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America's policy regarding illegal drugs has been accused of being a failure and being racially biased against blacks and other minorities. The author asserts that while drugs and crime exist in all parts of the society, problem-generating drug use and serious crime are indeed concentrated among the urban poor, some of whom are black. He further explores what this disproportionate drug-related suffering means when it comes to the provision of addiction treatment, law enforcement resources and other responses to the problems spawned by addiction.
Opponents of the nation's current policies prohibiting use of drugs such as marijuana, cocaine and heroin argue that such policies are racially biased against African-Americans and other minorities and that the drug war has failed. These criticisms were dramatically presented in the article "Criminalization of Drug Use" by Joseph D. McNamara, D.P.A., in the September 2000 issue of Psychiatric Times.
My experience of over three decades of work in addiction medicine leads to quite different conclusions. While drugs and crime exist in all parts of the society, it is also true that problem-generating drug use and serious crime are indeed concentrated among the urban poor, some of whom are African-Americans. What does this disproportionate drug-related suffering mean when it comes to the provision of addiction treatment, law enforcement resources and other responses to the problems spawned by addiction? If the war on drugs has failed, has it failed disproportionately for the poor? Would drug legalization help the poor as some critics of current drug laws have proposed?
Examining the Data
It is well-documented that African-American non-Hispanics are significantly more likely than other groups to be incarcerated for both drug and non-drug offenses (National Center on Addiction and Substance Abuse at Columbia University [CASA], 1998). In addition to minority adults, the National Council on Crime and Delinquency (1999) found that African-American and Hispanic youths are treated more severely than white teen-agers charged with comparable crimes at every step of the juvenile justice system.
When race/ethnicity is looked at by offense type, however, we find that the percentages by race were similar for drug law violations and violent and property crimes (the three major divisions of serious crimes). For example, African-American non-Hispanics made up 50% of state inmates serving sentences for substance offenses, 45% for violent crimes, and 43% for property crimes. Among state prison inmates, the population who were drug abusers was similar for the three major racial/ethnic groups: 61% of African-American non-Hispanics, 65% of Hispanics, and 63% of white non-Hispanics (CASA, 1998).
These numbers are especially important because some critics of drug laws have based their criticisms on claimed disparities in populations in prison for drug and non-drug offenses. When it comes to drug use patterns that lead to addiction treatment and incarceration, the reason there is a higher percentage of African-Americans in both treatment and prison is that a small but important minority of African-Americans are more likely to use illicit drugs in ways that lead to these outcomes.
Measures of drug use show that racial disparities extend beyond the criminal justice system. In 1994, the Centers for Disease Control and Prevention (CDC) published a study looking at 14,968 newborns in Georgia over a two-month period that year. Cocaine was identified in the blood of 73 or about 0.5% of the newborn infants. Eighty-four percent of the positive tests were for African-American infants although only 50.9% of newborns were African-American. Although a higher percentage of African-American babies were cocaine positive, it is important to note that the vast majority of both African-American and white newborn infants showed no evidence of recent maternal cocaine use.
Like babies born with cocaine, drug-related deaths are not related to the criminal justice system at all. The recently released data on overdose deaths show that the racial disparity has substantially increased between 1979 and 1998 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2000).
So the answer to the question of why there are higher percentages of African-Americans in public sector treatment and in prisons is that there is a substantial minority of African-Americans who have a variety of social problems that put them at a relatively higher risk for these outcomes. Drug abuse treatment admissions, emergency room episodes and overdose deaths all showed an excess of African-Americans compared to their share of the total U.S. population that was on the same scale as the excess in prison populations (SAMHSA, 1999a). It is as hard to see racism in the war on drugs as the major cause of the excess of African-Americans among public addiction treatment, emergency room visits for drug problems, and overdose deaths as it is to see racism in the war on drugs as a credible explanation for the preponderance of African-American newborns among cocaine-positive infants in Georgia. In addition, although we are focusing on race/ethnicity, it will come as no surprise that similar disparities among those incarcerated are evident when looking at education, income and mental health status (CASA, 1998; U.S. Department of Justice, 1999).
There is an even larger gender disparity-in the opposite direction. Females constitute 51.8% of the population and 35.7% of illicit drug users (SAMHSA, 1999b), but only 30.1% of public sector drug treatment admissions (SAMHSA, 1999c) and 6.5% of incarcerated individuals (Beck and Mumola, 1999). Yet, most people are prepared to accept that proportionately fewer females are incarcerated because they commit fewer imprisonable offenses than males do.
Many changes have occurred in the criminal justice system over the past 30 years that have contributed to the increasing prison population. The rise in drug use and in crime over the past three decades has been met by tougher laws and stricter law enforcement with sustained bipartisan support at the federal, state and local levels for three decades (DuPont and MacKenzie, 1994).
These policies have increased the population in prisons and reduced the rate of crime in the country. For example, earlier discretion in sentencing was replaced by more rigid sentencing guidelines with more mandatory minimum sentences. Parole and probation were curtailed as alternatives to incarceration by a curious synergy of liberal and conservative critics of the criminal justice system. In the end, the earlier criminal justice reforms were abandoned in the 1990s as much by their supporters as by their critics.
