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Journal of Trauma-Injury Infection & Critical Care:
doi: 10.1097/01.ta.0000174926.68892.1c

Changing the Battle Plan

Kleber, Herbert D. MD

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From the Division of Substance Abuse, Columbia University College of Physicians and Surgeons, New York, New York.

Submitted for publication April 21, 2005.

Accepted for publication April 21, 2005.

This article was written for the proceedings from a conference entitled Alcohol Problems among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism, in Arlington, Virginia, May 28–30, 2003. It does not reflect the official policy/opinions of the participating agencies, the U.S. Department of Health and Human Services, or the Centers for Disease Control and Prevention, and does not constitute an endorsement of the authors or their programs by the Centers for Disease Control and Prevention, the U.S. Department of Health and Human Services, or the federal government, and none should be inferred.

Address for reprints: Herbert D. Kleber, MD, Division of Substance Abuse, Columbia University College of Physicians and Surgeons, 1051 Riverside Drive, Unit 66, New York, NY 10032; email:

Although there may be other innovative approaches to fighting the “War on Drugs,” legalization is neither the solution nor the most reasonable approach. As with other social wars we have waged—alcohol, poverty, racism, school desegregation, women’s voting rights, and cancer—the issues prompting calls for change in public policy involving illicit drug use have evolved over a long period of time. By the time we realized the scope of the problem, illicit drugs had already become entrenched in our society. We need to learn from history and proactively formulate plans for addressing this social problem.

Within these conference proceedings are articles by authors who advocate legalization and decriminalization as plausible plans for dealing with the public health menace of illicit drugs. One article describes in graphic detail the severe disease of cocaine and heroin use found in trauma centers. Although these trauma center cases are horrendous, it would be counterproductive to advocate legalization on the basis of emotional pleas for change; more likely, these horror stories would only get worse. A second article describes the history of drug and alcohol use in our country and strongly suggests that illicit drugs should be made legal, similar to the alcohol model. Because much of the disease and carnage treated in hospitals is related to alcohol use, the preference for this model seems dubious. It takes many battles on many fronts to win a war–-have these authors fully considered the medical, public health, and criminal implications such a radical change would evoke? Can their plans be effectively coordinated? Or would legalization and decriminalization spawn even more problems? As H. L. Mencken noted in 1920, “There is always a well-known solution to every human problem—neat, plausible, and wrong.”

This editorial does not take issue with the clinical findings these authors cite, but strongly disagrees with the proposed policy solutions they offer. Furthermore, it calls attention to several key issues glaringly omitted from their articles. The authors make an error common to many advocacy articles by citing only those references that support their positions, and by failing to discuss the volume of literature that counters their viewpoints. The fact that alcohol and tobacco, both accepted and legal drugs, are also among the most widely abused demonstrates that substance-use behavior is influenced by accessibility, affordability, and acceptability. Changing the legal status of users and addicts raises important questions: Will legalization decrease addiction? Will it reduce crime or improve public health? Will legalization improve prevention and treatment efforts? Will legalization lower economic, social, and health care costs related to drug use and abuse—or will it have the opposite effect?

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Proponents of legalization claim there would not be a significant increase of drug-dependent persons. If they are wrong, as I contend, and the number of users and addicts—particularly among adolescents—increases significantly, any proposed benefits of legalization will evaporate.

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Legalization Would Increase Accessibility

It is fair to say that although the authors acknowledge the possible downsides to legalization—increased experimentation and dependency—they present only arguments to the contrary. Increased accessibility would increase experimentation and casual use leading to dependency (e.g., the rates of alcohol and tobacco use among adolescents substantially exceed that of illicit drug use).1 Casual drug use among adolescents is a real danger; young people are much more likely to experiment with drugs than are adults, and the experience produces more pronounced brain effects that can be permanent. Plus, impulses toward novelty develop far more quickly in adolescents than does the mechanism to inhibit urges. Drugs like cocaine affect the frontal cortex, which is responsible for controlling behavior and helping to put the brakes on impulses like unprotected sex. “Direct pharmacological-motivational effects of addictive drugs on dopamine systems may be accelerated during these developmental epochs, enhancing the progression or permanency of neural changes underlying addiction.”2 A greater understanding of this mechanism may increase our understanding of why drug dependence is, so often, a chronic relapsing disorder.

