In one of the strangest White House photographs ever taken, Elvis Presley shakes hands with President Richard Nixon in the Oval Office on December 21, 1970.
You can always count on Americans to do the right thing—after they’ve tried everything else.
—WINSTON CHURCHILL
So far we have discussed the qualities, circumstances, and outside factors that can contribute to dangerous drug use and dependence, but what are the solutions? The United States has pursued ineffective, costly, and deadly policies in addressing our ongoing drug crisis. We can call those policies fail first, borrowing the term from the management practices often used by insurers, HMOs, managed care, and pharmacy benefit medications with subscribers (patients in need). Often called step therapy, this requires that a patient fail on one of a selected group of medications in a class before the payer will cover the cost of a more expensive, but potentially more effective, agent.
This practice is terribly maddening to patients, families, and doctors, who especially rebel against rules made for them by proprietary companies driven by financial incentives. In human costs of persistent disease and suffering, fail first can sometimes be penny wise and pound foolish, especially in mental health. The medical and business costs, in emergency-room visits and hospital stays as well as absenteeism and reduced productivity, often outweigh any savings generated by the fail-first gauntlet. Some states have limited the classes of drugs, for example the antipsychotic medications, that can be put into step-therapy programs, though that does not mean offensive delays in treatment are eliminated.
The United States has pursued a similar policy, with even greater consequences and over a longer time, against the persistent, exploding problem of drug use. Thus far, the principal policy and practice approaches to the illegal use of drugs have been control and consequences.
Among the many misguided endeavors by President Richard Nixon was his creation of “the War on Drugs,” he being the first to use that metaphor. Not to be outdone by President Lyndon Johnson’s “all-out war on human poverty,” Nixon was going to take on drugs. (He had already declared war on cancer.) A combination of prohibiting drug use in the United States and military intervention in other countries, he asserted, would destroy the illegal drug trade. A “control” strategy in spades.
The casualties of this “war” have been enormous, and no evidence of its benefits has been demonstrated by any responsible government, including our own. Since President Nixon declared this war, the incarceration rate in the United States has increased by over 400 percent, resulting in the highest national incarceration rate in the world. By 1994, the war led to 1 million Americans being arrested each year for drugs, with about one in four arrests for marijuana possession; more recently marijuana possession has been the charge in half of the arrests in this country. Many states implemented “three strikes” laws in the 1990s that mandated long sentences for those convicted of a crime three times. Some states instituted minimum mandatory sentences for drug trafficking, a crime often committed by people seeking to fund their addiction. By 2008, 1.5 million Americans were arrested annually for drugs, and one in three of those were incarcerated. Our prisons are filled with people of color; African Americans are sentenced to state prison thirteen times more frequently than people from other ethnic groups, making the war fundamentally racist in its effects.
Many years later, John Ehrlichman, Nixon’s domestic-policy chief, admitted as much. In a recently published interview that took place in the 1990s, he said:
You understand what I’m saying? We knew we couldn’t make it illegal to be either against the [Vietnam] war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities . . . We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.
By prosecuting this drug war, the Nixon team believed they would gain the white vote, especially in the South (his “Southern strategy”), and remain in the White House.
The wonderfully acted and ironic film Elvis & Nixon (2016) has Elvis (played brilliantly by Michael Shannon) arrange to meet with President Nixon (played deadpan by Kevin Spacey) in 1970. Elvis, “the King,” more famous than the president, wants to become an undercover agent for the Feds to help break the backs of hippies and druggies, a soldier in Nixon’s War on Drugs. Whatever the truth of their encounter, the photo of the two shaking hands in the Oval Office is the most requested picture in the National Archives Catalog.
In one of the strangest White House photographs ever taken, Elvis Presley shakes hands with President Richard Nixon in the Oval Office on December 21, 1970.
Ronald Reagan too could not resist this ersatz and fabricated war, contributing to enormous rates of incarceration. The number of people in jails and prisons, largely people of color, for nonviolent drug law offenses went from fifty thousand in 1980 to more than four hundred thousand by the late nineties.
Concerns about crack cocaine were all over the press when Reagan took office in 1981. Nancy Reagan had already begun to contribute to the ill-begotten war with her Just Say No campaign. President Reagan proposed and enacted an even more militant war than Nixon. Reagan declared that “drugs were menacing our society” and asserted that his administration would achieve drug-free schools and workplaces, more vigorous law enforcement and drug interdiction, and greater public awareness.
