Addiction

Drugs and Drug Policy: What Everyone Needs to Know, by Mark Kleiman, Jonathan Caulkins, and Angela Hawken (2011, Oxford University Press, 234 pp., $16.95 PB)

Mark Kleiman isn't real popular among the drug reform set. The UCLA professor of public policy is no legalizer, and even though he's too much of an evidence-minded academic to be a wild-eyed drug warrior, he still seems to have an unbecoming fondness for the coercive power of the state. Kleiman, who gets top-billing over coauthors Jonathan Caulkins of Carnegie Mellon and Angela Hawken at Pepperdine, also ruffles reformers' feathers with unnecessary snideness and snark.

But I watched Kleiman address Students for Sensible Drug Policy conventions a couple of times, and I thought it was a good thing, a very useful jolt to the group-think that can grip any gathering of congregants committed to a cause. I thought having the students have to hear the arguments of a leading academic thinker on drug policy who, while not "the enemy," was not especially saying what the average SSDPer wanted to hear, was salubrious for their critical thinking skills. I still think so.

In Drugs and Drug Policy, Kleiman and his coauthors continue with the occasional jibes aimed at the drug reform movement, at times reach conclusions at odds with my own, but also serve up a surprisingly chewy work of drug policy wonkery in delicious bite-size chunks. The innovative format, something like a series of FAQs organized within broader chapters -- "Why Have Drug Laws?" "How Does Drug Law Enforcement Work?" "What Treats Drug Abuse?" "Can Problem Drugs Be Dealt With at the Source?" -- allows us to unpack that all-encompassing monster called "drug policy" one subset at a time, and for that achievement alone, is worthy of praise. That it manages to cover so much ground in a paltry 234 pages is all the more laudable.

Overall, Drugs and Drug Policy is smart, reasonable, and thoughtful. It wants policies based on evidence and it advocates for some intelligent alternatives to current policies. It recognizes the utility of needle exchanges, safe injection sites, and opiate maintenance, even as it complains that "harm reduction" has been hijacked by legalizers. It explains that most people who use drugs -- even those diagnosable as suffering from substance abuse disorders -- will quit using drugs themselves without recourse to treatment. And it even allows that drug use can have beneficial effects, even if it doesn't do so until the seventh chapter.

But Kleiman et. al dismiss decriminalization as unlikely to have a big impact on the social fiscal burden of drug law enforcement because, even though it doesn't appear to have much impact on consumption, drug consumers are not, for the most part, filling our prisons -- drug dealers are. While they do concede that not criminalizing otherwise law-abiding citizens could have "significant benefits," they seem to underplay the negative, life-long impact of a criminal drug record on one's life prospects.

In fact, they seem all too comfortable with maintaining the pernicious role of the criminal justice system in drug policy even as they recognize that enforcing the drug laws is "unavoidably an ugly process," with its reliance on snitches, surveillance, and other "intrusive methods" of enforcement. To give them credit, they want smarter drug law enforcement -- concentrating police repression on violent drug dealers while turning a blind eye to discreet dealing, triaging coerced drug treatment spots so they are reserved for the people who could most benefit from them, giving up on interdiction and source country eradication as ineffective -- that might actually reduce the social and fiscal costs of both drug abuse and enforcement, and since drug prohibition isn't going away anytime soon, at least wasting less money on drug war tactics that don't work well should be on the table.

And they reject drug legalization as too scary to experiment with, but seem to imagine it as possible only within a corporate-controlled, heavily-advertised, low-priced scenario similar to that which has accreted around the alcohol industry. Yes, it's probably true that selling cocaine like Coors, would lead (at least initially) to a significant increase in use and problem use, but why does that have to be the only model? A government monopoly similar to the state liquor store model, with reasonable taxes and no corporate pressure to advertise could conceivably allow legalization without the increases in consumption that the authors predict, even though they concede they don't know how large they might be.

Still, when you get to what it is Kleiman et al. would do if they had their druthers, all but the most purist of legalization advocates will find a lot to like. They create three separate lists of recommendations -- a "consensus list" of reforms they think are politically doable now or in the near future, a "pragmatic list" of reforms that would appeal to dispassionate observers but could raise the hackles of moralists, and a "political bridge too far list" of reforms too radical for mainstream politicians to embrace.

The "consensus list" includes expanding opiate maintenance therapy, encouraging evidence-based treatment, early intervention by the health care system, encouraging people to quit on their own (as opposed to being "powerless"), relying less on interdiction, ending the charade that alternative development is drug control, and concentrating drug enforcement on reducing violence and disorder, as well as smarter, more effective coerced treatment in the legal system. If we saw the drug czar's office produce a National Drug Control Strategy with these recommendations, we would consider that a great victory. It ain't legalization, but its headed in a more intelligent, more humane direction.

The "pragmatic list" includes recommendations to lower the number of drug dealers behind bars, not reject harm reduction even if it's been "hijacked," stop punishing former dealers and addicts, reduce barriers to medical research on illegal substances, and be open-minded about less harmful forms of tobacco use.