Current prevention and treatment programs cannot effectively counter the increased number of users and problems that would result from legalization and greater accessibility. Some proponents for legalization argue that because young people are going to experiment with drugs anyway, we should promote “safe” drug use. But this argument fails to address the possible long-term consequences of even casual drug use in young people—permanent brain changes, future drug dependency, and behavioral consequences such as motor vehicle crashes and unprotected sex.

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Legalization Would Make Drugs More Affordable

Unless the general laws of economic supply and demand are repealed, if illicit drugs become legal, the cost will decrease and consumption will increase, thereby increasing addiction. For example, cocaine now sells for $60 to $200 per gram, but it would retail at less than $10 per gram if it could be produced and distributed legally. This would set the street price at less than 50 cents per dose—well within the reach of virtually every young person in America. If taxes were increased to keep the price high, an illegal black market would remain. Furthermore, as is the case with existing taxes on alcohol, tobacco, or gambling, tax revenues from drugs would not likely go to treatment.

Ironically, the fastest growing drug problem among the general population has been the prescription opioid analgesics. Would the authors advocate making OxyContin and Dilaudid readily available and therefore more affordable without prescription? It would be ironic—and tragic—if heroin addicts could legally obtain cheap heroin to support their habit while terminally ill cancer patients incur great expense to obtain prescriptions for essential pain medication.

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Legalization Would Make Drugs More Acceptable

Laws express the will of the people by defining acceptable societal conduct. Drug laws not only reflect prevailing attitudes and create criminal sanctions but also educate the public and shape attitudes. Reducing addiction would be decidedly more challenging if society passed laws that indicated these substances were not sufficiently harmful to prohibit their use. For example, when Prohibition was repealed, society became more accepting of alcohol use. The authors point out that crime, corruption, and violence associated with the alcohol trade during Prohibition diminished after it ended, but they fail to emphasize that alcohol addiction also increased. During Prohibition, the amount of alcohol consumed declined, as did the incidence of alcohol-related medical problems and violence. Furthermore, although it is true that arrests for alcohol trafficking decreased after the repeal of Prohibition, the number of alcohol-related arrests attributable to behavior resulting from intoxication nearly doubled.3 Prohibition was repealed because of broad public support for legal access to alcohol. The “freedom” to drink alcohol was perceived as more important than the individual and public health “consequences” caused by alcohol use. Similarly, legalization of illicit drugs would send a signal that protecting the public health should be secondary to the freedom to use these substances. If only 15% of the population began using drugs after legalization, the current level of drug use (7%) would more than double.

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Yes it would, to a degree, but only with respect to the buying, selling, and use of illicit drugs, each of which is presently a crime. Crimes associated with the physical and mental effects secondary to drug use and addiction would increase. Most street users are already well established in their criminal careers before the onset of either narcotic or cocaine use. They commit crimes not only to support their habits but also to pay for basic daily living expenses such as food, clothing, and shelter. If the price of legalized drugs is kept low in an effort to diminish crime, widespread use will escalate quickly; if kept high by means of taxes to provide funds for treatment and prevention, an illegal market would persist both for hard-core addicts and for those who want to begin experimenting with drugs. In a 1970s study conducted in England, two thirds of those who received heroin by prescription continued to commit crimes; many either sold heroin or bought more heroin on the black market to feed their habit.4

The argument that legalizing drugs will diminish crime is simply not well founded. To the contrary, legalization will reduce the price of illicit drugs and will increase accessibility, leading to increased casual use and the greater likelihood of addiction. Remember when crack was readily available at $3 per rock? Crack addicts committed crimes other than using, buying, or selling the drug. It is estimated that if cocaine were as available as alcohol, the number of cocaine addicts would rise sharply—perhaps 3 to 10 times the current number of approximately 2.8 million.5 Because cocaine use is associated with paranoia, psychosis, and violence, the legalization of this drug would only increase crime and the resultant injuries and deaths associated with its use. Let’s not tear down our current legal system but make it more effective by concurrently expanding and improving treatment and prevention programs.

