Controlling psychoactive substances: can we reach a stable equilibrium?1
Robin Room
Centre for Social Research on Alcohol and Drugs
Sveavagen
Stockholm University
S-106 91 Stockholm, Sweden
Robin.Room@sorad.su.se
ABSTRACT
The last 20 years have seen substantial changes in the situation and in the social
definition of heavy use of different psychoactive substances. Cigarette smoking has become
increasingly enclaved and indeed marginalized in daily life, and new efforts are being made
to develop a system of international controls. Meanwhile, controls have been further relaxed
on alcohol beverage consumption, while our understanding of the consequences of drinking
has complexified, with new emphases both on potential health benefits of drinking and on
social and casualty harms from drinking. Illicit drugs have moved more into mainstream
culture in societies like Britain, while the international prohibitionary control structure has on
the one hand increased its ambitions but on the other hand fallen further and further short in
controlling the market.
Is there a stable and rational equilibrium in controls to aim for in the new
millennium? Outright prohibition has failed, and thinking about decriminalization and
legalization has increased. On the other hand, it has proved increasingly difficult to sustain
serious market controls on legal substances. Individual-level controls such as rationing are
viewed as an intolerable intrusion on personal freedoms, except in the medical context of the
prescription system. Aggregate measures such as high taxes, government monopolies and
limited sales hours have been considerably weakened for alcohol. Some principles are
suggested for consideration in thinking about control of psychoactive substances.
Trends in consumption, in problems, and in societal responses in the last 20 years
In the last twenty years, much has changed, and much has stayed the same with
respect to psychoactive substances. In 1979, an international group of scholars of which I was
a member was in the middle of considering what had happened to alcohol consumption,
problems and policies since the Second World War (Mäkelä et al., 1981; Single et al., 1981).
We documented a substantial rise in alcohol consumption in most developed societies (other
than wine cultures) over the preceding thirty years, although we noted signs that the trend
was stabilizing or even reversing in the late 1970s. Sure enough, there was a period of slowly
declining consumption in many places in the 1980s and 1990s, though this period too seems
to be coming to an end. With respect to tobacco, the last 20 years have seen in most
developed societies a definite reversal of the long rise in cigarette consumption in the
preceding decades. Looking back, the peak of psychoactive drug experimentation by
American youth came about 20 years ago, succeeded first by a long slow decline in drug use,
1
Prepared for presentation at a Substance Use Policy and Practice Conference, Centre for
Alcohol and Drug Studies, University of Paisley, Paisley, Scotland, 9-10 September 1999.
Parts of this presentation are adapted from a paper presented at a conference on Alternative
Nicotine Delivery Systems: Harm Reduction and Public Health, March 21-23, 1997, Toronto,
Canada.
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and more recently again by an upturn. The picture is more complex concerning trends in
Europe. In Britain the number of heroin users has increased manyfold in the last 20 years.
Youth in corners of Europe like Finland are now experimenting with drugs, where before
they stuck with alcohol. In the Netherlands, however, where drugs had come earlier, the
picture in the last two decades has shown more stability. With respect to
psychopharmaceuticals, the barbiturates have disappeared from use in developed societies,
and amphetamines have moved out of the clinic and onto the street, but, what with the
benzodiazepines and the anti-depressants, not to mention methadone and nicotine,
psychopharmaceutical prescribing has if anything increased its importance in medical
practice.
The last twenty years have also seen both stability and change with respect to societal
responses to the problems of psychoactive substance use. There is a long-term drift towards
greater control of tobacco marketing, but changes on this have been painfully slow, reflecting
the power of economic interests and entrenched habitual use. Quitting smoking, which
twenty years ago was primarily a matter for the individual smoker, has become more of a
social concern, and to some extent medicalized with nicotine replacement therapies. For
alcohol, the picture in most English-speaking places and in northern Europe has been of the
continuing gradual erosion of the structures of alcohol control set in place three generations
ago. Alcoholic beverage producers and marketers have become ever more globalized, though
many of their products now carry quaint cottage-industry labels (Jernigan, 1998). While
tobacco companies find themselves increasingly in the status of social pariah, alcohol
companies have been increasingly effective in their influence on policy and the research
world. Alcohol treatment, increasingly combined with drug treatment, has been whipsawed
by efforts to contain the growth of welfare and health care costs, but has mostly held its own.
