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DRUG ABUSE: A NATIONAL POLICY PERSPECTIVE* MATHEA FALCO, J.D. Visiting Fellow New York Hospital-Cornell University Medical College New York, New York
A MERICAN VOTERS RATE DRUG ABUSE as the nation's most important
A domestic and foreign political problem, more serious even than the budget deficit and arms control. During the past five years, rapid spread of crack cocaine has created a deep sense of crisis over the failure of national drug policy. Unprecedented increases in violent crime by users and traffickers have stretched an already overburdened criminal justice system and left many citizens fearful for their own safety. The spread of the AIDS virus and sexually transmitted diseases by drug users has further intensified public fear. Increasing numbers of drug addicted babies have raised economic questions about who will bear the long-term costs of caring for them. At the same time, crack has accelerated the disintegration of many poor families and neighborhoods, exposing the deeper structural problems of poverty, race, education, and employment opportunity in our society. The crack epidemic caught the nation unprepared to respond to its catastrophic consequences. Although programs to reduce the demand for drugs through prevention, education, and treatment had been widely developed since the early 1960s, they were designed for very different drugs and drug users. Preventive efforts targeted school children, usually from the white middle class, while treatment generally centered on adult male heroin addicts and, to a lesser extent, polydrug and alcohol abusers. Moreover, national policy during the past decade placed a far lower priority on reducing the demand for drugs than on law enforcement efforts to cut the supply. (This policy emphasis was generally reflected at the state and local level.) Because of substantial reductions in federal funding from 1981 to 1987, research into new models was severely constricted. So, too, was the provision of services: *Presented as part of a Symposium on Pregnancy and Substance Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City, Columbia University of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
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prevention and treatment programs were not available for many of those who needed them. DEFINING THE DRUG PROBLEM
In view of the national preoccupation with crack, it is important to remember that there is no single drug problem. Rather, there is a nationwide problem with drugs, including legal substances such as alcohol, tobacco, and prescribed medications. While heroin, cocaine, and marijuana are the most widely used illegal drugs, different cities also experience severe problems from other drugs such as PCP (phencyclidine) in Washington, D.C., and Los Angeles. Furthermore, whatever the primary drug problem, most abusers combine a complex variety of drugs and alcohol. This intertwined pattern of polysubstance abuse is often overlooked in discussions of national drug policy, particularly during periods when one drug -currently crack -dominates public concerns. The most recent surveys report that more than half of the nation's high school seniors have tried illicit drugs and that 28 million Americans used drugs at least once in the past year.' Nonetheless, overall drug use has declined significantly during the past decade. Current cocaine use (once during the past month) dropped by half from 1985 to 1988; marijuana use declined by a third. Heroin use has remained relatively constant at about half a million addicts. However, intensive use of cocaine and crack (weekly or daily) increased, involving an estimated 862,000 Americans compared to 647,000 in 1985. Cocaine use is highest among unemployed young adults aged 18 to 25. Most significantly for this conference on pregnancy and substance abuse, more than five million of the 60 million women of childbearing age reported using an illicit drug the month prior to the survey. Drug use by high risk groups (school dropouts, truants, criminal offenders, and homeless people) is generally not measured by national drug surveys, which rely on interviews with high school and college students and those living in households. As a result, experts believe that surveys substantially underreport use. Estimates from arrest and hospital emergency room data show that these high risk groups are much more likely to use crack and heroin. Reduced drug availability has not been a factor in the overall decline in use. Rather, concerns about health and increased awareness of the dangers posed by drugs seem to be major deterrents, along with economic factors and future aspirations. Teenagers whose parents have some higher education report a greater decline in illicit drug use than those whose parents have not Vol. 67, No. 3, May-June 1991
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finished high school; teenagers who plan to go to college report substantially less drug use than those who do not. The picture that emerges from the national surveys suggests an increasingly divided America. Illicit drug use remains a problem for all social, economic, and ethnic groups but less so among the affluent. The encouraging downward trend of the past decade has been most pronounced among middle class educated Americans. Heroin addiction continues to be concentrated among poor minorities; crack has become widespread in the nation's inner cities. In addition, a new generation of children has been recruited into the crack traffic which often involves them in criminal violence as well as drug use. The poor and disadvantaged suffer the multiple consequences of drug abuse and trafficking more grievously than the general population. They are at much greater risk for unemployment, AIDS, homelessness, and crime, either as victim or perpetrator. Their children are more likely to drop out of school or be placed in foster care. Treatment for drug abuse is less available to them than to those who are insured or can afford private programs. OVERVIEW OF FEDERAL DRUG POLICY
Federal drug policy during the past decade has been dominated by efforts to reduce the supply of illicit drugs through law enforcement and interdiction. During the first year of the Reagan Administration, spending for these programs was increased by half: by the end of the Reagan presidency spending had more than quadrupled (from $800 million to $3.5 billion). Almost half of this amount went for interdiction programs to keep drugs from crossing the borders and international efforts to reduce illicit drug production in other countries. At the same time, support for demand reduction programs was drastically cut. Total federal funding for prevention, education, and treatment declined from $404 million in 1981 to $338 million in 1985; adjusted for inflation, this amounted to a real drop of almost 40%. From 1981 to 1988 overall funding for demand reduction efforts represented about one fifth of the national antidrug budget. The remaining four fifths went to drug law enforcement, which received more than 90% of the massive drug funding increases of the past decade. Public frustration over the continuing failure of this heavy reliance on law enforcement led Congress to adopt a comprehensive Anti-Drug Abuse Act in 1986 which more than doubled funds for demand reduction. Nonetheless, law Bull. N.Y. Acad. Med.
