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Journal of Trauma-Injury Infection & Critical Care:
doi: 10.1097/01.ta.0000176046.87147.c5
Session 1

A Rational Approach to Formulating Public Policy on Substance Abuse

Trunkey, Donald D. MD; Bonnono, Carol RN, CEN

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From the Division of General Surgery (D.D.T.) and Department of Emergency Medicine (C.B.), Oregon Health and Science University, Portland, Oregon.

Submitted for publication January 24, 2005.

Accepted for publication February 1, 2005.

This article was written for the proceedings from a conference entitled “Alcohol and Other Drug Problems Among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism” in Washington, DC, May 28–30, 2003. It does not reflect the official policy or opinions of the Centers for Disease Control and Prevention (CDC) or the U.S. Department of Health and Human Services (HHS) and does not constitute an endorsement of the individuals or their programs—by CDC, HHS, or the federal government—and none should be inferred.

Address for reprints: Donald D. Trunkey, MD, Division of General Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., L223A, Portland, Oregon 97239; email:

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Unlike alcohol, which is legal and regulated, current public policy makes drugs such as heroin, cocaine, methamphetamines, and marijuana illegal. This article summarizes the history of drug and alcohol use in the United States, compares our public policies on alcohol to those on drugs, and shows the direct link between alcohol or drug use and crime, corruption, violence, and health problems in other countries and in our own. A rational approach to formulating a workable public policy is presented.

We are losing the war on drugs.1–3 Unlike alcohol, which is legal and regulated, drugs such as heroin, cocaine, methamphetamines, and marijuana are not. Because our current public policy makes these drugs illegal, we are contributing to crime, corruption, and health problems in other countries and in our own. This article summarizes the history of drug and alcohol use in the United States, compares our public policies on alcohol to those on drugs, shows the direct link between alcohol or drug use and violence, and presents a rational approach to formulating a workable public policy.

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Brief History of the Evolution of Alcohol or Drug Use

Psychoactive drugs and alcohol have been used and abused throughout history. From the time of the Revolutionary War, the Lewis and Clark expedition, and when Chinese laborers came here after the Opium Wars, opium use increased dramatically in the United States. To combat the growing problem, San Francisco passed an ordinance in 1875 banning opium dens and other establishments where opium was smoked.4,5 Five years later, the United States followed suit banning the smoking of opium by Asians only. However, then others in our population turned to opium, morphine, heroin, cocaine, and marijuana, all of which had very few restrictions.6

Many patented medicines contained laudanum or other opiate derivatives. Vin Mariani and Coca Cola were popular tonics containing cocaine. The American Medical Association actually endorsed heroin when it was introduced by Bayer Laboratories in 1898. At this time, only a small number of the population, 350,000, were addicted to opiates, and some physicians even prescribed opiates to treat alcoholism because it was considered a more serious problem. However, physicians and government officials soon became concerned about psychoactive compounds in patented medicines.

In 1906, Congress passed the first Federal Pure Food and Drug Act. This law required over-the-counter drug producers to disclose the psychoactive ingredients in their products. Despite this action, concern about opiate addiction continued to increase, and additional laws were enacted. Congress passed the Harrison Act in 1914. This law further restricted the use of opiates and required all persons involved in the opium or cocaine trade to register with the Internal Revenue Service. Specifically, the title of the law was, ‘An Act to Provide for the Registration of, With Collectors of Internal Revenue, and to Impose a Special Tax upon all Persons Who Produce, Import, Manufacture, Compound, Deal In, Disperse, Sell, Distribute, or Give Away Opium or Coca Leaves, Their Salts, Derivatives, or Properties and for Other Purposes.’ Heroin and cocaine could only be obtained with a doctor’s prescription. (Marijuana was excluded from the law until 1937). In 1916, the interstate shipping of cocaine and heroin became illegal. Opium could still be imported for medical purposes, but only to 12 U.S. ports.

Alcohol—‘Demon Rum,’ as it was labeled in the late 1800s—was subjected to intense scrutiny and pressure, particularly by the temperance movement. The medical community considered alcohol and the social consequences of alcoholism a more serious problem than the drug problem. Five years after the Harrison Act, the 18th Amendment to the Constitution was ratified to prohibit the sale, manufacture, or drinking of alcoholic beverages of any kind after 1920.