The one dramatic exception for alcohol has been the experience of the former Soviet
Union, which undertook in 1985-1988 the most thoroughgoing campaign anywhere since the
1920s to change the cultural position of alcohol (White, 1996). Though it was quickly
apparent that this top-down campaign rapidly became politically unpopular, it has taken
longer to document that while it lasted it did have very favourable effects on the health of
Soviet drinkers. Male life expectancy rose from 61.7 in 1984 to 64.9 in 1987 (Leon et al.,
1997). The picture was dramatically reversed in the early 1990s, with the abandonment of
the campaign, the shrinking of alcohol treatment provision, and the state’s loss of control of
the alcohol market. Other changes in this period also had adverse effects on health. By 1994,
the average age of death of Russian men fell to 57.6, a level which had not been seen for
many years in industrialized countries. The statistics suggest that the situation in the countries
of the former Soviet Union has stabilized and may even be improving in the later 1990s.
Twenty years ago, America had already experienced, under Nixon, its first modern
“drug war”; the mid- and late 1980s saw its second, under the Reagans and Bush. The
medium-term result has been a dramatic explosion in the numbers in U.S. prisons. In 1980,
approximately 50,000 Americans were incarcerated for drug-law violations; today, about
400,000 people are in U.S. jails for nonviolent drug-related offenses (Baker, 1999).
Meanwhile, under the initial impetus of the threat of AIDS, the societal response to drugs has
been transformed in the last decade in much of Europe, with “harm reduction” approaches
coming to the fore. At the local level, despite the continuing rhetoric from Washington, some
of the same changes have come to the United States. Even in northern Europe, the societal
response to drugs is now premised on the idea that illicit drug use will be a continuing feature
of the society, rather than something temporary and alien.
Changes in international control systems
So far we have considered only experiences and reactions at the national level,
interlinked as these may be. There are also ongoing changes in the response to psychoactive
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substances at the international level. Twenty years ago, the international drug control system
was in the course of expanding its mandate, under the 1971 Convention on Psychotropic
Substances, from dealing only with plant-derived substances – opiates, cocaine and
marijuana – to dealing also with synthetic psychopharmaceuticals. The system’s ambitions
expanded yet again with the 1988 Convention on illicit trafficking, which seeks to control the
markets in precursor chemicals used in manufacturing drugs, and includes provisions on
money laundering and extradition (Room and Paglia, 1999).
This year has seen two further moves to expand the scope of international control on
drugs. One was the action of the World Conference on Doping in Sport, last February in
Lausanne, which decided that “an independent International Anti-Doping Agency shall be
established so as to be fully operational” in 2000 (World Conference..., 1999). This action
reflected the transition of the issue of doping in sports from the hands of the sports
federations into being a matter for intergovernmental action.
The other action was the agreement by the World Health Assembly to move forward
with negotiations on a Framework Convention on Tobacco Control, to be completed by 2003.
The Framework Convention is a centrepiece of an anti-tobacco program which is one of the
World Health Organization’s main current priorities (World Health Organization, 1999).
The crescendo of activity at the international diplomatic level is at least in part a
reflection of trends in international drug markets. The market in illicit drugs has grown year
by year, in the teeth of the international efforts to combat it. “I am reminded of the film title,
Same Time Next Year”, said the representative of Interpol, the international police
organization, at the annual meeting of the Commission on Narcotic Drugs in 1995; “as the
years go by, there is no real improvement in the situation.... Next year we hope for serious
progress, but we can’t report it today” (Room and Paglia, 1999). The issue of drugs in sports
attained its highest media profile ever with the events of the 1998 Tour de France. With the
dissolution of the Soviet Union and the opening of eastern European markets, the
international tobacco companies have increased their dominance of the global tobacco
market.
The conspicuous exception, in terms of international control attention and activity, is
alcohol. There is some irony in this, since alcohol was the first psychoactive substance
subject to international control a century ago, in the long-forgotten treaties among European
powers to prohibit the sale of spirits for use by natives in colonial Africa (Pan, 1975). In
terms of international trade treaties and dispute mechanisms, currently alcohol is primarily
treated as an ordinary commodity like wheat noodles or steel tubing. The European Union,
Canada and the U.S. have spent considerable energy through trade dispute mechanisms on
efforts to break down each other’s internal alcohol controls (Room and West, 1998), and
similar official attacks on market controls have been directed at Asian and other developing
countries (e.g., Korea Herald, 1999). No international mechanism is available or currently
planned which would commit countries, for instance, to mutual support in controlling alcohol
smuggling.
With the World Health Organization study of the Global Burden of Disease, we have
for the first time estimates of the relative health impact of the different psychoactive drugs.