Why do some people become addicted to drugs and others do not? Gender looms large in addiction risk. Males are more likely to try illicit drugs than are females. They are far more likely to use heavily and to experience severe consequences of that drug use, including both treatment and incarceration. Age is also a big risk factor. The risk of starting to use illicit drugs is almost limited to the age range of 10 to 20 years with an earlier age of onset being associated with a more malignant prognosis. Environment also plays a pivotal role in the risk of drug addiction. The more drugs are around and the more illegal drug use is tolerated, the more a person is likely to use and to have problems with illicit drugs.
Risk of addiction can be found in every social class. My experience with adult addicts has shown me that some of the most talented people in all segments of the population have some of these high-risk characteristics. It is also true that high-risk characteristics are common in lower-class communities. These characteristics are maladaptive and create as well as reflect lower-class status. This is one of the reasons for a concentration of the most serious forms of addiction in these communities.
Character plays a significant role in addiction risk, too. The more a person has high-risk characteristics, the more likely that person (especially during the vulnerable age range of 10 to 20 years) is to use and to have problems with illicit drugs (U.S. Department of Health and Human Services, 1987).
High-risk characteristics include habitual patterns of focusing on current reward (rather than delayed reward), dishonesty and lack of empathy for the feelings of others. These characteristics are more often seen in males and among adolescents than in other population groups. Among teen-agers, high-risk traits include negative attitudes toward adults, not doing homework (a classic "pain now, reward later" experience), dishonesty and lack of religious values. Genetics is another important risk factor.
I believe the drug war could be improved, but it has been remarkably successful. The number of illicit drug users in the United States peaked in 1979 at 25 million; that figure now stands at 13.6 million, a 46.5% decrease. That same year there were 114.1 million alcohol users, and that number has only fallen 1.1%; cigarette use has fallen 18.9% since 1985 (the earliest comparison figure) (SAMHSA, 1999b). When the total cost to society from each of the three categories is compared, all illicit drugs (including all criminal justice costs, such as prosecution and prison) in 1990 came to $66.9 billion while the cost attributed to alcohol and tobacco were $98.6 billion and $72 billion, respectively (DuPont, 1997a). The fact that all illegal drugs combined are used by fewer people, and that this use creates lower total social burden, is evidence of the beneficial effects of prohibition.
Some argue that the major reason drug use contributes to crime is the high cost of prohibited drugs, implying that if drugs were legal and cheap the crime rate in the nation would be reduced.
A recent review of the role of alcohol in crime showed clearly how counterproductive it would be to have more and cheaper drugs available. In state prisons, 21% of the people imprisoned for violent crimes were only under the influence of alcohol when they committed the crime for which they were imprisoned (CASA, 1998). Alcohol and other drugs cause crime primarily because they are intoxicating and impair judgment. More drug use means more, not less, crime. The data detailed here do not support the conclusion that our nation is losing the war on drugs or that legalization of currently illegal drugs would reduce the social cost resulting from drug use, including crime rates.
Have you ever met an addicted individual whose life would be improved if they had access to better and cheaper drugs? Have you ever met a family member of an addicted person who thought their loved ones would be better off with better and cheaper drugs? When people in impoverished communities have an opportunity to express their views, they ask for more law enforcement and less illicit drug use, not less law enforcement and more drug use.
Relaxing drug laws and, even worse, legalizing currently illegal drugs, is a major threat to poor and minority communities. In recent years some opponents of current drug prevention policies have abandoned the "L" word, legalization, and adopted a less divisive policy called harm reduction. A central aim of harm reduction is to reduce the socially imposed negative consequences of illegal drug use. Harm reduction targets drug laws and drug testing by employers. Harm reduction supports "medical marijuana," needle give-aways and wider use of "hemp" products. This approach, while superficially appealing, is unwise because it will lead to increased use of illegal drugs. Most "harm" is caused by drug use, not anti-drug activities. Since harm reduction encourages drug use, it will actually raise the level of harm caused by illegal drug use (DuPont and Voth, 1995).
The criminal justice system plays a vital role in the nation's efforts to reduce the use of illicit drugs. The criminal law is a powerful expression of the community's attitude toward drug use. The law creates a bright line that is the foundation of addiction prevention and treatment. When people violate drug laws, they need to be confronted with serious consequences that are escalated for repeated offenses. A commitment to the public interest requires a strong endorsement of the legal standard against drug use and vigorous and consistent enforcement of this standard.
Conjure this common image: A rich white man drives an expensive car into a ghetto neighborhood and buys drugs from a African-American man who comes up to the window of his car to exchange drugs for money. What should be done about this problem? The clear answer is to arrest them both. That easy-to-imagine illegal drug transaction takes place where it does because the participants think that they can get away with it there. The solution to the problem of heavier drug use in poorer communities is not less law enforcement but more law enforcement, especially when it comes to the drug laws.