Before Prohibition, ironically, alcohol consumption dramatically fell.6 Undoubtedly, this was because of the success of the temperance movement and public education regarding alcohol use. Deaths from cirrhosis were reduced by 50% during the 1920s. Why, then, did Americans repeal Prohibition after 13 years and not repeal the Harrison Act? Nadelmann and Courtwright6 contend that the prohibition of alcohol affected tens of millions of Americans of all ages ‘including many of society’s most powerful members‘; drugs threatened far fewer Americans. When Prohibition was repealed, crime, corruption, and the violence associated with that period diminished. Unfortunately, few treatment programs for alcoholism emerged.

We have had four separate wars on drugs: 1909 to 1923, 1951 to 1956, 1971 to 1973, and 1982 to the present, all of which have arguably been lost.5 Since 1933, we have had two distinct public policies on alcohol and drugs. Alcohol is legal; drugs are not. We are losing the current war on drugs because the focus is on supply rather than on demand or treatment programs. Consequently, in the last 30 years, violence associated with illegal drug trafficking has escalated.

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Rise of Organized Crime in the United States

The early 1800s were marked by criminal activity of ethnic gangs in the United States, including Irish, Jewish, and Italian groups. After the Opium Wars in 1840, Chinese were brought to the United States as laborers, and Chinese gangs became part of this community, almost immediately bringing opium into this country. Although at times these gangs were violent, they were disorganized. In contrast, Sicilian secret societies organized to control the drug trade, particularly in big cities on the East Coast.

One man, Arnold Rothstein, did more to change the way drugs and alcohol were distributed than any other single person or group. He was the son of a pious orthodox Jewish family. According to Jill Jonnes, Rothstein ‘permanently transformed American crime from petty larceny into big business.’7 He excelled at blackmail through labor racketeering and a stolen-bond business. He personally financed rum smuggling and was one of the first to smuggle rum from Europe during Prohibition. Rothstein’s legacy was organizing and bankrolling big time international narcotics trafficking. Not only did Rothstein have the capital to finance this endeavor, but he also gained political clout by bribing Tammany Hall politicians. Through Italian street gangs, he organized a distribution network, bought drugs legally in Germany, and then brought the drugs into the United States. Ironically, he shipped the drugs by U.S. merchant ships. In November 1928, Rothstein was found shot in the Central Park Hotel in New York. He had $6,500 in cash on him when he was found; clearly, he was not a petty criminal. He lingered 48 hours and died on November 6th. Posthumously, Rothstein won a $500,000 bet that Herbert Hoover would win the election. Hoover was elected President 2 days after Rothstein’s death. It was ultimately thought that Legs Diamond was his killer. One month later, federal agents, who had confiscated Rothstein’s office files, arrested four suspects and seized steamer trunks of drugs worth $3 million. Rothstein’s apprentice, Lucky Luciano, took over the empire and ran it until his death in 1962. During Luciano’s reign, the illegal distribution of alcohol and drugs was, at times, very violent. It was only when the Medellin and Cali cartels of Colombia became involved with cocaine distribution that a more profound and random violence took over.

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The Golden Triangle

The opium-producing areas in the world are steeped in crime and corruption.5 When Mao Tse Tung took control of mainland China in 1949, remnants of the Kuomintang Army fled to Laos, Cambodia, Thailand, and Burma (renamed Myanmar in 1989). With Taiwanese capital, these renegade troops established the Golden Triangle, a premier opium-producing venture. Inevitably, this led to corruption within the Burmese government, and violence became rampant. According to some sources, the Central Intelligence Agency (CIA) supported the Kuomintang army troops and the Shan States, which increased Burma’s opium crop during the 1950s.5

