Thursday, September 03, 2009

Is heroin consumption like other kinds of consumption?

The critique of the drug war of LEAP speaker, Major Stanford O. ("Neill") Franklin of the Maryland Transit Administration, a career cop, was highlighted in Esquire magazine. Franklin recently co-authored a very cogent piece on the op-ed page of The Washington Post with former Baltimore cop, Peter Moskos, about the price of prohibition in the deaths of cops.

The Esquire writer uses Franklin's estimates about the fraction of drug-related or drug prohibition-related homicides, and the number of drug overdoses from heroin, cocaine and methamphetamine, to estimate that 15,233 Americans were killed as a result of the drug war in an unspecified year. The precision is absurd. But as suggestion of the scale -- on the order of 10,000 deaths annually from drug violence and overdoses -- it is definitely "in the ballpark". Would those deaths "go away" if drugs were legalized? Maybe -- but doesn't it depend on what legalization means in practice?

My friend Mark Kleiman uses the Esquire story renew his attack upon drug legalizers for making up facts, and for having "stupid" proposals that do not pass his "giggle" test.

Having a degree in economics and being a professor, and the founder of the blog, The Reality-Based Community, he tells us about the real world of drug consumption:

In the real world, drug consumption responds to price, and the consumption of heavy users is more responsive than the consumption of casual users, because heavy users spend a bigger fraction of their income on drugs. In the real world, prohibition increases price. Therefore, an end to prohibition would decrease price, and therefore increase consumption, especially heavy consumption. In the real world, alcohol and cocaine (like any depressant-stimulant pair) are economic complements: using more of one leads to using more of the other, and therefore a price drop for one leads to a consumption increase for the other. The legalizer rant consists mostly of ignoring those simple realities.

Many of the arguments in favor of legalization are often incomplete. They are often catch-phrases picked up by a reporter, or squeezed out, soundbite-style, on a broadcast argument couched as a "debate." A key feature of the legalization argument is making the important point that the status quo is not working, and must be replaced. The details of a replacement are rarely analyzed for the purpose of improving the likely outcome of the replacement -- they are usually avoided.

Looking at such presentations for the meat of a regulatory scheme can leave an impatient analyst barking from hunger, and despising the empty calories of such offerings. Certainly Esquire's article is not making a detailed description of what necessarily must be complex regimes of control. Most speakers don't have that opportunity either.

In his defense, Major Franklin told Esquire that we need a system of regulation and, "You can't sell it [the drugs] to just anybody, and you still go to jail if you sell it to the wrong people." What else he said, by way of explanation, may have been omitted, or was deemed unnecessary for the point of the article.

In commenting about heroin sales and price, to simply assert that consumption responds to price, I think omits a key point regarding initiation of use. Currently most new users are initiated into heroin use by another user. Guys encourage their buddies to share the thrill. Boyfriends encourage their lovers to share the pleasure of the high. Without being encouraged to try heroin by a peer, few persons who have never used heroin ever go down the open air drug market and simply ask around for some heroin to buy to shoot up.

As we try to design a legal heroin distribution regime that cuts out most of the criminal market, can it be designed to discourage new users?

Once one is a habituated heroin user, finding a reliable source becomes very important. Such sources are frequently found in networks of users. Yes, the price of heroin has been a factor in an individual addict's consumption, recognizing the uncontrolled nature of the criminal heroin market and the barriers to obtaining treatment outside the criminal justice system. But price is a much smaller factor in initiation, I believe.

My current thinking about heroin legalization is that the government would make heroin available only to addicts. The price may not be so high in dollars, but would be high in potential loss of privacy, and high in the loss of deviant status and outlaw cred. (Such a price may be too high to attract addicts to a legal regime.) If heroin addicts enroll in the government distribution program, it would eliminate most of the illegal heroin market because addicts consume the overwhelming majority of all of the heroin that is sold. The heroin would be dispensed in pre-measured syringes, each with a serial number that is registered to the addict. Addicts will be assured of their supply. Can addicts be provided with varying supplies so that on some days they get enough to avoid getting sick and on other days they can get enough to "get off" on? What can be done to assure that the addicts sticks with the legal regime and does not stray to the criminal regime to get more heroin to "get off" on?

On August 20, 2009, The New England Journal of Medicine reported [try your university library] on the NAOMI project in Vancouver and Montreal which made heroin available for injection to 115 intractable addicts twice a day from 2005 to 2008 at a site where it had to be used. On the European Addiction Severity Index, the experimental population showed improvement, especially in comparison with the "control" population of addicts who received oral methadone. Notably, at some point, 16 of the 115 patients suffered a life-threatening overdose or seizure. Because the drug was used at a supervised site, prompt treatment was applied and all 16 recovered. The NAOMI study authors recommend against unsupervised use.

One key condition of my vision of a legal heroin regime is that the addicts must not be allowed to share their supply with anyone. Perhaps the least troubling approach would be the inconvenient requirement that the injection be done at the place of distribution. To what extent would such an inconvenience lead to a market opportunity for the criminal market to fill?

A more convenient regime would permit syringes to be taken home, but the health risks go up. The syringes would be required to be returned and would be periodically inspected. If there were DNA evidence of the blood of another, the addict would be punished in various ways, but not in a way that would drive him out of the legal system of supply.

Can we reduce the initiation of new users in such an approach? Perhaps. Can we dramatically shrink the size of the criminal market? Most likely? Will this system work perfectly? Of course not! Will there need to be some enforcement of the regulatory system? Sure. Is there a perfect system? Of course not!

Our challenge is to find a better system that meets and balances a variety of needs:
* defunding terrorists and organized crime,
* preventing street crime to get the money to buy drugs,
* keeping addicts out of the criminal justice system,
* getting more order into neighborhoods,
* helping to keep families together,
* reducing deaths and overdoses,
* reducing the initiation of new users,
* does not promote use.

Whatever approach is suggested is likely to have features that "reality-based" critics like Mark will find uproariously flawed.

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