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enforcement continued to receive more than three quarters of the total $3.9 billion drug funds. Congress again attempted to increase support for demand reduction in a new Anti-Drug Abuse Act in 1988; however, because of deficit ceiling constraints on spending, very little new money was available, and demand reduction remained only one quarter of the total drug budget. The 1988 Act also targeted funds for special high risk groups, including pregnant women, children, and intravenous drug abusers. At the same time, the Act established tougher criminal penalties for traffickers and new "user accountability" provisions aimed at so-called middle class users. Those found with small amounts of drugs can now be assessed civil fines, while courts are given discretion to deny federal benefits such as school and housing loans. The new national drug control strategy, which President George Bush announced in September 1989, essentially continues the policies of the Reagan Administration. While recognizing the importance of demand reduction efforts, the strategy maintains the dominance of supply control programs, which receive approximately two thirds of the $9.8 billion drug budget. It also emphasizes user accountability, reflecting the view that even occasional users sustain the illicit drug traffic. THE POLICY DEBATE In the 1970s public debate over drug policy focused on whether illicit drugs were dangerous; today, most Americans assume that they are and focus instead on the appropriate policy response to a situation clearly out of control. The current debate ranges from "zero tolerance" of any illicit drugs to legalization of all drugs. Former First Lady Nancy Reagan, through her "Just Say No" campaign, has been a leading proponent of zero tolerance -the belief that any illicit drug use is criminal, regardless of circumstances or consequences. This position views casual drug users as accomplices to murder because they keep drug traffickers in business. President Bush and his former "Drug Czar" William Bennett support this view, reflected both in intensive enforcement of possession laws and increased penalties for users. A diametrically opposite view proposes legalization in response to failure of present drug policies. Proponents argue that drug related crime would be greatly reduced, and that, although millions of additional Americans might become drug dependent, resources now devoted to drug law enforcement could be diverted to expanded prevention and treatment programs. Although Vol. 67, No. 3, May-June 1991
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the media have given considerable attention to the proposal, legalization has not received significant political support. Recent polls indicate that more than 80% of Americans oppose legalization and two thirds believe that marijuana possession should be a criminal offense. There are, of course, other policy alternatives between these two extremes. One approach would target resources toward the most dangerous drugs rather than all drugs equally and shift policy and program priorities toward demand reduction. This could also involve a fundamental revision of the traditional view of drug abuse as a problem to be dealt with primarily through the criminal law rather than the public health system. Experience of the past several decades demonstrates that law enforcement as a dominant policy response has not succeeded in reducing drug abuse or drug-related crime. Instead, the encouraging declines in overall drug use have resulted from personal health concerns and increased social disapproval of use. WOMEN AND DRUGS -A NEW Focus OF NATIONAL CONCERN
Historically, women have been the hidden substance abusers of American society. At the turn of the century, when there were no legal restrictions on the sale of heroin, cocaine, and marijuana, there were an estimated 250,000 opiate addicts in the U.S.2 Apart from Civil War veterans who had become addicted to morphine administered for pain, most addicts were women dependent on patent medicines. Despite their addiction, they were generally viewed as respectable if somewhat pitiable members of the community. After the passage of the Harrison Narcotic Act in 1914 and subsequent laws prohibiting these drugs, many women turned to psychoactive prescription drugs to avoid the public stigma of illegal use. Consequently, women have been underrepresented in national drug surveys. At the height of the heroin epidemic in the early 1970s, fewer than one fifth of all addicts were female. Unlike earlier illegal drugs, crack has proved particularly popular with women. Rapidly addictive and very cheap, crack has the reputation of being "cleaner" than heroin and other street drugs, perhaps because it can be smoked rather than injected. The numbers of women seeking treatment for cocaine/crack have jumped dramatically. At Phoenix House in New York City, they almost tripled from 1985 to 1989. About 40% of crack abusers admitted to publicly funded treatment in New York in 1989 were women. This surge in crack abuse by women has had devastating consequences for the women themselves, their unborn infants, and their families. Bull. N.Y. Acad. Med.