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The Golden Crescent

Another source of opium is the Golden Crescent, which consists of the opium-producing areas of Iran, Pakistan, and Afghanistan. These areas have been a major source of illegal drugs since the late 1970s. Violence and corruption in this part of the world is profound. Again, the CIA has contributed to the problem.5 In 1964, the South Vietnamese government was toppled, which increased narcotics trade in the Golden Triangle. Corrupt South Vietnamese government officials and generals used Vietnamese and Laotian planes paid for by the CIA to ship heroin from the Golden Triangle. The same thing happened in Afghanistan and Central America, and in both instances, the drug flow to the United States increased. It is noteworthy that in 2002, opium production in Afghanistan was 20 times what it was in the last year of the Taliban rule (2001).8

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The French Connection

Illegal distribution of drugs has a major effect on the countries involved, particularly because of the associated crime. For example, in 1952, the Italian government banned the manufacture of heroin in response to pressure from the United States. The Mafia responded by sending raw opium to Marseilles, resulting in the so-called ‘French Connection.’5 Since 1970, there have been 350 judicial judges assassinated in Columbia. Fifty federal judges (25% of all judges in Columbia) have been threatened. The murder rates in Cali and Medellin are some of the highest in the world. In Mexico, about $50 million is spent every year just to corrupt officials so that illegal drugs can be transported across the U.S.-Mexican border. Assassinations are rampant. Distribution of illegal drugs corrupts governments, military, and police.5

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East Coast and Florida

In the United States, money laundering is a huge problem along the East Coast, particularly in Boston and Florida. Many legitimate banks are involved. The Bank of Boston was found to have laundered approximately $1.12 billion dollars in illegal drug money. This money laundering has now shifted to the Cali cartel, the Yakuza in Japan, and Mexico.5

In 1980, the substance-abuse industry was the biggest retail industry in Florida at $12 billion per year. A $5 billion surplus in the Miami Federal Reserve Bank indicated it was drug money. There was no other explanation. Homicide in Miami went from 349 murders in 1979 to 621 murders 2 years later. This was the highest murder rate in the United States at the time.9 One of the authors, Dr. Trunkey, witnessed a similar trend during his general surgery residency in 1966 at San Francisco General Hospital. Approximately 100 gunshot wounds a year were seen at the beginning of his residency. Five years later, during his chief residency year in 1971, gunshot wounds had increased to three per day. This was at the height of the Haight-Ashbury era. Initially, young people were making LSD in bathtubs, but then the Mafia moved in and took over drug distribution, resulting in an increased incidence of violence-related injury in emergency rooms. Dr. Trunkey suggests that there may be a direct link between money laundering and higher incidence of murder.

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Problems Associated with the Current War on Drugs

Since 1931, domestic abuse and violence in the United States have increased 700%.5 Victims of this abuse show up in emergency rooms. In addition, HIV infections have increased 35%, and organic brain disease, psychiatric disorders, sudden death syndrome, and overdose result in tremendous costs to society.4 Drug and alcohol abuse in trauma patients was well documented by Schermer and Wisner in 1999 (Table 1).10 Their research showed that methamphetamine use in Sacramento, Calif, nearly doubled in their emergency room. Cocaine use and heroin use remained fairly constant, although alcohol use may have decreased slightly. This certainly mirrors the authors’ experience in Oregon; however, methamphetamine use was found in more than 20% of the patients, many of whom also presented with alcohol abuse.

Table 1
Table 1
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Public Policy

There have been four wars on drugs and one war on alcohol. From a public policy standpoint, Congress recognized that the war on alcohol was not effective; consequently, the Volstead Act was repealed. In contrast, despite four wars on drugs, the lessons learned from the war on alcohol are continually ignored. These lessons should be applied toward developing a rational policy on substance abuse. As stated earlier, we are losing the current war on drugs because we are not focused on demand and treatment strategies for those addicted. Does interdiction of drugs work? Absolutely not. One kilogram of cocaine costs about $100,000 at the distribution point. A pilot who could smuggle drugs into the United States would demand $500,000 to fly 250 kilograms of cocaine, which costs $2,000 per kilo to produce. This is 2% of the retail price to bring it into the United States. Thus, if the pilot and accomplices are at risk of being caught, they simply abandon the airplane and flee. This increases the cost of the cocaine by $2,000 per kilo at the distribution point. The cost of production, distribution, and street sales shows a dramatic increase of price and, presumably, profit. According to The Economist, 1 kilogram of heroin brings $90 to the farmer, $80,000 to the wholesaler in the United States, and costs $290,000 when sold on the street. Similarly, the farmer sells 1 kilogram of coca leaves for $610, and the street price for cocaine powder jumps to $110,000/kg.3

