The culture of the United States is unique in its diversity and generally precipitated attitude toward individualism and self-reliance. Yet societal and personal struggles with substance abuse and dependence in the United States are hardly unique as drug use is a human condition. The United States has made leaps and bounds in the last century in its policies and social attitudes toward drug abuse, however there are still many reforms needed. This essay will explore the unique issues that the United States faces when dealing with substance use. This treatise will to address the deficiencies in public policy and reforms needed in United States drug policy and substance abuse treatment. Ultimately this article will attempt to show the need for significant fundamental changes in the attitudes and policies toward substance use, abuse, dependence and treatment.
United States Public Policy and Substance Abuse: Factors that foster addiction in the United States
There are many factors that foster and precipitate substance use and dependence in the United States. For instance, there are cultural norms, social injustices, individual mental health issues, and many other societal problems that contribute to substance use and abuse among individuals and peer groups. Unfortunately these issues are symptoms of a greater problem, and they will remain inflexible unless public policy changes are made. There are three key flaws in United States drug policy. Those flaws are inadequate and misguided substance abuse education, a lack of faith in the efficacy of addiction treatment in the medical profession and lastly the criminalization of drug use and abuse.
The first issue to address in the United States is how we educate children about drugs. Drug abuse education has suffered from an identity crisis in the United States, and policy makers have struggled with how to address the issue. Should it be addressed at all? Should blatant lies be told in the hopes that those lies will deter drug use? Or should children of all creeds and ethnicities learn to “just say no?”
As of today, there is mounting that evidence-based education is an effective approach to dealing with the issue of substance use and abuse (Cahill, 2007). According to Helen Cahill, evidence based drug education works best if it is introduced before most children are introduced to drugs in an uncontrolled environment. Ideally the information should be delivered in age appropriate packets that do not encroach upon the recipient child’s level of social and psychological development (2007). However, this is not always possible.
Many children are introduced to drug use and abuse long before the majority of their peers, be it by their parents, siblings or neighborhood environment. This exemplifies the need to address drug abuse early and identify children who are at risk to early exposure to drug abuse. Identifying at risk children based on self-reporting may not be feasible, however many behavior traits may shed light on a child’s propensity towards drug abuse in later life. For instance children may be at risk for drug abuse in later life should they display poor restraint, subdued desire to thrive, desire to seek novel sensations, lack of ego control, learning deficits, unconscientiousness, low self esteem or shyness (Hampson et al., 2006).
These traits do not guarantee that a child will develop substance abuse in later life, however it has been shown that alcohol abuse is linked to unconscientiousness and extroverted tendencies in childhood. Also, emotional instability in young males has been linked to substance abuse issues in later life. These factors are significant, as traits such as conscientiousness have been linked to longevity (Hampson et al. 2006). Longevity suggests life long risk avoidance behaviors. These are traits that are worth identifying at an early age in order to introduce preemptive intervention. If any institution has this capacity, it is the education system.
However it is important to note that once at risk students are identified, they should not be grouped separately from other student populations. Consorting high-risk students may cause those children to internalize the idea that they are abnormal or deviant (Cahill, 2007). Ideally, at risk students should be dispersed as evenly as possible among a student body. This affords high-risk children the opportunity to internalize the positive perspectives of their successful peers.
It is also important to consider how educators address the issue of drug abuse. Some experts have indicated that it is best to allow students to make their own judgments based on unbiased presentation of evidence. Cahill suggests teachers should refrain from treating students as prey to their own ignorance or. Most importantly, instructors should avoid taking a moral stance or using scare tactics (2007).
According to Cahill, the risks to taking moral stances and using scare tactics outweigh the benefits. Taking a moral standpoint on drug use and using scare tactics to back up that standpoint will likely only prescribe to students what a teacher deems to be desirable behaviors. This may lead to resistance. Also, using scare tactics may glamorize the behaviors that the person using those scare tactics wishes to deter (2007).
An excellent example of a very public scare tactic is a public service advertisement that was aired during the early part of the twenty first century. It depicts three black males smoking a joint in a car while getting food from a drive through restaurant. The young men in the ad are laughing and having a good time, and they are also clearly distracted. At the very end of the ad they fail to see a little girl in front of them on a bicycle and it is implied that they run the girl over with their car.
Such a commercial may have produced a broad range of reactions from various individuals depending on their background. While some may have agreed with the message that cannabis is harmful, others may have seen the events of the commercial as unlikely or inane. Those who identify as black may have reacted very negatively to this ad because they may have seen the commercial as overtly derogatory. In any event the potential negative reactions to the ad detract from the intended message. This may lead individuals to decide that there is nothing wrong with the behavior depicted in the advertisement.