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No. As noted earlier, laws both reflect and shape public perception of what is acceptable behavior. Legalization suggests that illicit drugs are not harmful, making both prevention and treatment more difficult. Increased resources can be dedicated to prevention and treatment programs without changing the legal status of illicit drugs.

Proponents contend that legalization would free up monies from law enforcement for redistribution to treatment and prevention programs. This is essentially saying, “Let’s make drugs legal so that we can have additional funds to treat the public health problems they cause.” The drug problem in this country is already an epidemic. Creating more drug addicts is not the answer. There is no evidence that demand-reduction efforts—prevention and treatment—are adequately successful to stem the increased drug use in a legalized environment. Millions still engage in risky sexual behavior, and ironically, improved treatment for acquired immunodeficiency syndrome has apparently led many to give up safe sex practices. Fifty million Americans still smoke cigarettes on a regular basis despite heavy antismoking campaigns and a variety of treatment methods.

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Advocates for legalization point to the exploding prison population, generated in large part by stricter laws, tougher enforcement, and mandatory minimum sentencing. However, recidivism also contributes to the prison population. Rather than make hard drugs readily available and affordable, we need more treatment programs in prison, after prison, and instead of prison to address recidivism. Although strict law enforcement does not necessarily deter addicts from using drugs, the criminal justice system can play a major role by diverting nonviolent offenders into treatment through drug courts, which have been shown to increase the number of individuals likely to complete treatment. Mandatory treatment with close supervision and credible sanctions is about as effective as voluntary treatment. However, legalization will decrease the number of people referred for mandatory treatment.

It is true that legalization would initially decrease law enforcement costs and our prison population, but these costs would quickly rise again as criminal activity increases because of the psychological and physical effects of drug use. An increase in drug-related injuries and fatalities associated with motor vehicle crashes, domestic violence, and crime in general would inevitably show up in our trauma centers. So, over time, it is doubtful that legalization would produce any cost savings in law enforcement. Furthermore, it is unrealistic to expect that taxes imposed on newly legalized drugs would be sufficient to cover the additional law enforcement costs generated by increased use and resultant drug-related crimes.

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Today, advocates of legalization claim that taxes on the legal sale of drugs would dramatically increase revenues and even help erase the federal deficit. Years ago, opponents of alcohol prohibition made similar claims, but the reality has been quite different. In 1995, although state and federal alcohol taxes generated more than $11 billion in revenues,6 this tax revenue paid for less than half the $40 billion health care burden imposed by alcohol abuse.7 Similarly, health care costs directly attributable to illegal drugs already are approximately $15 billion,8 an amount that would increase significantly with legalization. When illicit drugs become readily accessible, cheaper, and viewed as more acceptable because they are legal, use will increase along with drug-related injuries and the resultant health care costs.

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It is commonplace for those who oppose current U.S. policy on drug use and abuse to argue, “The war on drugs is lost.” The battlefield analogy is an unfortunate one. It is true that this war should be fought on a number of fronts; however, legalization is not an appropriate front. To write off the additional millions of addicts that would be created by legalization is a policy of despair. Rather than tearing down the current legal system, legal sanctions should be paired with treatment programs. I do agree with the authors that treatment and prevention must be priorities—but these programs cannot replace criminal sanctions. There are a variety of innovative programs that can be implemented: eliminating mandatory minimum sentences for certain drug-related offenses; expanding drug courts as well as postprison treatment; expanding the recently created Parents Corps; creating incentives for large pharmaceutical companies to focus on developing medications, especially for cocaine treatment; and expanding buprenorphine programs to reach more of the 75% of heroin addicts not in treatment—a far better alternative than heroin maintenance.