By 1986, Reagan had passed and signed legislation that appropriated $1.7 billion to fund his War on Drugs. This included mandatory minimum prison stays for drug offenses and massive programs, at home and abroad, for crop eradication and interdiction. Public education, prevention, and rehabilitation programs had their funding reduced. Nancy Reagan traveled the country to speak about the dangers of drugs. Meanwhile, they both turned a blind eye to HIV/AIDS, which had begun to ravage the country.
The consequences of our history of punitive approaches to drug addiction are manifold. Public safety, particularly from incarcerating nonviolent offenders, is not significantly improved; families are broken and shattered, especially when the parents of young children are incarcerated; and recidivism is terribly high, indicating that this method of control does not effectively address the intended problems. According to the Brennan Center for Justice in New York, 39 percent of the people in US prisons are there unnecessarily since no degree of public safety is achieved. We know, as well, that two-thirds of people in correctional settings have a history of abusing drugs or alcohol or both. The Brennan Center report notes that “approximately 79% of today’s prisoners suffer from either drug addiction or mental illness, and 40% suffer from both. . . . Among inmates, suicide is now the leading cause of death, accounting for 34% of deaths in 2013.” Vast amounts of money are ill-spent and thus unavailable to fund prevention, alternatives to incarceration, more robust community policing, and reentry programs for prisoners upon their release.
It took until 2009 to start to move toward the light, when President Barack Obama declared that the term War on Drugs was not useful and would not be used by his administration. His Office of National Drug Control Policy stated, in 2011, “Drug addiction is a disease that can be successfully prevented and treated.” Yet, despite these indications of forward progress, crop control, border interdiction, and state and local drug raids and seizures continue to occur, wasting billions and billions of dollars nationally and globally.
Our former president also commuted the sentences of well over one hundred people before he left office. This story was dramatized by Shruti Ganguly, one of the incredibly creative members of Fictionless, an Oscar-awarded documentary company. She directed five short films, each depicting the story of a man or woman who had been incarcerated for a nonviolent drug offense in the days of extreme mandatory sentencing. All five, two black men, two black women, and one white man, had their life or lengthy mandatory sentences commuted by President Obama, as part of his ongoing clemency for people whose punishment did not fit the crime, and who had spent most of their adult lives behind bars.
Yet there is still so much more to be done, in and out of our prison system. We know that fiction can reveal many a truth. HBO’s The Wire (2002–08) portrayed the fictitious but alarmingly real Baltimore drug world, offering a depiction of the prison pipeline for drug offenders. The series repeatedly showed a strategy called buy-bust, in which undercover police officers buy drugs from dealers and then bust them. Their targets were invariably black. Photo ops typically ensued after a police bust, often with the display of a folding table covered with plastic-wrapped bricks of drugs and an assortment of deadly weapons and cash.
Without losing a beat, the dealers, still on the streets or incarcerated, portrayed in this series—again, fictional but very real—would mobilize even younger boys, black adolescents too young to go to prison, to sell the very same drugs that were confiscated. What remained unchanged was the ubiquity of illegal drugs; unsafe neighborhoods; the murderous violence of the drug culture and its leaders; and the power and financial success of the dealers, who became heroes for the young to emulate, thereby inspiring the next generation of dealers and users.
“Follow the money” is the other fuel, besides covert racism and political propaganda, that propels the engine of the drug wars. To see the futility of drug-control endeavors, read Tom Wainwright’s illuminating book Narconomics (2016). He meticulously shows how supply-side interventions, such as crop control, interdiction, and buy-bust, are as useless in Colombia and Mexico as they are on the streets of Baltimore, New York, and London. Wainwright, now UK editor for The Economist, had been the magazine’s correspondent in Mexico for years. The only major form of “news” was drugs, the cartels, and their murderous ways, which became his material for Narconomics.
Wainwright reveals how the hundreds of billions of dollars spent on efforts to control drug supplies in recent years have failed miserably to reduce cartel production and the use of illegal drugs, which are consumed by 250 million people worldwide. The heart of Wainwright’s argument is that the relentless focus on supply-side efforts to reduce illegal drug use has proven useless and that a demand-side approach would likely yield far more success. His examples about supply-side drug economics are compelling.
For example, he writes that the world economies spend an estimated US$100 billion annually to combat the cartels, $20 billion federally in the United States. Crop eradication and interdiction, favorite tactics in the drug war, have almost zero financial impact on cartel costs. Even when growers have had to produce twice the amount of cocaine, for instance, the buyers (i.e., the cartels) pay them no additional money; the price at the end of the line stays the same, on the streets of London and New York, thereby not adversely affecting sales. This is because the cartels have what he calls a monopsony, in which only one, or one predominant, purchaser exists, who then dictates the price it will pay: either sell to us at the price we set or you get nothing.