Do we stop drugs at our border? Again, the answer is no. U.S. officials check only 4% of all containers that come into the country. Most drugs coming into the United States cross the borders illegally, primarily by airplane. This has not changed since 1990. Further, there is a 3,000-mile border with 30 ports of entry, through which 640,000 pedestrians and 240,000 cars, trucks, and other vehicles pass daily. In 1996, the U.S. government estimated that 70% of the cocaine smuggled into the United States came across the U.S.-Mexican border. According to the Drug Enforcement Administration, in a 5-year period (1990–1995), cocaine seizures remained constant at approximately 20%. More recently, attempts to use herbicides in Columbia have met with some success, but the drug producers have countered this action by shifting production to other countries. The cost of our war on drugs is now over $18 billion per year.11

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Alternative Strategies

There are at least two alternatives to our current strategy:1 decriminalize drugs2 or make drugs legal and subject to regulation. We already have examples of decriminalization in the United States. Drug courts are an effort by the judiciary system to solve some of the terrible social problems within our current system. Mandatory sentences and full jails are simply not the answer. In drug court, miscreants are often given a choice of treatment program and probation, provided a major felony has not been committed. This keeps people out of jail and addresses the problem from a treatment standpoint. Ironically, it was during the Nixon administration that we had some of our best success with methadone treatment programs, and these alternative strategies did work.11 Legalization is another strategy where possession and sale, like alcohol, becomes legal. From a public health standpoint, this has a number of positive aspects. It reduces demand through treatment programs and regulates and controls the drugs that are used in the treatment program. This reduces the consequences of dirty needles, overdose, and psychiatric disorders. If drugs were legalized, it has been predicted that the prison population could be reduced by perhaps two thirds.12 Those people who do go to prison for felonies could be put into mandatory treatment programs. In addition to the practical aspects of legalization, the benefits would be significant to the countries where producers reside. Drug trade financiers and powerful gangs that threaten these countries would, in theory, go away. Corruption, bribery, and intimidation would diminish.

There is a down side to legalization. More people might become dependent and more people would experiment with drugs. However, the evidence doesn’t necessarily support this, as shown in Europe after the Frankfurt Resolution was initiated in November 1990.13 Four cities initiated this resolution, and an additional 11 cities have subsequently signed on. The approach in Europe has been a mixture of decriminalization and legalization, with cannabis being the drug that has been legalized de-facto. The experience is somewhat contradictory. There may have been some minimal increased use of drugs, such as cannabis. However, there was no evidence that decriminalizing cannabis significantly increased use.13 There are between 5,000 and 7,000 addicts in Amsterdam (a city of 700,000) compared with 45,000 addicts in Baltimore, Md, which has a similar population. We acknowledge this is comparing apples and oranges because rates may vary and drug policies may differ not only within the various classes of drugs, but also between cities. However, in two separate reports, overwhelming evidence supports the effectiveness of prevention and treatment programs in 1996.4,14 Drug sales decreased 78% and physical assaults decreased 77%, shoplifting and arrest rates decreased, respectively, by 81% and 50%, arrest for drug possession decreased 64%, crack use decreased 50%, and heroin use decreased 6%. These results would have a dramatic national impact, assuming there were enough treatment programs.