The authors don't neglect alcohol and tobacco -- the two most widely-used drugs -- and that is really evident in their "political bridge too far" recommendations. The first three items there are aimed squarely at reducing alcohol consumption and its ill effects. They also argue for the legalization of individual or collective marijuana cultivation, a sort of legalization without the market, increased study of the non-medical benefits of drugs, and increasing cigarette taxes in low tax states.

I think Drugs and Drug Policy needs to be read by anyone seriously interested in drug policy reform. It hits almost all the bases, and it's well-informed, provocative, and challenging of dogmatic positions. You don't like the authors' conclusions? Refute them. It'll be good for you.

In a new wave of repression aimed at drug users, the government of Thailand has begun rounding up suspected "drug addicts" to be forced into "rehabilitation centers." That has health, human rights, and harm reduction groups expressing grave concerns, especially given previous Thai pogroms against drug users, like that in 2003, when tens of thousands were rounded up and more than 2,000 killed by police in summary executions.

The official announcement from the National News Bureau of Thailand of the government's plans came only last week. "The Ministry of Interior has picked next week to get all drug addicts across Thailand clean," it said, with Deputy Permanent Secretary for Interior Surapong Pongtadsirikul as putting the number of untreated addicts at 30,000.

"During 20-27 February, 2011, drug abusers in Bangkok will be brought to the rehabilitation centers to get clean," the notice continued. "There will be those who are encouraged to receive treatment on their freewill and those who will be forced against their will. A rehabilitation camp will be open for addicts elsewhere in Thailand where a rehab center is scarce."

The announcement also said staff training would be carried out and a location for a "makeshift rehab center for drug addicts" will be selected. Chillingly, it added that "their names will be recorded in the database specifically designed for easy tracking and providing updates on their progress in the future."

The roundup has already begun in Bangkok, according to Karyn Kaplan of the Thai AIDS Treatment Action Group (TTAG). "Yes, people are being arrested right now," she said. "The police have quotas, they do this every few months, and this is just another excuse to round people up again. Even in our own small network of people who use drugs, people have been arrested, even workers at our harm reduction center."

While the Thai government officially embraces harm reduction principles -- it adopted harm reduction as a national strategy last fall -- it schizophrenically continues its crackdowns on drug users and sends them to "treatment centers" not worthy of the name.

"We don't call them treatment centers, because they aren't run by people who know how to treat people," said Kaplan. "They were originally set up because of prison overcrowding, but even though they have a policy that says drug users are patients, not criminals, they still use the police to sweep the streets and throw people into the system. But then the system says there is no room in prison, send them to the camps. The camps are in military bases and run by the military, and they aren't trained for that. The military is just housing them, and there are beatings and forced labor for no money. There is no due process," she said.

It is as if the Thai government's left hand doesn't know what its right hand is doing, said Kaplan. "The government at least pays lip service to harm reduction, but the Ministry of the Interior is not talking to the Narcotics Control Board, which sponsors the harm reduction policy," she said. "We have gotten unofficial statements from senior officials inside the Public Health Ministry saying they are going to speak with the board and the Interior Ministry about what Thailand might do more effectively."

In the mean time, the roundups continue.

The threat of the mass roundup of suspected drug users has led a coalition of Thai and international health, harm reduction, and human rights organizations to publicly air their fears that it will trample on human rights and could lead to the widespread abuses of drug users seen in other Thai anti-drug campaigns.

"These plans for mass detention and forced treatment raise considerable human rights concerns, especially given Thailand’s history of nationwide punitive and ineffective anti-drug campaigns," they said in an open letter to the Thai government. "There is no way for the government to implement a campaign to forcibly 'treat' tens of thousands of people who use drugs without widespread human rights abuses taking place."

Groups signing on to the letter include the TTAG, the International Harm Reduction Association (IHRA), the International Drug Policy Consortium (IDPC), the International Harm Reduction Program of the Open Society Institute, the Canadian HIV/AIDS Legal Network, and the International Network of People Who Use Drugs (INPUD).

"The mandatory rounding up and detention of people who use illicit drugs for the purpose of enforced treatment is not only a violation of their human rights, it's a violation of common sense -- enforced detention doesn't work," said INPUD's Jude Byrne. "Never has, never will! Communities need to look to the reason people are using drugs. Stop the systemic violence against the poor, minorities, people of different sexual persuasion and the unemployed. Rounding up the most marginalized people in the community will do nothing except provide jobs for the police and the people who run the detention centers. It will also drive INPUD's community underground so they are not able to access harm reduction information or equipment where it is available. The transmission of HIV and Hep C among the injecting drug using community will soar, and that is the real crime, not the use of drugs."

"This crackdown flies in the face of Thailand’s 2002 policy, which states that people who use drugs should be treated as patients, not criminals. There is nothing therapeutic about rounding up thousands of drug users and forcing them into military boot camps that fail to provide appropriate services and support," said Paisan Suwannawong, TTAG executive director and co-founder of the Thai Drug Users' Network.

