COMMENTARY

The War on Drugs Is Lost; What Comes Next?

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Hello and welcome. I am Dr. George Lundberg, and this is At Large at Medscape.

"God damn the pusher man" -- 1969, Steppenwolf, from Easy Rider.

'It's So Good, Don't Even Try it Once': Heroin in Perspective -- by David E. Smith, MD, 1972.

What is a drug? I define a drug as any chemical which, when administered to a living creature, produces an effect. As such, there are thousands and thousands of drugs. But today we are speaking about a subset called psychoactive drugs. A psychoactive drug is a drug that affects the way you think, feel, or behave.

What is drug abuse? I define drug abuse as the use of a drug in a manner that is likely to cause harm -- predictable harm. There have always been drug abuse and drug abusers. There is no reason to believe that there will not always be drug abuse and drug abusers. The drive to take psychoactive drugs is irresistible to many people.

You will notice that I have said nothing about "legal" or "illegal," because most drug abuse in the United States in 2014 is legal. The laws that attempt to prevent drug abuse vary by country and state, century and year. Why? Because no society ever has figured out how to deal with this issue successfully through its laws.

Most drug laws have to do with controlling availability. If you don't have a drug, you won't have a drug problem. That's great. It's very sensible. That is called supply-side control. The problem is that it never has worked in anything approaching a free society. Drugs are just too easy to grow, make, transport, give, buy, sell, or steal.

Every legal action to interdict the supply side is countered by an "unintended consequence," similar to the current game of Whac-a-Mole.

Think South America and coca fields; think Afghanistan and opium poppies. Think every drug bust you have ever heard of. Supply-side drug control fails on a colossal, a macro-, and a micro-scale.

There is reason for some hope on the demand side. It's called harm prevention and harm reduction. When you buy a drug on the street, you never know for sure what it is, or what else it is, or how much of which is what. This is well known but is still a giant problem. A century or so ago, I used to run a street-drug identification program for drug users in southern California. We published a "dope scorecard" weekly in the Los Angeles Free Press to try to inform the users about what they were getting into. The differences between street-drug representation and reality were often stark.

What to do, what to do?

  1. Follow Hippocrates; try not to make a bad situation worse. Especially don't support laws that cause more harm than the drugs do.

  2. Prevent addiction, especially by delaying initial exposure to the rapid addicters -- nicotine, crack cocaine, heroin, perhaps methamphetamine, and to a somewhat lesser extent, alcohol -- to as old an age as possible, if ever. Even experimentation can turn lethal with some.

  3. Prevent overdose death, especially by making naloxone as widely available as possible to counteract heroin overdose.

  4. Manage addiction primarily as a chronic disease, especially in physicians' offices, and not primarily by law enforcement.

  5. Balance pain relief with enlightened prescribing of opioids, especially ambulatory.

  6. Educate, educate, educate -- at all levels, with honesty.

Of course this approach will fail with many. But it will also succeed with many. The "war against drugs" is over. We all lost. Now is the time for cultural reconstruction, rehabilitation, and evidence-based nation-building.

That's my opinion. I'm Dr. George Lundberg, at large for Medscape.

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