Other studies show that the annual cost of outpatient treatment programs in the United States is $2,700 compared with incarceration, which costs $39,000 per year. Residential treatment costs $12,000 per year; without treatment, the estimated cost to society is $43,000 per addict.15,16 One of the more striking comparisons, however, comes from the journal The Lancet.14 The authors compare the success rate of treating alcoholism, opiate, cocaine, and nicotine dependence with other chronic medical diseases such as insulin-dependent diabetes mellitus, hypertension, and asthma (Tables 2 and 3). Among addictive disorders, nicotine dependence has the worst success rate, but the treatment of alcoholism, opioid dependence, and cocaine dependence are slightly better than the success rates for the three chronic medical conditions. This highlights other problems associated with substance abuse. The patient who has a substance-abuse problem is stigmatized by society and even some health professionals; yet three fourths of patients are gainfully employed. In contrast, alcohol use is socially acceptable, and in some instances, the medical profession encourages moderate consumption of red wine. Treatment of alcohol abuse is more socially acceptable than treatment for illicit drug use. Our public policies reflect this disparity. These policies are unfair and ultimately destructive to our society and to the societies of drug-producing countries as well.

Table 2
Table 2
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Table 3
Table 3
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A Rational Solution

There are at least two well-articulated public policies on substance abuse.16,17 Table 4 contains a list of the goals of a rational drug policy published in the American Journal of Public Health.17 The actual solutions emphasize that our public policies should focus on providing adequate treatment programs. Reducing demand through treatment programs is not only cost effective, but also, as previously stated, has a success rate somewhat better than treatment of other chronic medical diseases.

Table 4
Table 4
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The Physician Leadership on National Drug Policy has also recommended changes to the current public policy on substance abuse.16

•Refocusing national drug policy on our investment in the prevention and treatment of harmful drug use.

•Eliminating the stigma associated with the diagnosis and treatment of drug problems.

•Improving training for health professionals to ensure clinical competence in this endeavor.

•Establishing community-based health partnerships to solve these problems. This would include working with drug courts and community leaders.

•Investing in research to better understand the biological and behavioral aspects of drug addiction and research on the outcomes of prevention and treatment programs. This would obviously include cost accountability to the public and Congress.

The nonmedical use of psychoactive drugs is inevitable. In a private environment, the use of such drugs would probably not cause public harm. Like alcohol, driving under the influence of drugs is a major social harm and seems to be increasing. The unregulated use of drugs causes other health problems, including HIV, Hepatitis B, Hepatitis C, and overdoses. The public harm that trauma surgeons see is violence. If we could agree that substance abuse is a public health problem, the obvious choice from a public health standpoint is to treat the disease. The corollary is that we must identify those individuals who use drugs inappropriately and cause harm to the public.

In the early 1990s, one of the authors (C.B.) appeared before our state legislature in an attempt to get a law passed allowing physicians to report alcohol and drug toxicity results to the Department of Health. After two unsuccessful attempts, a law was passed in 1995. The original intent was that this would be a ‘must report’ law. However, the Oregon Medical Association and the Oregon Hospital Association objected to this stating they would not support the bill unless it was a ‘may report’ law. In other words, physicians could do it, but they were not required to. After the law was enacted, some physicians supported it. In fact, about one third of emergency physicians and trauma surgeons did care and thought substance abuse was a public health problem. However, one third of the emergency physicians and surgeons simply did not care and did not report patients who were intoxicated or on drugs. One third of the physicians did not order the tests because they thought they were violating the patients’ civil liberties or they were violating patient trust, despite the fact that, by law, they know they are required to report certain infectious diseases and gunshot wounds. Illinois passed a similar ‘may report’ law in 1998, but after 3 years, they found that this was not working and amended the law to ‘must report.’ Because of HIPAA (Health Insurance Portability and Accountability Act) regulations, the Oregon Legislature made the Oregon law a ‘must report’ law in 2003.

This experience reinforces the recommendation from the Physician Leadership on National Drug Policy—‘We must educate physicians to treat alcohol and drug addiction as a public health problem, and health professionals should be clinically competent in referring and treating these conditions.’ There are other articles within this supplement reinforcing the fact that brief interventions are effective. Over time, recidivism may occur. Treatment interventions, like treatment for all other chronic diseases, must be ongoing.