The unit of analysis in the GBD study is “DALYs” -- disability-adjusted life years. That is,
the study takes into account disability as well as death, and years of life lost to disability or
death rather than just the fact of disability or death regardless of age. On a global basis,
according to the GBD study, 0.6% of DALYs are lost because of drugs under international
control, 2.6% because of tobacco, and 3.5% of DALYs because of alcohol (Murray and
Lopez, 1996). For the “established market economies” -- countries like Britain – the figures
are 2.3% for illicit drugs, 11.7% for tobacco, and 10.3% for alcohol. Against these figures
for the relative scope of the problems we can set the level of staff effort devoted to the three
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classes of drugs by agencies of the UN system. In terms of full-time equivalent staff, there
are over 200 positions devoted to illicit drugs, about 20 to tobacco, and about one to alcohol.
Perhaps a goal for the next two decades should be to reach a better match between the extent
of the problems and the international effort devoted to them.
Lessons for the path forward
Out of the welter of experience of the last twenty years, then, there are four lessons
which we might draw in considering paths forward in the new millennium. The first is, in the
words of a recent headline in the Daily Telegraph (4 September 1999), that “drugs are here to
stay” -- that experience suggests that we must abandon as an illusion the idea that a
prohibition regime will put the genie back in the bottle, once a drug has gained a significant
foothold even in a subculture within a society. The second is that the emphasis on illicit
drugs has distracted attention from where our biggest health and social problems with drugs
lie -- which are with tobacco and, particularly, with alcohol. The third is that, when all
psychoactive drugs are taken into account, they are responsible for a very substantial portion
of the burden of disease, disability and social problems in societies like ours; there is
certainly no justification in the figures from the Global Burden of Disease study for
slackening off on efforts to limit the social and health harm from psychoactive substances.
And the fourth is that we would be well-advised to be realistic and limited in setting goals
and strategies for governmental and international action in the field. It can be argued that
governmental actions have played only a limited part in the great shifts in the last two
decades in the amount and patterning of psychoactive drug use. International action, while
potentially important in backing up national actions, cannot substitute for responses and
policies at community, regional and national levels.
Regulating the market in psychoactive substances
The conclusion that “drugs are here to stay” implies that there will continue to be
markets in psychoactive substances, whether licit or illicit, and raises the issue of how
governments should seek to manage those markets. Discussions of this topic until recently
have revolved particularly around two substances: alcohol and marijuana. With respect to
alcohol, such comparative analysis has been invited by the diversity of control systems which
have existed in places like North America and Europe in the current century. Kettil Bruun
suggesting in 1970 that alcohol control strategies could be divided into three categories,
according to the aspect of use which they aimed to control: the "phase of choice", i.e., of
decisions to use, the "phase of use" and the "phase of consequences" (Bruun, 1971). In the
context of discussions of control systems for psychoactive substances, the special
contribution of the alcohol literature has been the recognition that a full public health control
strategy must involve much more than simply the prohibition or regulation of the availability
of the substance.
With respect to marijuana, the emphasis in typologies of control has been on
prohibition and its alternatives. In his 1970 analysis, John Kaplan discussed four alternatives:
the "vice" model of decriminalizing possession and use; the "medical model" of medical
prescriptions for use; the licensing model, modeled on alcohol control; and the "sugar candy"
model, where the substance is regulated only as a foodstuff would be (Kaplan, 1970).
Neither for alcohol or marijuana has there been much elaboration on these general
models in the last 20 years, although we have a learned a great deal empirically about when
and how much particular strategies are effective, particularly in alcohol control. Only
recently has systematic discussion begun of alternative control systems for the whole range of
psychoactive substances. A useful and thought-provoking analysis by Rob MacCoun, Peter
Reuter and Thomas Schelling in 1996 ranges control regimes on a single dimension of
restrictiveness, according to "the extent of justification a user has to provide to obtain the
drug". Their categories are “pure prohibition”; “prohibitory prescription” where a doctor’s
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prescription is required, but the prescription is for limited purposes and cannot be for
maintenance; “maintenance” by prescription; “regulatory prescription”, where the purposes
of the prescription are not controlled; “positive license”, where an adult would have access on
gaining a license; “negative license”, where an adult would have access unless forbidden to
use; “adult market”, where use is forbidden for children; and “free market” (MacCoun et al.,
1996). It will be noted, however, that this schema includes levels of restriction both of the
consumer and of prescribing doctors. It is questionable whether control regimes can usefully
be ranked on any single dimension of restrictiveness.