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Child abuse and neglect cases have risen dramatically since crack appeared on the streets. Substance abuse is the dominant characteristic in child abuse cases in 22 states and the District of Columbia according to a recent study by the National Committee for Prevention of Child Abuse.3 Nationwide, the number of children in foster care has increased by almost a third since 1988: in New York City the foster care population jumped 90% from 1987 to 1989 (from about 27,000 to 52,000).4 Foster care agencies have difficulty finding families willing to take children who might have drug-related problems, including the possibility of AIDS. Once these children are placed, there are often not enough resources to pursue permanent placement options such as supportive services to the mother or adoption. The cumulative impact of these trends has destabilized many inner city communities, long dependent on its women to provide the backbone of its families. Recent national surveys estimate that 375,000 drug exposed babies are born annually.5 The 1989 National Drug Control Strategy reported that one fifth of the pregnant women at some major hospitals test positive for cocaine and that 100,000 cocaine addicted babies are born each year.6 The human and economic costs continue to mount. Nationally $2.5 billion was spent last year for intensive care for crack babies, and an additional $15 billion will be required to prepare them for kindergarten. The longer term prospects are not encouraging. Research on babies exposed to cocaine before birth has found that they can be severely damaged even with very little cocaine use by the mother. These babies show a wide range of ill effects, including retarded growth, neurological abnormalities, and even strokes. They also tend to be smaller and have smaller heads and brains than normal babies. The relative neglect of demand reduction during the past decade has been particularly acute for drug abusing pregnant women. For those who cannot obtain private care, treatment has been extremely limited. The New York State Division of Substance Abuse Services reported that in 1988 New York City provided about 42,000 treatment slots -30,000 for methadone maintenance and the balance for drug-free residential and nonresidential programs as well as detoxification beds within hospitals. Current levels of methadone maintenance treatment can reach only 15% of the city's estimated 200,000 heroin addicts at one time. For all other drug abusers, including heroin addicts who want to become drug free, treatment is currently available for only 3%. Vol. 67, No. 3, May-June 1991
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The problem of limited treatment resources has been compounded by the failure of programs to respond to special needs of pregnant women. Many programs have simply refused to serve this group; others will not accept Medicaid coverage. Many women are unwilling to enter treatment if they have to relinquish their other children to foster care and face difficulties in regaining custody. A few programs in New York City, like Project Return, PACE, Odyssey House, and PAAM (Pregnant Addicts and Addicted Mothers) have developed special programs for drug-dependent mothers and their children. An outpatient acupuncture program at Lincoln Hospital for women referred by the Division of Social Services as a condition of keeping their children also obtains Medicaid reimbursement. Additional models are urgently needed for pregnant drug abusers across the country. RECENT TREND TOWARD CRIMINALIZATION OF DRUG USE
President George Bush has called for tougher user accountability provisions, including criminal sanctions and jail terms. His views enjoy widespread popular support. A September 1989 New York Times/CBS poll found that two thirds of the public favor more severe penalties for drug use, drug testing of high school students, and allowing the police to search cars and houses for drugs without warrants. This trend toward stricter user accountability is particularly clear in relation to drug abusing pregnant women and mothers. Many hospitals report drug positive urine tests in newborns to child protection agencies which then investigate the mother's fitness to keep the child. Half the states permit hospitals to hold endangered children against the parent's wishes (without a finding of abuse or neglect). "Boarder babies" who remain in hospitals pending these investigations or because they have been abandoned have become an increasingly serious burden in already crowded facilities. During the past several years, in about 35 cases around the country women have faced criminal charges for using drugs and/or alcohol while pregnant. In California a Butte county district attorney announced that any evidence of cocaine, heroin, or methamphetamine in a baby's urine would be used to prosecute the mother for illegal drug possession, although prosecution would be deferred if she entered a treatment program. In New York a pregnant woman's use of cocaine and failure to seek prenatal care has been ruled to constitute criminal neglect. An Illinois woman was recently convicted of child abuse and neglect for using cocaine during pregnancy. In Florida women have been prosecuted for felony drug offenses usually reserved for traffickers. One mother whose son was born addicted to cocaine Bull. N.Y. Acad. Med.
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and infected with syphilis was charged with child abuse and delivery of drugs to a minor. Child abuse normally carries a sentence of no more than 60 days in Florida while delivery of drugs to minors can entail a maximum prison sentence of 30 years. In July of last year another Florida woman whose two babies tested positive for cocaine was convicted of this felony charge and sentenced to 15 years; however, the prosecutor recommended that she continue drug treatment and remain on probation. In Washington, D.C., a pregnant woman who pleaded guilty to forgery was sent to prison although she normally would have received probation. Because she tested positive for cocaine, the judge incarcerated her to prevent her from taking drugs during her pregnancy. An Illinois prosecutor recently carried the notion of accountability even further by charging a woman with involunatry manslaughter when her baby died two days after birth due to cocaine exposure late in her pregnancy. Underlying these cases is the assumption that the threat of criminal prosecution will deter pregnant women from using drugs and therefore protect their unborn children. There is no evidence that this approach is effective, and it may produce the opposite result. Faced With the prospect of losing custody over their infants and/or a jail term, many pregnant women will be reluctant to seek help. Although criminalizing drug use effectively expresses society's outrage at women who inflict permanent damage on their unborn children, it also exacerbates the already difficult task of engaging this often hard to reach group in treatment. In fact, these prosecutions reflect increasing widespread frustration at the limits of the criminal justice system in addressing maternal drug abuse, and some judges recognize that making an example of one pregnant woman by jailing her for drug use may effectively drive thousands of others away from health care.7 This trend toward criminalization is driven by concern for the unborn child rather than the mother; it is ironic that this focus has also served to illuminate the need for treatment responsive to the special needs of women.