Another of the recommendations by the Physician Leadership on National Drug Policy is that we must have community-based health partnerships to solve the alcohol and drug problem. If emergency department physicians can identify this problem in routine screening, many patients could be referred to the appropriate treatment centers. If violence or accidents were involved, an alternative strategy would be drug court. Clearly, if a felony has been committed, such as vehicular manslaughter, drug courts could recommend mandatory treatment in the event a prison term was handed down. Alternatively, for a misdemeanor, it would be more appropriate for society to have the patient treated and remain out of jail, which would reduce costs and increase the chance of rehabilitation.

Trauma surgeons must also help identify patients whose injuries are related to alcohol and substance use and refer these patients for treatment. We have found that work-related accidents and home accidents are often associated with either alcohol or drugs. Most acts of violence involve alcohol and drugs, and, as noted earlier, the underlying pathophysiology of vehicular accidents is alcohol or drugs. Thus, trauma surgeons should be involved in reporting these cases to public health departments to assist in surveillance data collection.

There are some interesting allies in the effort to change our current drug policy. In two conservative publications, The National Review and The Economist, there is support for a change in public policy by conservatives.1,2 One editorial in The Economist states, rightly, that nicotine has more addictive power than that of heroin.2 The author further argues, ‘The practical case for a liberal approach rests on the harms that spring from drug bans and the benefits that would accompany legislation. At present, the harms fall disproportionately on poor countries and on poor people in rich countries.’ Like the public health advocates who argue for harm reduction, The Economist reinforces this. “Removing these harms would bring with it another benefit. Precisely because the drugs market is illegal, it cannot be regulated.” The editorial concludes, “A legal market is the best guarantee that drug-taking will be no more dangerous than drinking alcohol or smoking tobacco. And, just as countries rightly tolerate those two vices, so they should tolerate those who sell and take drugs.” The only two adjuncts we would add are 1) trauma patients should be routinely tested for alcohol and drugs, and 2) patients with alcohol- and substance-abuse problems should be referred to appropriate treatment centers.

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1. Buckley WF Jr, Nadelmann EA, Schmoke K, et al. The war on drugs is lost. Natl Rev. 1996;34–48.

2. The case for legalization [editorial]. Economist. 2001;360:11–12.

3. Cairncross F. A survey of illegal drugs: high time. Economist. 2001;360:1–16.

4. Stein JJ, ed. Substance Abuse: The Nation’s Number One Health Problem. Princeton, NJ: Robert Wood Johnson Foundation; 2001.

5. Chepesiuk R. Hard Target: The United States War Against International Drug Trafficking, 1982–1997. Jefferson, NC: McFarland & Co; 1999.

6. Nadelmann EA, Courtwright DT. Should we legalize drugs? History answers. Am Herit. 1993;44:41–47.

7. Jonnes J. Founding father: one man invented the modern narcotic industry. Am Herit. 1993;44:48–49.

8. Biden JR. Don’t forget Afghanistan. New York Times. October 1, 2003;sect A:23.

9. Harris AR, Thomas SH, Fisher GA, Hirsch DJ. Murder and medicine: the lethality of criminal assault 1960–1999. Homicide Stud. 2002;6:128–166.

10. Schermer CA, Wisner DH. Methamphetamine use in trauma patients: a population-based study. J Am Coll Surg. 1999;189:442–449.

11. Massing M. The Fix. New York, NY: Simon & Schuster; 1998.

12. Drug Policy Foundation. The Drug Policy Letter. 1994;22:28.

13. MacCoun R, Reuter P. Interpreting Dutch cannabis policy: reasoning by analogy in the legalization debate. Science. 1997;278:43–52.

14. O’Brien CP, McLellan AT. Myths about the treatment of addiction. Lancet. 1996;347:237–240.

15. DesJarlais DC. Harm reduction: a framework for incorporating science into drug policy [editorial]. Am J Public Health. 1995;85:10–11.

16. Physician and Lawyers for National Drug Policy. Physician Leadership on National Drug Policy. [consensus statement online]. Brown University, Providence, RI. Available at: Accessed October 12, 2004.

17. Reuter P, Caulkins JP. Redefining the goals of national drug policy: recommendations from a working group. Am J Public Health. 1995;85:1059–1063.


Substance abuse; Public policy; Alcohol; Cocaine; Heroin

© 2005 Lippincott Williams & Wilkins, Inc.

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