Implicitly, discussions using such a single dimension tend to be organized around
prohibition as one end of the spectrum. But even most regimes which are labelled
prohibitionary have some exceptions, often involving regulation. National Prohibition of
alcohol in the United States, for instance, involved few restrictions on the buyer or consumer,
and provided for production and sale for religious and medical purposes. The international
prohibitory regime for opiates, cannabis, cocaine and other psychoactive substances excludes
medically-prescribed use from the prohibition, and in fact spends considerable energy
organizing the global supply for legitimate pharmaceutical use. Furthermore, depending on
the national laws, some drugs subject to international control may be available from
pharmacies or elsewhere without a doctor’s prescription. Some forms of codeine, for
instance, are available in Canada without prescription.
Legalization of a product, even under a restrictive regime, opens up avenues for state
influence on the market which are not available where the product is entirely prohibited.
Those producing, selling, or authorizing provision of the product in legal channels can be
licensed. They then have a strong interest in following the state’s regulations, if they wish to
maintain their license. They also have a common interest with the state in eliminating
competition from the illicit market.
An alternative way of classifying control measures is in terms of who or what is being
regulated or restricted. The object of control may be the product itself; the provider or seller;
the conditions of sale or provision; and the buyer or consumer. Let us briefly consider each
of the dimensions in turn.
Regulation of the product. Modern industrial societies typically regulate a large
proportion of all marketed products, in terms of such factors as purity, safety, strength or size,
and labelling and claims made for the product. Psychoactive substances -- such as tobacco,
alcohol and pharmaceutical products -- tend to be subject to particularly stringent product
controls. The purity, form, strength and composition of the product is typically regulated.
Frequently, there are also controls on labelling, advertising and other promotional activities
with respect to the product. Another aspect of regulation of the product is controls on price,
through taxes and other means. As a means of limiting harm from use, price and other
regulations may be used to favour more dilute or less harmful forms of the product. Nicotine
products offer a particularly fertile field for such regulatory tipping of the playing field, since
the harm associated with cigarettes is mostly not connected to the main psychoactive
ingredient, nicotine.
Typically, regulations of the product are enforced primarily through the manufacturer
or importer of the final form of the product. Manufacturing or importing often requires a
license, and the primary enforcement mechanism for product regulations is often the threat of
losing this license -- an efficient and relatively inexpensive means of enforcement. Other
parts of the chain of production and distribution to the retail level may also be licensed.
Regulation of the provider or seller. A primary form of restriction of the market in
psychoactive substances is by limiting who can provide or sell the product, or authorize its
provision or sale. In this sense, the most restricted legal psychoactive product in the U.S. is
methadone: provision of it is limited not only by prescription, but also to registered clinics or
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hospitals. For most psychopharmaceuticals, the prescription system is a primary means of
regulation. This means that the state delegates the power to decide who may obtain the drug
to two sets of professionals: primarily to doctors and other prescribers, and secondarily to
pharmacists. Again, a primary enforcement mechanism for the system is the threat of losing
a license to practice as a professional.
There are various other ways governments can restrict who can sell a psychoactive
substance. In about one-third of U.S. states and most Canadian provinces the government
reserves to itself the retail sale of at least some forms of alcoholic beverages. Such
government monopolies were set up in part to remove the private profit motive from alcohol
sales. They also tend to have the effect of limiting the number of places and hours of sale and
maintaining a more effective control over the conditions of sale. Recently, there has been
some discussion in North America of the possibilities of using these existing government
control systems also for cigarette sales. In Washington state, a voter initiative is currently
being circulated which would, if passed, provide for the regulated sale of marijuana through
the state alcohol retail stores to customers aged 21 or over (Galloway, 1999).
The alternative mode of sale of alcoholic beverages in English-language countries is
by private persons or entities which are specifically licensed by the government to sell
alcoholic beverages. The number of such licenses may be limited on a per-capita basis or
otherwise. Again, the threat of losing this license serves as an effective and inexpensive
enforcement mechanism.
In one or another jurisdiction, there are other examples of limits on who can sell
psychoactive drugs which offer potential leverage for regulatory controls. For instance, in
Canada, some pharmaceuticals which do not require prescription must nevertheless be sold in
a pharmacy, which mildly limits availability and also offers scope for an additional level of
control: some products can only be sold by a pharmacist from behind the counter.
Regulation of the conditions of sale. Part of the alcoholic beverage control structure
in Britain and many other nations is a set of controls on the hours of sale. For alcohol and
now for tobacco products, there is a restriction which forbids selling to customers under a
minimum age. Other regulations of the conditions of sale of alcoholic beverages, particularly
for on-premises consumption, may include specifications concerning physical design and
layout, requirements on the availability of food, prohibitions of particular activities (e.g.,
dancing, gambling, smoking) and a prohibition on serving someone already intoxicated.