Questions and Answers PARTICIPANT: One of the problems in this area is that effective treatment models for cocaine abuse have really not been developed and tested. In alcoholism certainly there's a great deal of research on effectiveness of alcoholism treatment. Now the biggest problem is cocaine, but there has not yet been to my mind effective treatment and prevention in relation to cocaine abuse. With that kind of difficult clinical and scientific situation, how could Vol. 67, No. 3, May-June 1991
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you convince the people who are going to decide on giving money that you should give money to this treatment area? DR. FALCO: Tell them that we don't have any magic bullets in this as in many other areas. But we do know a lot about what does have at least a partial effect in treatment. We do know that comprehensive programs help pregnant women. There's a whole history of dealing with women abusers and abusers in general. Clearly, crack is a special problem, but the problems of addiction are more universal. It is very easy to fall into the trap that since "nothing works," why should we do anything? I believe we know a lot more than we pretend to know, and that we need to proceed on those bases. There is a lot I could spend money on today. PARTICIPANT: How do you put together your predictions about home grown synthetic drugs and the sort of urges to profiteering market drugs? DR. FALCO: You mean what will happen to the international traffickers? PARTICIPANT: How do you see those two forces? DR. FALCO: It is already happening. The international traffickers are moving toward Europe. They are always drawn toward hard currency, and European currency is even more attractive now than U.S. dollars. I think we shall see a huge surge in crack addiction in Europe in the next five years. It is already beginning. Traffickers are in business and it is just a question of which way they shift their effort. Europe has been relatively protected from the crack traffic until now. PARTICIPANT: I would like you to comment on the other major policy development in 1981, which was the shift in how drug treatment and prevention were funded in this country, which I think had as much impact on at least the amount of money that went in. DR. FALCO: That is absolutely right. What the questioner refers to is that in 1981 President Reagan decided to give all the demand reduction funding in block grants through state agencies instead of handling it directly out of the National Institute of Drug Abuse in Washington. I think that was really catastrophic for all kinds of reasons. First, we lost important national information that we used to get. Second, and probably more important, policy in this area really does have to be nationally developed, at least at some stage. A lot of states, given the block grants, simply did not put money into prevention and research. There is real resistance to some of these longer term projects because the payoffs are very obscure. When you run on two year political cycles, you have to produce Bull. N.Y. Acad. Med.
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things that look good in the short run. Unfortunately, that happened to a lot of drug treatment programs. PARTICIPANT: While we have RICO laws to get back some of the ill gotten gains from traffickers, what about governments that repay U.S. debts from the drug dollars? I'm having difficulty with us allowing governments to repay debts to us by their home grown narcotics and drugs going to this country. We have RICO. What about other statutes? DR. FALCO: That's an interesting point. Peru, one of the two largest coca producers in the world, is not even paying interest on their debts to us. It is true that Peru and Bolivia are completely supported by cocaine dollars, that their economies probably would collapse without that money. What should we do about it? Well, that is a long answer. I would say that we need to work with them in a long-term way. They don't control their own countryside. These are very weak central governments. Even if they were able to magically snap their fingers so that no peasants would grow coca, everybody would starve. Their economies have depended on this crop so long that it will take a concerted effort to get them off coca. The addiction analogy is not a bad one. During the 1980s we continued to focus on the notion of spraying herbicides on their crops. We never found a herbicide that works. Second, they have serious internal problems. A lot of peasants really object to having American law enforcement officials jumping out of helicopters. So it has created very serious political problems. I would say our international policy is really in a terrible state right now with regard to drugs. DR. FALCO: I don't know. PARTICIPANT: You mentioned that you think you should shift focus overnight from interdiction to treatment. How do you propose we go about doing that in terms of really affecting public policy? DR. FALCO: I'm a great believer in democracy. I used to work in the Senate and know that people who pass laws are greatly influenced by the people who vote for them. How many people in this room have communicated directly with their Congressman or Senator about their views on these issues? (Show of hands.) DR. FALCO: This is extraordinary. We must have about 5%, a much higher percentage than I usually get when I ask these questions. That's terrific, but it should be 98%. Keep talking to everybody who will listen. You carry a lot more weight because you are the ones who are on the front lines. Vol. 67, No. 3, May-June 1991
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We really all have that responsibility, not only to stay on the front lines, but to turn around occasionally and tell the people who are developing policy what the reality is. REFERENCES 1. Johnston, L, O'Malley, P. and Bachman, J.: Drug Use, Drinking & Smoking: National Survey Results from High School, College, and Young Adults Populations 1975-1988. DHHS Pub. No. (ADM)89-1638(1989). Washington, D.C., Govt. Print. Office, 1989. National Household Survey on Drug Abuse: Population Estimates 1988. DHHS Pub. No. (ADM)89-1636. Washington, D.C., Govt. Print. Off., 1989. 2. Blanken, A., Adams, E., and Durrel, J: Drug abuse: implications and trends. Psychiatr. Med. No. 3, 1987. 3. Besharov, D.: The children of crack. Public Welfare, p. 7, Fall 1989.
4. Besharov, D.: Crack Children in Foster Care. U.S. Senate Subcommittee on Children, Families, Drugs, and Alcoholism Hearing, November 13, 1989, p. 3. 5. Survey by National Association for Perinatal Addiction Research, reported in Brody, J.: Widespread abuse of drugs by pregnant women is found. N.Y. Times, August 30, 1988, p. 1. 6. National Drug Control Strategy. Washington, D.C., Govt. Print. Off. 1989, p. 44. 7. Lewin, T.: Drug use in pregnancy: new issue for the courts. N. Y. Times, February 5, 1990, p. 22.
