Medicine
A couple of years ago, I served for several weeks on a grand jury for the Superior Court of the District of Columbia. Mine was designated a RIP (Rapid Indictment Protocol) jury, assigned to efficiently hand down indictments for small drug-related offenses. These cases usually involved undercover officers posing as customers making purchases from street dealers, or uniformed police stopping suspicious vehicles and searching them for drugs. Although rarely we heard testimony about defendants caught with thousands of dollars of contraband, the vast majority of offenses were possession of small amounts of marijuana, heroin, or cocaine for "personal use." Many of the latter defendants had multiple such offenses, which had resulted in probation, "stay away" orders (court orders to avoid certain neighborhoods where drugs were highly trafficked), or brief stints in jail. Few, if any, had received medical treatment for their addictions.
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Medicine
Rethinking the war on drugs
A couple of years ago, I served for several weeks on a grand jury for the Superior Court of the District of Columbia. Mine was designated a RIP (Rapid Indictment Protocol) jury, assigned to efficiently hand down indictments for small drug-related offenses. These cases usually involved undercover officers posing as customers making purchases from street dealers, or uniformed police stopping suspicious vehicles and searching them for drugs. Although rarely we heard testimony about defendants caught with thousands of dollars of contraband, the vast majority of offenses were possession of small amounts of marijuana, heroin, or cocaine for "personal use." Many of the latter defendants had multiple such offenses, which had resulted in probation, "stay away" orders (court orders to avoid certain neighborhoods where drugs were highly trafficked), or brief stints in jail. Few, if any, had received medical treatment for their addictions.
After a few weeks of hearing these cases, my fellow jurors and I grew increasingly frustrated with this state of affairs. We felt like a cog in a bureaucratic machine, fulfilling a required service but making little difference in anyone's lives. A young man or woman caught using drugs would inevitably return to the street, violate the terms of his or her probation or "stay away" order, and be dragged before our grand jury again for a new indictment. We openly challenged the assistant district's attorneys about the futility of the process. They would just shrug their shoulders and tell us that was the way things were, and it wasn't our job to come up with a better strategy for dealing with illegal drug use. True enough, but then again, whose job was it?
An article by Michael Specter in the October 17th issue of the New Yorker reports on the recent experience of Portugal in decriminalizing personal drug use. To an American physician accustomed to our endless war on drugs, what Portuguese authorities did was hard to imagine: "For people caught with no more than a ten-day supply of marijuana, heroin, ecstasy, cocaine, or crystal methamphetamine - anything, really - there would be no arrests, no prosecutions, no prison sentences. Dealers are still sent to prison, or fined, or both, but, for the past decade, Portugal has treated drug abuse solely as a public-health issue." Rather than being paraded before grand juries for ritual convictions, people caught using drugs in Portugal are instead summoned before a 3-person panel (a judge, doctor, and psychologist or social worker) and assigned to counseling and medical treatment for their addictions.
Did this new policy result in an explosion in the number of Portuguese drug users, no longer cowed by the prospect of criminal prosecution? Hardly. In the words of a chief police inspector who initially resisted the change in tactics:
In the last years before the law, consumers were arrested by police. ... They were fingerprinted and made statements and took mug photos and were presented to court. And always, always, always released. It was a waste of everyone's time. It didn't stop drug use or slow down the dealers. So the idea that somehow people are getting away with what they did not get away with before is silly.
A public health approach to the consequences of illegal drug use in the U.S. might include increasing support for needle exchange programs, which have been banned from receiving federal funding for years but have been repeatedly shown to reduce rates of HIV transmission in controlled studies. Unfortunately, our inherent discomfort with such "permissive" interventions often gets in the way of recognizing the evidence that our current punitive approach to drug use is more harmful than beneficial to drug users and society in general. As Specter concludes:
It is common in the U.S. to judge drug addiction morally rather than medically, and most policy flows from that approach. ... Yet one has only to look at the American health-care system to be reminded that neither science nor evidence necessarily drives public-policy decisions. ... While it would make no sense to base American policy [toward drug use] on a decade-long Portuguese experiment, it seems even more foolish to ignore results that call so clearly for an increased focus on treatment, not jail time.
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Let us give thanks. Let us give thanks that we are not the parents of Michael Brown. One of the more thoughtful and moving pieces on this subject among the thousands to appear is by Charles Blow, Fury after Ferguson. Let us give thanks, if we do not live...
- The "neurontin Legacy"
The January 8, 2009 issue of the New England Journal of Medicine includes an article by Landefeld and Steinman called “The Neurontin legacy – marketing through misinformation and manipulation”[1] that should be required reading for every physician,...
- Pharma Industry Free Speech Is Anything But Free
Last month, the American Medical Association (AMA) called for a ban on direct-to-consumer (DTC) advertising of prescription drugs and medical devices, arguing that this type of advertising drives the nation's escalating drug bill by creating demand...
- Doctors, Don't "dispense As Written"
I've always favored prescribing generic drugs over handing out brand-name samples, since the latter, while initially "free" for patients, can actually be less effective and cost them more money in the long run. In fact, the only patient for whom I...
- Should Pharma Have Unrestricted Access To Doctors' Prescribing Profiles?
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