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A fascinating mix of fact and strongly held ideological tenets
underpins approaches to the management of addictions. Clinicians
dedicated to delivering care to individuals using drugs soon encounter
the impact of social policies on their lives as well as on the available
management options.
In the first chapter of this book, MH Moore outlines the distinction
between “demand reduction” policies that attempt to reduce
the flow of drugs and “supply reduction” policies that
involve prevention and treatment efforts. The objectives of these
policies may either be “zero tolerance,” aimed at eliminating
illicit drug use, or “harm reduction,” aimed at reducing
the adverse consequences of drug use. This matrix affects the implementation
of prevention policies and the points of intervention. The prevention
efforts discussed in the chapter are conceptualized as encompassing
enforcement initiatives.
Brownsberger follows, with a demographic description of drug users
and dealers. He discusses the measurement weaknesses of the current
database on prevalence: both the Monitoring the Future survey of
high school students and the broader National Household Survey rely
on self-reports, which leads to underestimation. These surveys also
fail to interview dropouts, a high-risk subgroup for drug use. While
drug users come from all ethnic groups and socioeconomic strata,
heavy users live disproportionately in poverty and have a high probability
of criminal behaviour.
The next 3 chapters critique the meanings of addiction. Heymann
discusses the concept of addiction as a chronic relapsing disease
and suggests conceptualizing it as, rather, a matter of ambivalent
drug use. Treatment-outcome studies showing high relapse rates are
contrasted with community samples and naturalistic studies, such
as one on Vietnam veterans, where addicts report significant recovery
rates with some consistency.
SL Satel reviews the evidence provided by the “brain disease
lobby” and marshals the evidence of its limitations. The purported
limitations of pharmacotherapy (for example, Naltrexone) are contrasted
with the promises of therapeutic communities such as Phoenix House.
According to Satel, what is most needed is “enlightened coercion”
that includes drug courts and contingency management.
GE Vaillant provides easier reading with his review of the last
century’s evolving position regarding responsibility for drug
abuse—a shift from moralism, to malevolent dealers, to the
“powerful drugs,” to a guilty society. He also argues
that coercion rather than blame has provided more successful outcomes,
as exemplified by employee assistance programs, methadone therapy,
and self-help groups. He suggests that a structured “carrot
and stick” approach is more powerful than either coercion or
care alone.
MAR Kleiman’s chapter discusses the current pessimism surrounding
drug and correctional policies. Drug diversion involves offering
a defendant options to incarceration. In drug courts, the judge
acts as case manager. Drug diversion programs are examples of “coerced
abstinence” rather than “coerced treatment.” Kleiman
suggests that probationers and parolees should be subjected to twice-weekly
testing and briefly incarcerated if they test positive. In this
model, compliance would be rewarded by reduced supervision. According
to Kleiman, whether marijuana or alcohol should be excluded is debatable.
Brownsberger discusses the potential limitations of this approach:
while the costs of coerced-abstinence screening programs are likely
to be justifiable for serious offenders, the tedium and humiliation
of frequent court visits would not be acceptable to defense counsels
as a strategy,
About 1.5 million people are arrested in the US every year for
drug-related violations. VP Caulkins and Heymann focus on the million
or so “low-level” dealers who move drugs from “kingpin”
dealers to consumers. In the US, about 100 000 are sent to prison,
with an average time served of 33 months but with enormous heterogeneity
in the sanctions. How tough should society be, and with whom? As
an alternative to the current practice of “muddling through,”
these authors propose a shift to sentencing at the local level,
with tougher sentencing guidelines for the subset of dealers with
“unusually destructive patterns” of dealing.
The last chapter, by D Boyum and P Reuter reframes the conventional
“cops vs docs” debate. What priority should be given to
the roles of criminal justice and health care? Should strategic
objectives be expanded to include social assistance? For example,
what proportion of public assistance should be spent to support
drug habits? These authors argue that drug policy-makers should
pay more attention to programs such as job training or providing
public housing where drug use is not central.
Overall, the book aims to demonstrate that building walls between
prevention, treatment, and law enforcement creates misleading distinctions.
Yet, although it purports to offer thought-provoking insights into
all aspects of drug management in the US, the book is mostly an
analysis of the potential range of enforcement policies available.
Coercion, enlightened or not, is still coercion. The disease premises
underpinning demand-reduction programs are dismissed as a lobbying
effort by clinicians. To this clinician, the book—while providing
for some dry reading—is a good review of the literature supporting
the criminal justice efforts. The middle chapters critiquing the
“disease” concept are negatively selective in their references.
The authors, half of them from Harvard, appear mostly to be criminal
justice policy analysts, and the 3 chapters by clinicians present
a selective critique. The data are from the US, and there is little
attempt to present other countries’ experience. Harm-reduction
tenets, including the rights of addicts, are not considered. Like
many multiauthored books, the readability varies. At the price,
it is a valuable addition to libraries specializing in addiction
and useful to those who study a range of drug strategies.
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