Bull. N.Y. Acad. Med.
DRUG ABUSE: A NATIONAL POLICY PERSPECTIVE* MATHEA FALCO, J.D. Visiting Fellow New York Hospital-Cornell University Medical College New York, New York
A MERICAN VOTERS RATE DRUG ABUSE as the nation's most important
A domestic and foreign political problem, more serious even than the budget deficit and arms control. During the past five years, rapid spread of crack cocaine has created a deep sense of crisis over the failure of national drug policy. Unprecedented increases in violent crime by users and traffickers have stretched an already overburdened criminal justice system and left many citizens fearful for their own safety. The spread of the AIDS virus and sexually transmitted diseases by drug users has further intensified public fear. Increasing numbers of drug addicted babies have raised economic questions about who will bear the long-term costs of caring for them. At the same time, crack has accelerated the disintegration of many poor families and neighborhoods, exposing the deeper structural problems of poverty, race, education, and employment opportunity in our society. The crack epidemic caught the nation unprepared to respond to its catastrophic consequences. Although programs to reduce the demand for drugs through prevention, education, and treatment had been widely developed since the early 1960s, they were designed for very different drugs and drug users. Preventive efforts targeted school children, usually from the white middle class, while treatment generally centered on adult male heroin addicts and, to a lesser extent, polydrug and alcohol abusers. Moreover, national policy during the past decade placed a far lower priority on reducing the demand for drugs than on law enforcement efforts to cut the supply. (This policy emphasis was generally reflected at the state and local level.) Because of substantial reductions in federal funding from 1981 to 1987, research into new models was severely constricted. So, too, was the provision of services: *Presented as part of a Symposium on Pregnancy and Substance Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City, Columbia University of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
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prevention and treatment programs were not available for many of those who needed them. DEFINING THE DRUG PROBLEM
In view of the national preoccupation with crack, it is important to remember that there is no single drug problem. Rather, there is a nationwide problem with drugs, including legal substances such as alcohol, tobacco, and prescribed medications. While heroin, cocaine, and marijuana are the most widely used illegal drugs, different cities also experience severe problems from other drugs such as PCP (phencyclidine) in Washington, D.C., and Los Angeles. Furthermore, whatever the primary drug problem, most abusers combine a complex variety of drugs and alcohol. This intertwined pattern of polysubstance abuse is often overlooked in discussions of national drug policy, particularly during periods when one drug -currently crack -dominates public concerns. The most recent surveys report that more than half of the nation's high school seniors have tried illicit drugs and that 28 million Americans used drugs at least once in the past year.' Nonetheless, overall drug use has declined significantly during the past decade. Current cocaine use (once during the past month) dropped by half from 1985 to 1988; marijuana use declined by a third. Heroin use has remained relatively constant at about half a million addicts. However, intensive use of cocaine and crack (weekly or daily) increased, involving an estimated 862,000 Americans compared to 647,000 in 1985. Cocaine use is highest among unemployed young adults aged 18 to 25. Most significantly for this conference on pregnancy and substance abuse, more than five million of the 60 million women of childbearing age reported using an illicit drug the month prior to the survey. Drug use by high risk groups (school dropouts, truants, criminal offenders, and homeless people) is generally not measured by national drug surveys, which rely on interviews with high school and college students and those living in households. As a result, experts believe that surveys substantially underreport use. Estimates from arrest and hospital emergency room data show that these high risk groups are much more likely to use crack and heroin. Reduced drug availability has not been a factor in the overall decline in use. Rather, concerns about health and increased awareness of the dangers posed by drugs seem to be major deterrents, along with economic factors and future aspirations. Teenagers whose parents have some higher education report a greater decline in illicit drug use than those whose parents have not Vol. 67, No. 3, May-June 1991
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finished high school; teenagers who plan to go to college report substantially less drug use than those who do not. The picture that emerges from the national surveys suggests an increasingly divided America. Illicit drug use remains a problem for all social, economic, and ethnic groups but less so among the affluent. The encouraging downward trend of the past decade has been most pronounced among middle class educated Americans. Heroin addiction continues to be concentrated among poor minorities; crack has become widespread in the nation's inner cities. In addition, a new generation of children has been recruited into the crack traffic which often involves them in criminal violence as well as drug use. The poor and disadvantaged suffer the multiple consequences of drug abuse and trafficking more grievously than the general population. They are at much greater risk for unemployment, AIDS, homelessness, and crime, either as victim or perpetrator. Their children are more likely to drop out of school or be placed in foster care. Treatment for drug abuse is less available to them than to those who are insured or can afford private programs. OVERVIEW OF FEDERAL DRUG POLICY
Federal drug policy during the past decade has been dominated by efforts to reduce the supply of illicit drugs through law enforcement and interdiction. During the first year of the Reagan Administration, spending for these programs was increased by half: by the end of the Reagan presidency spending had more than quadrupled (from $800 million to $3.5 billion). Almost half of this amount went for interdiction programs to keep drugs from crossing the borders and international efforts to reduce illicit drug production in other countries. At the same time, support for demand reduction programs was drastically cut. Total federal funding for prevention, education, and treatment declined from $404 million in 1981 to $338 million in 1985; adjusted for inflation, this amounted to a real drop of almost 40%. From 1981 to 1988 overall funding for demand reduction efforts represented about one fifth of the national antidrug budget. The remaining four fifths went to drug law enforcement, which received more than 90% of the massive drug funding increases of the past decade. Public frustration over the continuing failure of this heavy reliance on law enforcement led Congress to adopt a comprehensive Anti-Drug Abuse Act in 1986 which more than doubled funds for demand reduction. Nonetheless, law Bull. N.Y. Acad. Med.