While the Thai government refers to "drug addicts," its plans appear to include any drug users. Under the current plan, "occasional" users will be detained for one week, "continuous" users for two weeks, and those showing signs of drug dependence for 6 1/2 weeks (45 days).

"There are many reasons to be worried," said IHRA executive director Rick Lines. "Due process guarantees have been thrown out the window. What is the legal basis for mass detention? There are numerous examples of how forced detention in the name of drug dependence 'treatment' can lead to human rights violations and breaches of accepted principles of medical ethics," he continued. "What is more, many who do not need any form of drug dependence treatment will be herded into detention centers. Where is the clinical assessment?" he asked.

The activists also expressed concern about the temporary detention centers that will be set up outside Bangkok. They feared they would be operated not by health workers, but by police or soldiers, they said.

"We are profoundly concerned that these centers may be run by public security forces such as the police or paramilitary civil-defense organizations" said Kaplan. "It is dangerous and extremely disheartening given recent progress made in the country on injecting drug use and HIV. This can only serve to undermine those efforts in the long term. The immediate concern, however, is for the safety and well-being of those targeted."

But the medium term goal is to persuade the Thai government to embrace not merely the rhetoric of harm reduction, but the practice. That is going to take continuing pressure on the government, and the United Nations needs to step up, said Kaplan.

"We need more high-level action to push the government over to harm reduction," she said. "The World Health Organization and the UN Office on Drugs and Crime don't listen to civil society, so we need governments to step up. It is very important and progressive that Thailand is talking harm reduction, but to actually do it, they need a lot of help."

A scarcity of heroin in England is leading to a growing number of drug overdoses and poisonings as users ingest dope cut with other substances by dealers trying to stretch supplies, The Guardian reported this week. Scene watchers there are calling it the worst drought in years.

The drought is being blamed not on seizures by law enforcement agencies, but on a fungus that has blighted the Afghan opium poppy crop, reducing the size of this year's poppy crop by half. Afghanistan accounts for more than 90% of the world's opium production and likely 100% of the British heroin supply.

"There is a very significant heroin shortage across the UK at the moment," said Gary Cross, head of drug policy for the non-profit group Release.  "It has been going on for some time now, but the last two months have seen stockpiles exhausted."

"I've never known anything like it in 30 years," wrote one long-time heroin user on an on-line forum discussing the shortage.

As dealers and users scramble to grapple with the shortage, users are turning up at hospitals after ingesting adulterated heroin or, in some cases, fake heroin consisting of a powerful sedative, caffeine, and paracetamol, a bulking agent. Some have passed out after smoking or ingesting, while others have reported vomiting, amnesia, and flu-like symptoms.

"This 'heroin drought' appears to be serious and geographically widespread," said Neil Hunt, director of research at KCA, a nationwide community drug treatment service. "Street heroin is in a complete and utter muddle at the moment, and users are collapsing unexpectedly. We need to standardize information about what's out there.

"If people use this intravenously, perhaps on top of alcohol and methadone [the prescribed substitute drug for heroin], it is extremely risky," said Dr. John Ramsey, who runs a drug database at St. George's Medical School in London. "We have had many reports of people overdosing. It's really important that accident and emergency departments understand that they may not be dealing with a 'normal' heroin overdose when people are brought in," he said.

Harm reduction drug agencies are aware of the problem and working to address it. Several of them held an urgent meeting last week to discuss setting up an online warning system to give users notice about contaminated or adulterated drugs.

As of Monday, the United Nations Office on Drugs and Crime (UNODC) is under new management. Russian diplomat Yury Fedotov , who was nominated for the post earlier this year by UN Secretary General Ban Ki-moon, has now taken over the organization that makes up a key part of the global drug prohibition regime. He replaces outgoing UNODC head Antonio Maria Costa.

The Vienna-based agency, established in 1997, is charged with fighting the illegal drug trade, as well as other international crime, such as corruption and human trafficking. It also publishes annual reports on the global drug scene, as well as regional reports, including annual surveys of Afghan opium poppy production.

"Public health and human rights must be central" to his agency's work, Fedotov said in a statement Monday. "Whether we talk of the victims of human trafficking, communities oppressed by corrupt leaders, unfair criminal justice systems or drug users marginalized by society, we are committed to making a positive difference," he said.

"Drug dependence is a health disorder, and drug users need humane and effective treatment -- not punishment," he added. "Drug treatment should also promote the prevention of HIV."

Harm reductionists and AIDS activists had earlier urged Ki-moon not to appoint Fedotov, pointing to Russia's abysmal record on human rights, the treatment of drug users, and HIV/AIDS prevention. But on Monday, the International Harm Reduction Association told the Associated Press it was willing to give Fedotov a chance based on his early remarks.

"We certainly hope this sets the benchmark for the path he'll be taking," said the association's executive director Rick Lines. "For any public official, they're going to be judged by what they do with the responsibility they're given."