Prevention and Treatment
The addicted person is locked in the embrace of an abusive chemical lover (DuPont, 1999). Usually when something painful happens as a result of drug use, the addicted person seeks to continue drug use believing that "next time it will be different." The challenge of addiction treatment is to convince the addicted person that, "No, the next time it will end badly just the way it ended badly this time."
Like a person in an abusive relationship, the addict's brain denies the evidence of problems caused by drug use and longs for the time when the drug use appeared to be problem-free. As the addictive disease progresses, the addict is less motivated by the search for euphoria (positive reward) and more motivated by relief of distress (negative reward) (DuPont and Gold, 1995).
Getting unhooked from drugs has two parts. The first is hitting bottom, experiencing consequences of drug use that are so serious and so repeated that the addicted person concludes that going on this way is no longer acceptable. The second part is finding a path out of the quicksand of addiction, a way to live a better, more stable and drug-free life. That is where addiction treatment and the 12-step programs come into the picture. Group support is also vital so that recovering addicts can work closely with others who have been caught in the addiction trap and found their way out.
Families, communities and social institutions, including the criminal justice system, must provide socially imposed consequences or "bottoms" for the users of illicit drugs. Additionally, the way out of the quicksand of alcohol and other drug use needs to be made clear to the addict. That is what good addiction treatment does. That is what the drug courts and driving while intoxicated (DWI) programs do. They all use an approach that has been popularized over the past two decades as "tough love" (DuPont, 1998).
No one with a heart starts off with tough love. Almost everyone begins their dealings with addiction by enabling. That means that they try to solve the problems of addiction with love and with support. Sooner or later, just as addicts learn that working things out with their chemical lovers is doomed, so the people who care about addicts slowly and reluctantly, in most cases, learn that enabling deepens the addicts' escalating problems. Success requires the determination to identify and actively discourage illicit drug use (DuPont, 1998).
This is what drug courts do, and it is the same way nationwide programs approach addicted doctors. Every state now has impaired physicians' programs that combine drug testing (with progressively escalating penalties for positive tests) and 12-step addiction treatment. The nation would benefit if this same approach were applied throughout all communities, especially for the people who are most disadvantaged in the criminal justice system (Angres et al., 1998).
The financial and human costs of addiction can be further reduced by using the leverage of the criminal justice system to enforce a standard of no-drug-use for all people under supervision. Violations of this standard would be met with more frequent drug testing plus additional help by way of counseling and 12-step meetings. Repeated violations would be cause for gradually escalating penalties, including more prolonged incarceration. With this approach, the beds in prisons-which are far more expensive than addiction treatment and intensive supervision in the community-would be reserved for those addicted offenders who have failed at intensive community supervision (DuPont and Wish, 1992). A standard that requires rigorously supervised drug-free living along with employment and payment by the offender for some of the costs of supervision and addiction treatment is preferable on humanitarian and economic grounds to expensive dead time in prison. Behind Bars: Substance Abuse and America's Prison Population (CASA, 1998) has an excellent discussion of these issues.
The modern DWI and drug court movements have pioneered this no-nonsense style of community-based corrections. The goal of this approach is not only to establish drug-free living but also to help addicted people change their lifestyles to responsible community participation. This is the hopeful common ground between the views of supporters and critics of the drug war (DuPont and Gold, 1995).
One of the great innovations in the contemporary drug court movement is universal and regular drug testing linked to strict and escalating consequences for positive drug test results (Cook et al., 1995; Wish, 1998). It is only when drug testing is routine and regular that illegal drug use is reliably detected. Today the criminal justice system imposes consequences for violations of the drug-free standard in a haphazard fashion (DuPont, 1999), and this could be improved. Another great innovation of drug courts and DWI programs is the systematic, well-enforced use of 12-step programs including Alcoholics Anonymous and Narcotics Anonymous.
While it is important to resist the unfair (and unjustified) stereotyping of addicts as African-American, it is equally important to acknowledge that there is an excess of particular serious problems in some populations that merit effective responses in the public interest as well as in the interests of the populations most adversely affected. There is no disadvantage so serious that illicit drug use will not make it worse. Families and communities disintegrate under the crushing burden of drug addiction. The disparity of African-American and other disadvantaged groups including the mentally ill, the poor and the undereducated among incarcerated people is a serious problem.
Unlike McNamara, who would eliminate drug laws, I believe that the best solution to the problem of illicit drug use and crime in all population groups is a significant effort to help communities rid themselves of illicit drugs by providing compelling reasons not to use them. The single best way to do that is to develop, throughout the criminal justice system, programs of drug testing linked to progressively more severe punishments for continued illicit drug use (DuPont and Gold, 1995). Other social institutions, including those in poor communities, need to be linked to drug testing and meaningful consequences for illicit drug use. Welfare is a prime candidate. Mothers on welfare as well as teen-age children would benefit from drug testing and consequences for drug use (DuPont, 1997b).
Drug treatment is an important part of this picture. The most important opportunity today to overcome addiction to alcohol and other drugs is wider use of 12-step treatment, which is the only lifelong approach to addiction to alcohol and other drugs that works, regardless of how much financial or public support exists.
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