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enforcement continued to receive more than three quarters of the total $3.9 billion drug funds. Congress again attempted to increase support for demand reduction in a new Anti-Drug Abuse Act in 1988; however, because of deficit ceiling constraints on spending, very little new money was available, and demand reduction remained only one quarter of the total drug budget. The 1988 Act also targeted funds for special high risk groups, including pregnant women, children, and intravenous drug abusers. At the same time, the Act established tougher criminal penalties for traffickers and new "user accountability" provisions aimed at so-called middle class users. Those found with small amounts of drugs can now be assessed civil fines, while courts are given discretion to deny federal benefits such as school and housing loans. The new national drug control strategy, which President George Bush announced in September 1989, essentially continues the policies of the Reagan Administration. While recognizing the importance of demand reduction efforts, the strategy maintains the dominance of supply control programs, which receive approximately two thirds of the $9.8 billion drug budget. It also emphasizes user accountability, reflecting the view that even occasional users sustain the illicit drug traffic. THE POLICY DEBATE In the 1970s public debate over drug policy focused on whether illicit drugs were dangerous; today, most Americans assume that they are and focus instead on the appropriate policy response to a situation clearly out of control. The current debate ranges from "zero tolerance" of any illicit drugs to legalization of all drugs. Former First Lady Nancy Reagan, through her "Just Say No" campaign, has been a leading proponent of zero tolerance -the belief that any illicit drug use is criminal, regardless of circumstances or consequences. This position views casual drug users as accomplices to murder because they keep drug traffickers in business. President Bush and his former "Drug Czar" William Bennett support this view, reflected both in intensive enforcement of possession laws and increased penalties for users. A diametrically opposite view proposes legalization in response to failure of present drug policies. Proponents argue that drug related crime would be greatly reduced, and that, although millions of additional Americans might become drug dependent, resources now devoted to drug law enforcement could be diverted to expanded prevention and treatment programs. Although Vol. 67, No. 3, May-June 1991
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the media have given considerable attention to the proposal, legalization has not received significant political support. Recent polls indicate that more than 80% of Americans oppose legalization and two thirds believe that marijuana possession should be a criminal offense. There are, of course, other policy alternatives between these two extremes. One approach would target resources toward the most dangerous drugs rather than all drugs equally and shift policy and program priorities toward demand reduction. This could also involve a fundamental revision of the traditional view of drug abuse as a problem to be dealt with primarily through the criminal law rather than the public health system. Experience of the past several decades demonstrates that law enforcement as a dominant policy response has not succeeded in reducing drug abuse or drug-related crime. Instead, the encouraging declines in overall drug use have resulted from personal health concerns and increased social disapproval of use. WOMEN AND DRUGS -A NEW Focus OF NATIONAL CONCERN
Historically, women have been the hidden substance abusers of American society. At the turn of the century, when there were no legal restrictions on the sale of heroin, cocaine, and marijuana, there were an estimated 250,000 opiate addicts in the U.S.2 Apart from Civil War veterans who had become addicted to morphine administered for pain, most addicts were women dependent on patent medicines. Despite their addiction, they were generally viewed as respectable if somewhat pitiable members of the community. After the passage of the Harrison Narcotic Act in 1914 and subsequent laws prohibiting these drugs, many women turned to psychoactive prescription drugs to avoid the public stigma of illegal use. Consequently, women have been underrepresented in national drug surveys. At the height of the heroin epidemic in the early 1970s, fewer than one fifth of all addicts were female. Unlike earlier illegal drugs, crack has proved particularly popular with women. Rapidly addictive and very cheap, crack has the reputation of being "cleaner" than heroin and other street drugs, perhaps because it can be smoked rather than injected. The numbers of women seeking treatment for cocaine/crack have jumped dramatically. At Phoenix House in New York City, they almost tripled from 1985 to 1989. About 40% of crack abusers admitted to publicly funded treatment in New York in 1989 were women. This surge in crack abuse by women has had devastating consequences for the women themselves, their unborn infants, and their families. Bull. N.Y. Acad. Med.