Take cocaine as an example. Even doubling the sale price of the coca leaf in the mountains, were that to happen absent a monopsony, would increase the cost to a street purchaser by less than 1 percent. Why? Because of the economics of the supply chain, the sequence by which a commodity is produced and distributed. The principal costs are not for the product, but for the multitude of illegal and expensive steps from the field to the nasal mucosa of the consumer. Wainwright likens efforts to reduce user (end-point) purchases by raising the price of coca leaves to trying to increase the price of expensive paintings by increasing the price of paint. He argues that the way to destroy the drug business is to cut the heart out of its revenues by reducing consumer demand. That might work because, as has been said, “it’s the economy, stupid.”
Control strategies have simply not done the job: drug delivery and access go unfettered, with only momentary interruptions, while the prices users pay are barely impacted and drug use goes unabated. Yet, the principal strategies for drug control pronounced by the Trump administration are to “build a wall” and “get tough on users and dealers.” Should all control efforts be suspended? While I greatly support decriminalizing possession of limited quantities of drugs, that is different from controlling such substances as synthetic marijuana (K2 or spice) and crack cocaine and crystal meth. Those are examples of drugs so damaging that we need more than demand reduction alone. But what we have not parsed out is which drugs and which control efforts should be sustained and which should be stopped, and then repurpose that money for prevention and treatment efforts. Budget woes at the federal and state levels are going to preclude sufficient new money for demand reduction, for prevention and treatment, and for us to succeed the funds must come from somewhere.
The metaphor the War on Drugs presupposes an enemy outside our borders or a civil uprising threatening the future of the nation. This is where the metaphor—applied to drugs as well as poverty and cancer—fails us from the very start. There is no external enemy.
Drugs are what people with addictions use; they are not armies at the gate. Addiction is “self-induced changes in neurotransmission that result in problem behavior.” Rather than facing an enemy, we have a powerful convergence of biology and social circumstances, the interplay of nature and nurture, that produces addictions—spanning alcohol, drugs, and a variety of compulsive behaviors such as gambling, video games, and some sexual disorders. How can we prosecute a war on human problems? The conditions to win such a “war” simply do not exist.
But the fatal consequences of the ongoing drug war are epidemic and visible.
In the film The Untouchables, the salty veteran Irish street cop Jim Malone (Sean Connery) takes a moment to advise the green, ambitious FBI agent Eliot Ness (Kevin Costner) after an eruption of deadly violence. Malone says, “You wanna know how to get Capone? They pull a knife, you pull a gun. They send one of yours to the hospital, you send one of theirs to the morgue. That’s the Chicago way.” But it is more than the Chicago way, though that city has certainly been a bleak poster child for violence. Just across the border in Mexico, cartels—such as Los Zetas, Knights Templar, and Sinaloa—enforce order and maintain their market shares through violence, including beheadings, torture, and mass killings. Homicides in Mexico peaked at almost twenty-three thousand a year in 2011, dropped to a bit over fifteen thousand in 2014, and are now on the rebound. Murder pays. And we all suffer, drug users and nonusers alike, from the policies of control and incarceration that have characterized the US approach to addiction for much of our long history.
Doctor: “Joe, you’re fifty pounds overweight. That’s starting to give you diabetes and high blood pressure. Plus, it’s one of the reasons your knees hurt so much. You need to lose that weight.”
Joe: “You’re right, Doc. I’ll do it.”
When Joe leaves his doctor’s office, he leaves his good intentions behind as if returning a magazine to a table in the waiting room. The next time he has a doctor’s appointment, he is reluctant to go, feeling ashamed. When he does go, the doctor-patient pas de deux is unchanged. The doctor once again exhorts Joe to lose weight. Joe knows the consequences of being overweight, but that is not enough to mobilize him to act.
I heard an apocryphal story many years ago before the use of seat belts became common. The public service ads and threats of fines were not getting good traction, nor was negative advertising, showing people in hospital beds or coffins. The story goes, however, that one advertisement was different. It depicted an adorable child in the back seat admonishing her dad to buckle up. That worked. Estimates are that today over 1 million lives have been saved by the use of seat belts.
The use of children to promote safety in adults, who can’t as a group seem to abide by simple and effective rules for their own welfare, has migrated to another grim problem: accidental shootings by youth with their parents’ handguns. When the tables were turned on the parents, hammering them with how they might be endangering their children, they paid more attention.
When I speak about how effective drugs, legal and illegal, are in achieving their desired effects on how a person feels, thinks, and acts, almost invariably the response is “But they cause cancer” or “They can lead to HIV infection” or “They destroy a person’s brain—and their lives.” Of course they can and sometimes do, especially if they are impure and used in unhygienic and unsafe ways. Cigarette smoking and vaping are always harmful, always. But while some limited effect is achieved by putting big black or red letters spelling out CANCER or CIGARETTES KILL on cigarette packs, what has worked far better has been making smokers pariahs in their own families and communities.