Another issue with using scare tactics is that adolescents tend to overestimate the drug usage and risk taking behaviors of their peers. A teacher who lends too much attention to the worst cases runs the risk of normalizing high-risk behavior (Cahill, 2007). It may be useful for schools to conduct anonymous school-wide behavior assessments that evaluate drug use and sexual activity among other factors such as involvement in school activities. These statistics could then be presented to students to paint a more realistic picture of the behaviors of their peers.
Of course there are some issues to such a proposal. At the risk of using anecdotal evidence, I recall an informal school wide survey conducted at a minor state university that I attended that assessed alcohol use and safe sex practices among freshmen students. Unfortunately 80% of respondents reported drinking regularly. Since the respondents were freshmen, it is reasonable to assume that the vast majority was underage. On the upside, 4 in 5 students reported regularly using condoms during sexual intercourse. Sometimes the bad must be taken with the good in the pursuit of truth.
Truth is the basis of the normalization approach to substance abuse education. The goal of normalization is to attempt to dismiss the notion that many adolescents have that many of their peers engage in risk taking behavior by presenting factual evidence (Cahill, 2007). According to Cahill, it is possible to bolster the normalization approach by encouraging students to feel connected to their school (2007). Ideally this will create the sense that students and their peers take pride in being members of their school’s community rather than engage in drug use. The best-case scenario is this effort transcends illusion and succeeds in the task.
The opposite of prevention efforts is treatment of substance abuse. Approximately 40% of emergency room patients use illegal drugs (Agrawal, Everett & Sharma, 2010). It is possible that this number is considerably higher given that many may fail to report their drug use to ER doctors for fear of legal ramifications or denial of treatment. It is easy to see why many ER doctors feel cynical about treating drug abusers. However, those very doctors are the first responders for presenting an intervention for hospitalized drug users.
Sadly, the medical profession has many deficiencies in addressing substance abuse and dependence. Lack of skill, time constraints, and poor confidence in treatment efficacy all hinder treatment and intervention (Agrawal, Everett & Sharma, 2010). According to a recent study conducted by Agrawal et al., medical professionals grow more pessimistic toward substance abuse treatment outcomes with the more training that they have. Only 22% of third year medical students interviewed for this study believe that addiction is treatable. It has also been found that 30% to 60% of clinicians believe that treatment outcomes for substance abusers are either very poor or negligible (2010). This is unfortunate as attending one Alcoholics Anonymous or Narcotics Anonymous will yield a multitude of success stories. It is reasonable that medical students should be required to attend at least one AA or NA meeting during their training to instill an understanding that there is a light at the end of the tunnel of substance abuse treatment.
Clinicians should feel even more optimistic about treatment outcomes given that there is now evidence that web based self-intervention programs are helpful for some problem drinkers. In a recent study conducted by Reid Hester, Harold Delaney and William Campbell through the University of New Mexico, non-dependent problem drinkers can learn to reduce their drinking and mitigate alcohol related problems through web-based intervention. The study evaluated the efficacy of web-based interventions through www.moderationmanagement.com and www.moderatedrinking.com (2011).
According to the study, participants were able to reduce their drinking considerably. Participants reduced their median peak blood alcohol concentration by 49% after one year. Also, participants reduced their average drinks-per-drinking-day from approximately 5 drinks a day to 3 (Hester, Delaney & Campbell 2011). Although a reduction in consumption is not abstinence, a reduction in consumption means a reduction in health related consequences in addition to the reported reductions in drinking related problems that participants faced. It is important to note that the best candidates for such an intervention were found to be well-educated, middle class, non-dependent drinkers. A broader implementation of such programs has the potential to free resources for higher risks groups.
Apart from prevention and treatment, there is one more considerably significant area of public policy that is proving to be more archaic and draconian as time passes. That is the criminalization of substance abuse. According to the 2007/2008 Human Development Report, the United States has 738 prisoners per 100,000 persons. To lend some perspective, out the 70 nations considered to have high levels of human development, the runner up was the Russian Federation with 611 prisoners per 100,000 persons. All other top nations had less, including Cuba (Watkins et al. 2007). Additionally, the Russian Federation has 19.9 homicides per 100,000 persons while the United States only has 5.6. Thus, while Russia has 355% more violent crime, the United States imprisons 120% more of its population (Watkins et al. 2007).