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Child abuse and neglect cases have risen dramatically since crack appeared on the streets. Substance abuse is the dominant characteristic in child abuse cases in 22 states and the District of Columbia according to a recent study by the National Committee for Prevention of Child Abuse.3 Nationwide, the number of children in foster care has increased by almost a third since 1988: in New York City the foster care population jumped 90% from 1987 to 1989 (from about 27,000 to 52,000).4 Foster care agencies have difficulty finding families willing to take children who might have drug-related problems, including the possibility of AIDS. Once these children are placed, there are often not enough resources to pursue permanent placement options such as supportive services to the mother or adoption. The cumulative impact of these trends has destabilized many inner city communities, long dependent on its women to provide the backbone of its families. Recent national surveys estimate that 375,000 drug exposed babies are born annually.5 The 1989 National Drug Control Strategy reported that one fifth of the pregnant women at some major hospitals test positive for cocaine and that 100,000 cocaine addicted babies are born each year.6 The human and economic costs continue to mount. Nationally $2.5 billion was spent last year for intensive care for crack babies, and an additional $15 billion will be required to prepare them for kindergarten. The longer term prospects are not encouraging. Research on babies exposed to cocaine before birth has found that they can be severely damaged even with very little cocaine use by the mother. These babies show a wide range of ill effects, including retarded growth, neurological abnormalities, and even strokes. They also tend to be smaller and have smaller heads and brains than normal babies. The relative neglect of demand reduction during the past decade has been particularly acute for drug abusing pregnant women. For those who cannot obtain private care, treatment has been extremely limited. The New York State Division of Substance Abuse Services reported that in 1988 New York City provided about 42,000 treatment slots -30,000 for methadone maintenance and the balance for drug-free residential and nonresidential programs as well as detoxification beds within hospitals. Current levels of methadone maintenance treatment can reach only 15% of the city's estimated 200,000 heroin addicts at one time. For all other drug abusers, including heroin addicts who want to become drug free, treatment is currently available for only 3%. Vol. 67, No. 3, May-June 1991
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The problem of limited treatment resources has been compounded by the failure of programs to respond to special needs of pregnant women. Many programs have simply refused to serve this group; others will not accept Medicaid coverage. Many women are unwilling to enter treatment if they have to relinquish their other children to foster care and face difficulties in regaining custody. A few programs in New York City, like Project Return, PACE, Odyssey House, and PAAM (Pregnant Addicts and Addicted Mothers) have developed special programs for drug-dependent mothers and their children. An outpatient acupuncture program at Lincoln Hospital for women referred by the Division of Social Services as a condition of keeping their children also obtains Medicaid reimbursement. Additional models are urgently needed for pregnant drug abusers across the country. RECENT TREND TOWARD CRIMINALIZATION OF DRUG USE
President George Bush has called for tougher user accountability provisions, including criminal sanctions and jail terms. His views enjoy widespread popular support. A September 1989 New York Times/CBS poll found that two thirds of the public favor more severe penalties for drug use, drug testing of high school students, and allowing the police to search cars and houses for drugs without warrants. This trend toward stricter user accountability is particularly clear in relation to drug abusing pregnant women and mothers. Many hospitals report drug positive urine tests in newborns to child protection agencies which then investigate the mother's fitness to keep the child. Half the states permit hospitals to hold endangered children against the parent's wishes (without a finding of abuse or neglect). "Boarder babies" who remain in hospitals pending these investigations or because they have been abandoned have become an increasingly serious burden in already crowded facilities. During the past several years, in about 35 cases around the country women have faced criminal charges for using drugs and/or alcohol while pregnant. In California a Butte county district attorney announced that any evidence of cocaine, heroin, or methamphetamine in a baby's urine would be used to prosecute the mother for illegal drug possession, although prosecution would be deferred if she entered a treatment program. In New York a pregnant woman's use of cocaine and failure to seek prenatal care has been ruled to constitute criminal neglect. An Illinois woman was recently convicted of child abuse and neglect for using cocaine during pregnancy. In Florida women have been prosecuted for felony drug offenses usually reserved for traffickers. One mother whose son was born addicted to cocaine Bull. N.Y. Acad. Med.
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and infected with syphilis was charged with child abuse and delivery of drugs to a minor. Child abuse normally carries a sentence of no more than 60 days in Florida while delivery of drugs to minors can entail a maximum prison sentence of 30 years. In July of last year another Florida woman whose two babies tested positive for cocaine was convicted of this felony charge and sentenced to 15 years; however, the prosecutor recommended that she continue drug treatment and remain on probation. In Washington, D.C., a pregnant woman who pleaded guilty to forgery was sent to prison although she normally would have received probation. Because she tested positive for cocaine, the judge incarcerated her to prevent her from taking drugs during her pregnancy. An Illinois prosecutor recently carried the notion of accountability even further by charging a woman with involunatry manslaughter when her baby died two days after birth due to cocaine exposure late in her pregnancy. Underlying these cases is the assumption that the threat of criminal prosecution will deter pregnant women from using drugs and therefore protect their unborn children. There is no evidence that this approach is effective, and it may produce the opposite result. Faced With the prospect of losing custody over their infants and/or a jail term, many pregnant women will be reluctant to seek help. Although criminalizing drug use effectively expresses society's outrage at women who inflict permanent damage on their unborn children, it also exacerbates the already difficult task of engaging this often hard to reach group in treatment. In fact, these prosecutions reflect increasing widespread frustration at the limits of the criminal justice system in addressing maternal drug abuse, and some judges recognize that making an example of one pregnant woman by jailing her for drug use may effectively drive thousands of others away from health care.7 This trend toward criminalization is driven by concern for the unborn child rather than the mother; it is ironic that this focus has also served to illuminate the need for treatment responsive to the special needs of women.