There’s a joke about a man going into a pharmacy and asking in a clear, loud voice for a package of condoms, then whispering a request for a pack of cigarettes. Social values and family influences matter, not exhorting people to not do what they already know they shouldn’t do.
Risky behaviors in youth (and even adults) also don’t respond particularly strongly to admonitions, such as against sexually transmitted diseases, injuries, unwanted pregnancy, texting while driving, sexting, and the development of anorexia nervosa. Yet, emphasizing the negative consequences of alcohol, tobacco, and drugs has been the second major strategy in dealing with drug use and abuse. A variant, also ineffective, is having uniformed policemen come to schools and warn students about the laws against drug use and the misery of prison. They may feel good for the moment, especially for educators desperate to help, but these warnings also don’t work.
Rattling on about consequences is akin to jousting with windmills, being unable to see the world as it is, just like Don Quixote. What we need is a Sancho Panza, a fellow companion who comments wisely and with humor and irony, to allow us to change the dialogue.
The disconnect between information, in this case cautionary details, and action is massive. If we all acted with reason, in our self-interest, my profession would not need to exist. But it does, and business remains brisk.
Ongoing campaigns, public service announcements, and school education programs that teach youth the consequences of their actions have been just as fixed and ineffective as efforts to control the use of drugs. Some youth do appreciate, it’s true, the difference between experimenting with drugs and becoming regular users, for instance, or the importance of staying away from the “needle barrier.” But prevention programs in schools have relied on adults, whom adolescents are more apt to rebel against than listen to; some programs have recently started to use other youth, peers, to deliver the demand-reduction message, which is an improvement. But still youth face the intrinsic limitations on controlling their behaviors that, in time, the maturation of their brains will provide.
Modern neuroscience has proven that the human brain does not fully myelinate—surround the massive number of connecting fibers among brain nerve cells with a fatty insulating substance, thereby enhancing conduction—until the early to middle twenties, sometimes later for males. The myelin enables our brains to work more effectively, especially our frontal lobes, where judgment derives from. Think of the times you or a friend asked teenagers to do something, remember something, control their impulses, cap their emotions, or even just cap the toothpaste. Something is missing in their heads, and it is called myelin. The absence of myelin is a neurological reason for not permitting voting until age eighteen and making the sale of tobacco and alcohol (and cannabis) subject to age restrictions, which I think are examples of selective control measures we should sustain.
That is not to say, however, that once humans have passed their third decade on earth they become exemplars of healthy and decent behavior. They have a better chance at it, but as we see every day, it is no foregone conclusion. We do know, though, that people whose adolescence was spent under the sway of substances lose those years of psychological and emotional development and remain rooted in more juvenile ways of thinking and being.
Bearing down on consequences is a puritan and punitive approach to controlling behaviors that time has shown—as has the growth of substance use, abuse, and overdoses—not worthy of the amount of effort and resources it has consumed. It’s not valueless, but it’s just not enough if we are to alter the trajectory and popularity of substance use in this country.
A technique that originated in the substance-treatment community years ago has now become popular in managing chronic physical conditions such as diabetes, hypertension, and heart disease, and habit disorders such as smoking and overeating, in general medicine and primary-care settings, as well as in mental health and addiction clinical services. It is called motivational interviewing (MI) or motivational enhancement (ME).
People don’t smoke because it makes them smell bad or gives them cancer. Painful relationships don’t persist because of the disappointments and grief they generate. Troubling habits of all sorts endure because of what they do for us. Motivation to change can come from a person’s getting more out of changing than staying where he or she may be, which is the basis of motivational interviewing.
Motivational interviewing is nonjudgmental. There is no saying a person is bad or his or her behaviors are shameful. Nor does it allow people to emotionally beat up on themselves, self-flagellating with negative, abusive comments. Quite the opposite: MI starts by recognizing that a person is doing something for powerful reasons. The best ideas that emerge in MI come from the patient, in a trusting relationship with the clinician.
In another section of this book, we will look at other ways to change damaging habits, especially addictions, based on the neuroscience of behavior.
We must employ more than exhortation, more than shame and nagging, to help a person live a healthier and more rewarding life. MI is but one example, as are other cognitive techniques, family supports, medication-assisted treatments, recovery groups, exercise, and a variety of useful mind-body approaches including yoga, slow breathing, mindfulness, and meditation. The alternatives to “accentuating the negative” work far better.