Nearly 20% of persons incarcerated at the state level are incarcerated for drug related offenses, while more than 50% of federal prisoners are incarcerated for drug offenses (Bewley-Taylor, Hallan, & Allen 2009). This is a tragedy given that prisoners who receive drug treatment while incarcerated are greater than three times more likely to recidivate than those who receive treatment under intensive community supervision. Incarceration also costs the taxpayers in excess of 1000% more than combined work-release treatment programs per annum.
The payoffs for treatment are tremendous. From 1995 to 2005 the federal government increased treatment funding a mere 14.6% while treatment admissions rose 37.4% and violent crime fell 31.5 percent (Natarajan et al. 2008). Although progress has been made, it is very clear that the United States is still stuck in the past.
In contrast, a decade ago, Portugal underwent a massive social reform experiment by decriminalizing the possession of all drugs for personal use. At the same time, Portugal doubled treatment funding. Rather than incarcerating drug offenders, Portugal now refers drug offenders to treatment. Three person panels comprised of legal advisors, social workers and medical professionals prescribe treatment and minor legal sanctions such fines and community service rather than jail time for drug offenders (Hughes & Stevens, 2007)).
According to Caitlin Hughes and Alex Stevens of the Beckley Foundation, by 2007, Portugal had realized considerable returns on its investment in reform. As admissions for treatment rose, drug related death and illness rates fell. From 1999 to 2003 Portugal had achieved a 59% reduction in drug related deaths while in the same time frame achieving a 17% reduction in new human immunodeficiency virus (HIV) cases. From 2001 to 2005 prison overcrowding dropped by 17.5%, allowing prisons to operate near their intended capacity. Although cannabis use rose, there was 50% drop in treatment referrals for heroin users. Additionally an increase in cannabis use during this time may be attributable to a Europe-wide trend as well as increased reporting due to decreased fear of legal ramifications (Hughes & Stevens, 2007).
The previously outlined facts in this essay exemplify the need for drastic public policy changes in the United States to reduce addiction rates. There is a need for greater implementation of evidence-based education while eliminating scare tactic oriented prevention methods. The unencumbered truth must be allowed to avoid skewing individual perceptions of the realities of drug use. There is also a vast need for improved medical training to intervene in substance abuse cases as medical professionals are often poised to be first responders to substance abuse dilemmas. Most importantly there is a dire need to move away from the criminalization of addiction. When these changes are made, the United States will be free to address the broader factors that engender addiction such as cultural perceptions and social injustice.
Although a drastic change such as decriminalization may have the potential to increase the use of certain softer drugs, the societal benefit in an overall reduction in drug related deaths and disease is undeniable. Is it better that individuals who chose to use drugs remain uninformed, and at great legal peril, while posing a vast liability to society and themselves, or is it preferable that individuals chose to use drugs in an informed manor with the security of an intervention network in a socially directed manor devoid of legal repercussions that often lead to socioeconomic disparity? These are the questions that United States policy makers should be asking and addressing.
Agrawal, S., Everett, W. W., & Sharma, S. (2010). Medical student views of substance abuse treatment, policy and training. Drugs: education, prevention and policy, 17(5), 587–602. doi:10.3109/09687630902729602
Cahill, H. W. (2007). Challenges in adopting evidence-based school drug education programmes. Drug and Alcohol Review, 26, 673-679. doi:10.1080/09595230701613593
Hampson et al. (2006). Forty years on: Teachers’ assessments of children’s personality traits predict self-reported health behaviors and outcomes at midlife. Health Psychology, 25 (1), 57–64. doi:10.1037/0278-618.104.22.168
Hester, R. K., Delaney, H. D., & Campbell, W. (2011). Moderatedrinking.com and moderation management: Outcomes of a randomized clinical trial with non-dependent problem drinkers. Journal of Consulting and Clinical Psychology, 79(2), 215-224. doi:10.1037/a0022487
Hughes, C., & Stevens, A. (2007). The effects of decriminalization of drug use in portugal. The Beckley Foundation Drug Policy Grogramme, 14, 1-10.
Natarajan et al. (2008). Substance abuse treatment and public safety. Justice Policy Institute , 1-17. Retrieved from http://www.justicepolicy.org/research/1949
Watkins et al. (2007). Fighting climate change: Human solidarity in a divided world. Human Development Report 2007/2008, 337. Retrieved from http://hdr.undp.org/en/reports/global/hdr2007-2008/