The abuse of psychoactive substances is among the leading causes of disability and criminal activity in the world. Drug addiction is difficult to study. Most drug transactions are effected illegally, which limits the acquisition of accurate data on drug abuse. However, in 1997, the United Nations International Drug Control Programme estimated that illicit drug trade accounts for about 8 percent of all international trade and shows no worldwide trend toward a reduction. In the United Kingdom, where drug addiction is less of a problem than in the United States, there has been a steady increase in drug use in the past 40 years, with the use of heroin reaching epidemic proportions.
Drugs: Dilemmas and Choices, written by a working group established by the Royal College of Physicians and the Royal College of Psychiatrists, covers a broad range of issues, including history, the individual and social consequences of drug addiction, the international drug trade, and policies for prevention, control, and treatment. The work was meant to stimulate debate and influence public-policy debates, and the authors write for a wide audience, in clear, nontechnical language.
The sections of the book on the history of drug misuse provide some instructive examples from the United Kingdom, the United States, Japan, and Russia. Interestingly, at various times, the British have been at opposing ends of the drug trade. In the 18th century, opium was still freely available in England, and the British were the leading suppliers of opium to the Chinese market. Opium addiction in China had devastating consequences because it affected large sectors of the society, including the imperial troops and the official classes. When the Ching dynasty imposed restrictions on opium, the so-called Opium Wars followed. The Chinese capitulated in 1842, Hong Kong was ceded to Great Britain, and ports were opened to opium trade. Now, ironically, Asia is the main supplier of illicit opium to the United Kingdom.
The book also compares the history of drug policies in the United Kingdom and in the United States. The United Kingdom has traditionally had a less radical approach to drug enforcement. The authors discuss the effects of the banning of alcohol during Prohibition in the United States, a measure they interpret as a partial failure: although alcohol consumption and associated deaths from cirrhosis decreased, the lack of compliance in conjunction with economic factors made Prohibition untenable. The authors reflect that restrictions on the availability of drugs may be ineffective when a large proportion of the population opposes them.
The history of the use of stimulants in Japan after 1945 is less well known to the general public. Amphetamines had originally been manufactured for the military to increase the alertness of the troops, among other purposes. After the war, army stocks were released, and an epidemic of amphetamine abuse occurred in a country already devastated by war. The amphetamine epidemic was over by 1957, superseded by a lesser one of heroin use -- a sequence that raises the issue of causal relations between successive drug epidemics.
Missing from this book is the history of the antitobacco and antialcohol movement in Nazi Germany, which is known mainly from the work of Robert Proctor. Eugenics, race "hygiene," and the antidrug movements were intimately intermingled in Nazi Germany and shaped public policy. This information would have served as a cautionary tale against the implementation of any ideals of social purity in the fight against drugs.
In the United Kingdom, law enforcement and customs or interdiction efforts account for about 75 percent of the expenditures to combat drug misuse and result in the interception of as little as 5 to 10 percent of illicit drugs. Interdiction does not work for many reasons, including the fact that powerful drugs require the trafficking of very small volumes to satisfy the demand, even a very large demand. For example, despite interdiction efforts, the price of heroin in the United Kingdom has decreased substantially since the 1980s, and the same is true in the United States. Very little of the budget for the "war on drugs" is devoted to research in general, including scrutiny of whether the current drug policies decrease drug misuse. There are also limited data on the demand for drugs, but some reports suggest that prevention programs may be less effective in reducing demand than once thought.
Hence, a key topic is whether or not treatment works. The answer is that comprehensive programs (i.e., programs that involve detoxification, pharmacotherapy, psychotherapy, counseling, housing, employment, and continued monitoring) work best. The book shows evidence collected by RAND in the United States that, dollar for dollar, treatment is much more effective than interdiction.
Over the past decade, use of the tools of molecular biology has led to important advances in our understanding of some of the biologic mechanisms related to addiction. This subject is not well covered in the book. Appropriate references (and updated discussions) are often missing in sections that deal with genetics and with biology.
Despite continued progress, particularly during the past few years, the biologic processes underlying drug addiction remain largely unknown, and little is known about the intersection of biologic and nonbiologic factors in drug addiction. In spite of the difficulties, the book makes sense of a large portion of the current body of knowledge on drug addiction. Policy makers in the United Kingdom and in other countries should give serious consideration to the book's arguments and advice.
Pablo V. Gejman, M.D.
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