers of cannabis (memory impairment, the fact that it contains more carcinogens than tobacco, etc). Secondly, drugs should be eliminated. The police are on the right track in the way that they tackle big dealers, but they should be allowed to tackle street dealing as well, because it is difficult to find drugs when petty sales are reduced.[v] Thirdly, users should be able to gain admission to drug free institutions where they are treated with respect and encouragement so that they can regain their self respect. Finally, good aftercare is necessary: any former user should have a counsellor, who could help him or her find accommodation and a job. Weekly urine checks are advisable so that any relapse can be recognised.

K F GUNNING President Dutch National Board of Drug Prevention

Groene Wetering 24 3062 PC Rotterdam Netherlands

i. Smith R. The war on drugs. BMJ 1995;311:1655-6. (23 - 30 December.) ii. Het Nederlandse drugbeleid (The Dutch drug policy). The Hague: Staatsdrukkerij en Uitgeverij), 1995. (24077 No 2.) iii. Dezwart WM, Mensink C. Alcohol, tabak, drugs en gokken in ciffers. Utrecht: NIAD, 1993. iv. Moll H. Meer jonge verslaafden door goedkope heroine (More young addicts through cheap heroin). NRC Handelsblad 1992 Jul 2. v. Swedish National Institute of Public Health. A restrictive drug policy; the Swedish experience. Stockholm; SNIPH, 1993.