Questions and Answers PARTICIPANT: One of the problems in this area is that effective treatment models for cocaine abuse have really not been developed and tested. In alcoholism certainly there's a great deal of research on effectiveness of alcoholism treatment. Now the biggest problem is cocaine, but there has not yet been to my mind effective treatment and prevention in relation to cocaine abuse. With that kind of difficult clinical and scientific situation, how could Vol. 67, No. 3, May-June 1991
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you convince the people who are going to decide on giving money that you should give money to this treatment area? DR. FALCO: Tell them that we don't have any magic bullets in this as in many other areas. But we do know a lot about what does have at least a partial effect in treatment. We do know that comprehensive programs help pregnant women. There's a whole history of dealing with women abusers and abusers in general. Clearly, crack is a special problem, but the problems of addiction are more universal. It is very easy to fall into the trap that since "nothing works," why should we do anything? I believe we know a lot more than we pretend to know, and that we need to proceed on those bases. There is a lot I could spend money on today. PARTICIPANT: How do you put together your predictions about home grown synthetic drugs and the sort of urges to profiteering market drugs? DR. FALCO: You mean what will happen to the international traffickers? PARTICIPANT: How do you see those two forces? DR. FALCO: It is already happening. The international traffickers are moving toward Europe. They are always drawn toward hard currency, and European currency is even more attractive now than U.S. dollars. I think we shall see a huge surge in crack addiction in Europe in the next five years. It is already beginning. Traffickers are in business and it is just a question of which way they shift their effort. Europe has been relatively protected from the crack traffic until now. PARTICIPANT: I would like you to comment on the other major policy development in 1981, which was the shift in how drug treatment and prevention were funded in this country, which I think had as much impact on at least the amount of money that went in. DR. FALCO: That is absolutely right. What the questioner refers to is that in 1981 President Reagan decided to give all the demand reduction funding in block grants through state agencies instead of handling it directly out of the National Institute of Drug Abuse in Washington. I think that was really catastrophic for all kinds of reasons. First, we lost important national information that we used to get. Second, and probably more important, policy in this area really does have to be nationally developed, at least at some stage. A lot of states, given the block grants, simply did not put money into prevention and research. There is real resistance to some of these longer term projects because the payoffs are very obscure. When you run on two year political cycles, you have to produce Bull. N.Y. Acad. Med.
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things that look good in the short run. Unfortunately, that happened to a lot of drug treatment programs. PARTICIPANT: While we have RICO laws to get back some of the ill gotten gains from traffickers, what about governments that repay U.S. debts from the drug dollars? I'm having difficulty with us allowing governments to repay debts to us by their home grown narcotics and drugs going to this country. We have RICO. What about other statutes? DR. FALCO: That's an interesting point. Peru, one of the two largest coca producers in the world, is not even paying interest on their debts to us. It is true that Peru and Bolivia are completely supported by cocaine dollars, that their economies probably would collapse without that money. What should we do about it? Well, that is a long answer. I would say that we need to work with them in a long-term way. They don't control their own countryside. These are very weak central governments. Even if they were able to magically snap their fingers so that no peasants would grow coca, everybody would starve. Their economies have depended on this crop so long that it will take a concerted effort to get them off coca. The addiction analogy is not a bad one. During the 1980s we continued to focus on the notion of spraying herbicides on their crops. We never found a herbicide that works. Second, they have serious internal problems. A lot of peasants really object to having American law enforcement officials jumping out of helicopters. So it has created very serious political problems. I would say our international policy is really in a terrible state right now with regard to drugs. DR. FALCO: I don't know. PARTICIPANT: You mentioned that you think you should shift focus overnight from interdiction to treatment. How do you propose we go about doing that in terms of really affecting public policy? DR. FALCO: I'm a great believer in democracy. I used to work in the Senate and know that people who pass laws are greatly influenced by the people who vote for them. How many people in this room have communicated directly with their Congressman or Senator about their views on these issues? (Show of hands.) DR. FALCO: This is extraordinary. We must have about 5%, a much higher percentage than I usually get when I ask these questions. That's terrific, but it should be 98%. Keep talking to everybody who will listen. You carry a lot more weight because you are the ones who are on the front lines. Vol. 67, No. 3, May-June 1991
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We really all have that responsibility, not only to stay on the front lines, but to turn around occasionally and tell the people who are developing policy what the reality is. REFERENCES 1. Johnston, L, O'Malley, P. and Bachman, J.: Drug Use, Drinking & Smoking: National Survey Results from High School, College, and Young Adults Populations 1975-1988. DHHS Pub. No. (ADM)89-1638(1989). Washington, D.C., Govt. Print. Office, 1989. National Household Survey on Drug Abuse: Population Estimates 1988. DHHS Pub. No. (ADM)89-1636. Washington, D.C., Govt. Print. Off., 1989. 2. Blanken, A., Adams, E., and Durrel, J: Drug abuse: implications and trends. Psychiatr. Med. No. 3, 1987. 3. Besharov, D.: The children of crack. Public Welfare, p. 7, Fall 1989.
4. Besharov, D.: Crack Children in Foster Care. U.S. Senate Subcommittee on Children, Families, Drugs, and Alcoholism Hearing, November 13, 1989, p. 3. 5. Survey by National Association for Perinatal Addiction Research, reported in Brody, J.: Widespread abuse of drugs by pregnant women is found. N.Y. Times, August 30, 1988, p. 1. 6. National Drug Control Strategy. Washington, D.C., Govt. Print. Off. 1989, p. 44. 7. Lewin, T.: Drug use in pregnancy: new issue for the courts. N. Y. Times, February 5, 1990, p. 22.
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