Currently, 65% of federal expenditure for drug control goes toward reducing supply; 35% is allocated to programs that focus on reducing demand.8 Keeping currently illicit drugs illegal does not mean we have to be bound by the same proportion of expenditures. A 50/50 split could realistically improve our chances of “containing” the drug problems in this country.

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Ironically, most legalization or decriminalization activity focuses on marijuana and not on heroin and cocaine, even though these drugs are the ones most often associated with crime and health problems. Given the focus on trauma, this discussion has mainly argued against legalization of drugs such as cocaine and heroin.

Although less dangerous than heroin or cocaine, marijuana is hardly innocuous.9 It can produce physical dependence and addiction in approximately 1 of 11 people who try it, compared with 1 of 3 who try smoking tobacco, 1 of 4 who try heroin, 1 of 5 who try cocaine, and 1 of 6 who try alcohol.10 Increased availability tends to correlate with increased experimentation and use. As use rises, the number of dependent users with drug-associated problems rises as well. If more Americans use marijuana, we will be left with substantially more persons in trouble with the drug. Finally, the increased vulnerability of adolescents and the potential for permanent brain changes caused by addiction may increase recidivism. Therefore, decriminalization of marijuana has its own unique drawbacks. Treatment for problems associated with marijuana use has become a common reason for seeking substance-abuse treatment, with almost 1 million individuals seeking such treatment in 2002.10 Even though marijuana toxicity is lower than that of opioids or cocaine, altering its legal status would not decrease the number of persons presenting to emergency rooms with problems associated with its use. Smoking marijuana increases lung cancer risk. Use of marijuana has been linked to impaired driving, impaired short-term memory, and decreased energy, a trait especially problematic for adolescents. Incarceration for individuals who possess only small amounts of marijuana is not likely to occur, but when it does occur, it is not a plausible solution either.

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1. Johnston L, O’Malley P, Bachman J. National Survey Results on Drug Use from the Monitoring the Future Study, 1975-2001. Ann Arbor, MI: University of Michigan; 2002.

2. Chambers R, Taylor J, Potenza M. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry. 2003;160:1041–1052.

3. Aaron P, Musto D. Temperance and prohibition in America: a historical overview. In: Moore, M, Gersten D, eds. Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National Academy Press; 1981:127–181.

4. Spear B. The early years of the “British System” in practice. In: Strang, J, Gossop M, eds. Heroin Addiction and Drug Policy: the British System. New York: Oxford University Press; 1994:3–28.

5. Homer J. Projecting the impact of law enforcement on cocaine prevalence: a system dynamics approach. J Drug Issues. 1993;23:281–295.

6. U.S. Department of Treasury, Bureau of Alcohol, Tobacco and Firearms. Statistical Release: Alcohol, Tobacco and Firearms Tax Collections. Fiscal Year 1995. Washington, DC: U.S. Department of Treasury: 1995.

7. National Center on Addiction and Substance Abuse at Columbia University. The Cost of Substance Abuse to America’s Health Care System. Final Report. New York: Center on Addiction and Substance Abuse; 1996.

8. Office of National Drug Control Policy. National Drug Control Strategy, February 2002. Washington, DC: The White House; 2002.

9. Solowij N, Stephens RS, Roffman RA. Cognitive functioning of long-term heavy cannabis users seeking treatment. JAMA. 2002;287:1123–1131.

10. Anthony JC, Warner LA, Kessler RC. Comparative Epidemiology of Dependence on Tobacco, Alcohol, Controlled Substances and Inhalants: Basic findings from the national comorbidity survey. Exp Clin Psychopharmacology. 1994;2:244–268.

11. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administrations, Office of Applied Studies (OAS). 2002 National Survey on Drug Use and Health: National Findings. Washington, DC: Office of Applied Studies; 2002. Available at: Accessed September 28, 2004.

Cited By:

This article has been cited 1 time(s).

Journal of Trauma and Acute Care Surgery
Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady
Hungerford, DW
Journal of Trauma and Acute Care Surgery, 59(3): S10-S17.
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Illegal drugs; Legalization; Prevention; Treatment

© 2005 Lippincott Williams & Wilkins, Inc.

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