Historically, alcohol sales on credit were also often forbidden.
Again, the primary means of enforcement of alcohol regulations has been the threat of
cancellation of the license of the provider or seller. Potential legal liability of the seller for
harm resulting from prohibited sales has also become an important support in some Englishlanguage jurisdictions for regulation of the conditions of sale.
Regulation of the buyer or consumer. The primary regulation of the alcohol buyer
or consumer these days is in terms of behaviour while or after drinking -- particularly the
behaviours of driving under the influence and public drunkenness. In addition to these
alcohol-specific offences, of course, the intoxicated consumer is also in principle held
responsible for the same standards of behaviour with respect to the general criminal law that
are expected of the sober.
Both for alcohol and for tobacco, it is now becoming more common to criminalize the
attempt to purchase under the legal age, along with control on the seller. With respect to
diversion for prescription products from the person for whom they were prescribed, in
principle both sides of the transaction are criminalized.
In earlier times, as we have noted above, other restrictions on the buyer or consumer
were fairly common. In some places, alcohol was rationed as a way of controlling
consumption (Frånberg, 1987). In Nordic countries, there were various "buyer surveillance"
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systems which attempted to control the individual's purchasing (Järvinen, 1991). In some
places, taverns were required to post and respect blacklists of drunkards who could not be
served alcohol. Developing notions of privacy rights and of equality in treatment under the
law have tended to make these kinds of restrictions on adults untenable for alcohol.
On the other hand, there is a flourishing rationing system which is well accepted in
modern societies: the drug prescription system. In this system, the individual’s ration is
determined by the physician who writes the prescription.
The promise and limits of control systems
I have laid out briefly some considerations about potential dimensions of application
in control regimes for psychoactive drugs. In my view, considering the control of all
psychoactive substances in a common analytical frame is long overdue. Flexible control
systems, attuned to the cultural situation and capable of responding flexibly to new trends in
use and problems, are an important tool in moving to more of an equilibrium in drug use than
the experience, particularly for illicit drugs, of the last 20 years.
But we should not harbor illusions that regulatory systems will be easily maintained,
nor that they will be all-powerful. In open societies, regulatory approaches operate within a
political system, and this limits their application, regardless of their effectiveness. Alcohol
rationing is a good example of the political limits on control measures. Rationing is
potentially a highly effective way of limiting harm from psychoactive substances, since it
limits the supply or at least raises the price to heavy users -- precisely those in the spectrum
of consumers most at risk of harm. Thus cirrhosis mortality rose considerably in Sweden
when the rationing system was abolished in 1955 (Norström, 1987). But it is politically
inconceivable in any developed society today that alcohol would be rationed. On the other
hand, as I have mentioned, the rationing aspects of the prescription pharmaceutical control
system seem to be well accepted.
Control systems are limited primarily by their acceptability to the public, in an era in
which the ideology of consumer sovereignty is very strong. As Canadians can testify for
tobacco taxes, and various European Union countries for alcohol taxes, they can also be
undercut by looser controls in neighbouring jurisdictions.
The history of control systems also suggests two further ways in which their
effectiveness can be limited. As we have noted, control systems operate most effectively
through a license system which restricts sales, provision, or authorization of sales to
particular professions or licensees. But this means that those who are licensed thus have a
very strong interest in the actions of the control system, and devote considerable efforts to
organizing politically to constrain its effectiveness.
Strict control systems on psychoactive drugs also offer a tempting target for
generational revolts. For the middle class generation of college students of the 1920s,
flouting alcohol prohibition was a perfect symbol of generational revolt (Room, 1984).
Marijuana and other drug prohibitions served a similar role for the counterculture of the
1960s. But controls do not have to extend to prohibition to provide a target for symbolic
revolt, as a look at such current glossy magazines as Cigar Aficionado suggests.
Designing and implementing control systems for psychoactive substances thus cannot
be simply a matter of technocracy. Attention needs to be paid to the cultural fit and meaning
of each element of the system, and to its potential to serve as an antagonizing symbol. There
are considerable differences in the potential symbolic power of different elements. In most
circumstances, there is only limited symbolic power, for instance, in paying a few cents more
for a cigarette or a drink of alcohol. At the opposite extreme, no control measure affecting a
legal market offers anything like the symbolic power of breaking the taboo inherent in a
prohibition.
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