United States | Drugs policy

Pills and progress

Signs of compassion mixed with pragmatism are emerging in America’s treatment of drug users, who are also changing their habits

|ATLANTA AND AUSTIN

ON A recent evening, some 50 people turned up for their weekly reckoning at Judge Joel Bennett's drug court in Austin, Texas. Those who had had a good week—gone to their Narcotics Anonymous meetings and stayed out of trouble—got a round of applause. The ones who had stumbled received small punishments: a few hours of community service, a weekend in jail, a referral to inpatient treatment. Most were sanguine about that. Completing the programme will mean a year of sobriety and the dismissal of their criminal charges.

After the session, Mr Bennett noted that the drugs problem has grown worse during his nearly 20 years on the bench, largely due to poverty, poor education and cycles of abuse. Still, he reckoned, less punitive approaches to drug users are gaining acceptance. That is largely because the punitive approach has failed.

More than 40 years have passed since Richard Nixon declared a federal “war on drugs”, and drug use is still a big problem. In 2008 roughly 8.9% of Americans aged 12 and older used an illegal drug, up from 5.8% in 1991-93. Nor have the consequences abated: in 2008, according to preliminary data from the Centres for Disease Control (CDC), there were 37,792 drug-induced deaths, compared with 14,218 in 1995.

The drugs of choice have also changed. Methamphetamine use, which spiked several years ago, has fallen off. But the past ten years have seen a rapid increase in recreational use of prescription drugs. In 2000 1.2% of Americans had misused these drugs, mostly powerful painkillers; by 2010, the proportion of users had doubled to 2.7%, second only to marijuana, long the most commonly used illegal drug.

In 2008, according to the CDC, some 15,000 people died after overdosing on prescription opioids and narcotics like oxycodone and hydrocodone. That is more than heroin and cocaine combined, and up from 4,000 in 1999. They are also far easier to obtain: 70% of users get them from friends or family. That last feature presents a particular challenge for the police. Prescription drugs are legal and often legitimately prescribed, and hence not suited for a zero-tolerance approach.

Rates of heroin and cocaine use have remained relatively constant over the same period—and compared with rates of prescription-drug use, quite low—despite tough penalties for distribution and possession. However, urban violence, traditionally associated with drug markets and dealing, has plummeted. Trafficking-related violence remains brutal along Mexico's northern border, but America's cities, even those along the border, are far safer than they were ten or 20 years ago. But if America's war on drugs has failed to curb drug use, it has been a boon to the prison industry: in 2008 non-violent drug offenders accounted for a quarter of American prisoners, up from less than 10% in 1980.

The cost of jailing so many people, particularly in straitened times, together with a lessening in the pressure on politicians (because of the declining violence) have led to a change in the tough-on-crime rhetoric. In 2009 Gil Kerlikowske, the director of the Office of National Drug Control Policy, announced that the office would no longer use the phrase “war on drugs”. Sixteen states have legalised marijuana for medical use, and over a dozen have similar legislation pending. In 2010 Barack Obama signed the Fair Sentencing Act, which lets judges take mitigating factors into account when sentencing a prisoner, reversing the mandatory-minimum policies that led to long jail terms for non-violent crimes. It also reversed the sentencing disparity between convictions for crack and powder cocaine, enacted in 1986 when crack was believed to be more addictive and dangerous than powder (as well as more popular with poor blacks than rich whites).

At least 23 states have passed or are considering similar reforms. Proposals vary, but many would grant judges more leeway in sentencing and also steer low-level, non-violent drug offenders away from prison and toward alternatives: community-supervised treatment, probation, halfway houses and daily reporting. Drug treatment is included in Mr Obama's health-care reforms, with effect from 2014. Public-health experts have long supported such policies, arguing that addicts are not much moved by the threat of prison. “By that stage, they've got so many other problems,” says Jane Maxwell, an epidemiologist at the University of Texas.

Still, the national drug-control budget provides more money for law enforcement than for treatment. States have struck out with their own efforts to expand treatment and harm reduction, but these programmes can be controversial, labour-intensive, and hard to scale up.

New Mexico, for example, has a harm-reduction programme that trains participants (mostly heroin users) in rescue techniques, and equips them with doses of naloxone, a drug that blocks the effects of an opiate overdose. Michael Landen, the deputy state epidemiologist, says that this programme has dealt with some 3,000 overdoses since 2001.

Prescription drugs are the one area where there is a drive for more stringent laws on the supply side. In 2000 pharmacies dispensed 174m prescriptions for opioids; in 2009 they dispensed 257m. Not all those prescriptions are phoney, of course, but presumably America did not become a 48% more painful place during those nine years. Over that same period a number of states saw a proliferation of “pill mills,” at which doctors distribute prescriptions, often for cash and following at best a cursory exam.

Last year Florida, which had been a particular hub for pill mills, passed laws tightening prescription regulations and increasing penalties for over-prescription. Michael McAuliffe, state's attorney for Palm Beach County in south Florida, says the number of clinics in his county has since dropped by half. He calls prescription-monitoring databases, which allows doctors to see what medications their patients have been given, “a critical tool”; today 48 states either have or will soon have such databases. The federal Office of National Drug Control Policy has made monitoring a critical part of its strategy to combat prescription-drug abuse as well.

The sad truth remains, though, that the courts, thankfully a bit more enlightened these days, are likely to remain the principal way of dealing with drug users. Some habits are hard to break.

This article appeared in the United States section of the print edition under the headline "Pills and progress"

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