Physicians and Lawyers for National Drug Policy, a partnership between physicians and lawyers, has been formed to promote an evidence-based public health approach to national drug policy. Through this initiative, physicians, lawyers, judges, medical organizations and bar associations will sponsor and implement non-partisan reforms, and harness the resources of community coalitions, national organizations, student associations (law, medicine, and public health), and specialist organizations across the United States.
Policy Priorities will include:
Physicians and other health care providers should be able to treat addicted individuals without undue barriers; insurance and health plans should cover the costs of treatment; and the legal system should help to identify people in need of treatment and should facilitate effective interventions.
Accessibility of treatment is imperative. In the absence of adequate treatment, people with addictions disrupt their own lives and impose heavy burdens on others; all too often the last physician to see them is the pathologist. We need to do better. More physicians need to be involved much earlier to help identify alcohol and drug problems, and to help people recover from them.
A leading proponent of evidence-based medicine, Dr. David Sackett, defines it as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external evidence, and neither alone is enough.”
We must take a hard look at the evidence regarding the effects of alcohol and other drug testing in the variety of settings in which it now occurs – in the health care system, on the job, in the schools, and in the criminal justice system. Alcohol and other drug testing and screening can be a useful clinical and public health tool when it can help identify people with alcohol or other drug problems not otherwise identified as needing a clinical intervention, but it should not be used as an instrument of harassment and punishment.
One context in which testing is not being used as often as it should be is in medical settings, and especially in trauma centers and emergency rooms. Studies repeatedly show that 40-50% of patients who show up in trauma centers were drinking at the time of their injuries. Most of these patients are chronic heavy drinkers. The evidence also clearly shows that a brief motivational intervention at such a “teachable moment” reduces alcohol consumption and the associated risk of injury. Blood alcohol testing should be routinely conducted for patients admitted to emergency rooms for traumatic injuries, and that all legal, procedural and financial barriers to such testing should be removed.
Drug policy should reflect a public health approach to the prevention and treatment of substance abuse and should avoid excessive reliance on criminal enforcement and disproportionate punishment. Sending addicted people to prison does not, by itself, help them recover and the collateral consequences associated with a criminal record create enormous barriers to effective recovery. Understanding that addiction is a disease does not absolve addicted persons of responsibility for their behavior, but their addiction should be given strong weight in mitigation of punishment, and as a basis for diversion from the criminal justice system.
Specialized judicial procedures for criminal offenders with substance abuse problems, including drug courts, have been a constructive development. A focus solely on the criminal courts, however, ignores many of those involved in the staggering rates of child abuse and neglect by parents with alcohol and substance abuse problems; between forty and eighty percent of these cases involved parental use of drugs or alcohol. Resources are currently available to provide only a small fraction of parents in the child welfare system with the treatment they need.
We need to give much more attention to the most serious drug problem among our nation’s youth – underage drinking. Almost one in five 8th graders and almost half of high school seniors report recent use of alcohol, compared with 21% of seniors who report recent use of marijuana. One in eight 8th graders and nearly 30% of high school seniors report recent heavy drinking. The age of first use is dropping and research shows that young people who begin drinking before age 15 are four times more likely to develop alcohol dependence as adults than those who begin drinking at age 21. Further, studies suggest that the younger an individual is at the onset of substance use, the greater the likelihood that a substance abuse disorder will develop and continue into adulthood. The social cost of underage drinking, conservatively estimated, is $53 billion.
A recent study by the National Academy of Sciences, proposed an evidence-based 10-point strategy for reducing underage drinking. The central premise for this approach is that the only way that underage drinking can be reduced in a society in which adult drinking is normative behavior and in which alcohol is widely promoted and available is for everyone – including parents, colleges, alcohol producers and retailers, the entertainment industries, and others – to recognize the ways in which many segments of our culture facilitate underage drinking, and each must accept responsibility for reducing it. This must be a collective effort with physicians taking the lead.
The drug policies of the United States are to often driven by politicians’ fears of being characterized as “soft” on drugs or as insufficiently committed to our nation's continuing but largely ineffective “war” on drugs. As a result, public discourse on drug policy tends to be highly polarized; the nation’s drug policies tend to lack focus; scientific evidence bearing on effectiveness tends to be overlooked, ignored or not sought; and policies are implemented and renewed without sufficient data on whether or not they have generated intended results. Drug policies, including those on enforcement, should be based on evidence of effectiveness in reducing the harmful consequences of drug use, and should take better account of the benefits and costs of different interventions, especially those associated with incarceration of drug offenders. More and better data is needed to assess the effectiveness of the nation’s current drug policies, especially those relating to enforcement, incarceration, and control of drug supplies.