AN Back in the National Spotlight: An Assessment of Recent ...

[Pages:26]an assessment of recent changes in drug use and drug policies in the united states

Back in the National Spotlight: An Assessment of Recent Changes in Drug Use and

Drug Policies in the United States

Beau Kilmer

RAND Drug Policy Research Center

Gregory Midgette

RAND Corporation

Clinton Saloga

RAND Graduate School

Improving Global Drug Policy: Comparative Perspectives and UNGASS 2016

EXECUTIVE SUMMARY

Key Findings

? Drugs are back in the national spotlight in the United States, but for different reasons than they were 25 years ago.

? Over the past decade, the United States' marijuana consumption rapidly escalated, heroin consumption increased, at least in part as a byproduct of a prescription opioid epidemic, and cocaine consumption plummeted.

? In addition to the unprecedented changes in marijuana policies in the United States, there have been other noteworthy changes to U.S. drug policies at both the state and federal levels over the past decade.

? Recent actions taken by U.S. states and the administration of President Barack Obama Administration are intensifying discussions about drug policy alternatives in the United States and abroad.

Policy Recommendations

? We are optimistic that changes in treatment quality and accessibility will significantly improve social welfare.

? We are encouraged by recent efforts to reduce the length of incarceration for non-violent drug offenders and by evidence suggesting that criminal justice resources can be reallocated to create credible deterrent threats that reduce both incarceration and crime at the same time.

? The Obama administration's commitment to some harm reduction approaches also seems promising, but these efforts--as well as the others just mentioned-- should be rigorously evaluated.

Center for 21st Century Security and Intelligence Latin America Initiative

1

an assessment of recent changes in drug use and drug policies in the united states

Introduction

Drugs are back in the national spotlight in the United States, but for different reasons than they were 25 years ago.1 In 1989, a plurality of respondents to a Gallup poll (27 percent) selected drugs as "the most important problem facing this country today," largely driven by fears about crack cocaine and the associated market violence.2 When the same question was posed in 2014, only 1 percent of respondents chose drugs or drug abuse as the most important problem.3 Perceptions about drugs are closely linked with crime, and the violent crime rate plummeted by more than 50 percent during this period.4 While there are still overt drug markets in urban areas that generate crime and disorder, this is not what is driving discussions at the state and federal levels.

Today, discussions about drugs in the United States are largely driven by marijuana and opioids. The passage of ballot initiatives in Colorado and Washington to remove the prohibition on marijuana and allow for-profit companies to produce and distribute it for non-medical purposes was unprecedented (see Mark Kleiman's contribution to this project for more information about these legalization initiatives and other approaches to liberalizing marijuana laws).5 While marijuana remains illegal under federal law, the administration of President Barack Obama has decided to tolerate state-legal marijuana activities as long as they have "strong and effective regulatory and

enforcement systems."6 This approach has sent a signal to other states and jurisdictions that it is acceptable to discuss alternatives to prohibition.7

Medical marijuana also remains a serious topic of conversation throughout the country. It received a boost in 2013 when famous TV personality--and one-time candidate for Surgeon General--Dr. Sanjay Gupta aired a special report about the medical benefits, largely focused on one of the (non-intoxicating) cannabinoids, cannabidiol (CBD).8 Since the show aired, more than 10 states have passed CBD-only laws, and clinical trials are underway to assess the efficacy of a CBD extract (Epidiolex) to reduce seizures among children.9 More recently, current Surgeon General Vivek Murthy brought attention to the issue when he remarked that, "We have some preliminary data showing that for certain medical conditions and symptoms, that marijuana can be helpful."10

The fact that drug overdoses are now responsible for more deaths than traffic crashes in the United States also generates a lot of discussion.11 This is partially attributable to a significant decline in auto fatalities, but there also has been a surge in deaths involving prescription opioids (e.g., oxycodone). The ubiquity of prescription opioids, suggestions that it serves as a gateway to heroin, and increased use of the phrase "heroin epidemic" by policymakers and journalists are also keeping drugs in the news. Indeed, when Vermont's Governor Peter Shumlin dedicated his

1 We thank Jonathan P. Caulkins, Brian Jackson, Peter H. Reuter, and the editors for their useful comments. The views presented here reflect solely those of the authors.

2 University at Albany, Hidelang Criminal Justice Research Center, Sourcebook of Criminal Justice Statistics, Table 2.1.2012, sourcebook/pdf/t212012.pdf. The Gallup responses from 1984-2012 are compiled here.

3 "Most Important Problem," Gallup, . 4 U.S. Department of Justice, Criminal Justice Information Services Annual Report 2014 (Washington, DC: Federal Bureau of Investigation, U.S.

Department of Justice, 2014). 5 Mark A.R. Kleiman, Legal Commercial Cannabis Sales in Colorado and Washington: What Can We Learn? (Washington, DC: Brookings Institution,

2015). 6 James M. Cole (Deputy Attorney General), Memorandum for All United States Attorneys: Guidance Regarding Marijuana Enforcement (Washington,

DC: U.S. Department of Justice, 2013), . 7 Beau Kilmer, "The U.S. Federal Government Tolerates Marijuana Legalization: Will it Last?" Internationale Politik und Gesellschaft, August 18, 2014,

. 8 "Gupta Opts Out of Surgeon General Consideration," CNN, March 5, 2009, . 9 John Ingold, "Lawmakers in 11 States Approve Low-THC Medical Marijuana Bills," Denver Post, June 30, 2014,

ci_26059454/lawmakers-11-states-approve-low-thc-medical-marijuana. 10 Juliet Lapidos, "`Marijuana Can Be Helpful,' Admits Surgeon General," New York Times, February 5, 2015, .

com/2015/02/05/marijuana-can-be-helpful-admits-surgeon-general/?_r=0. 11 "Prescription Drug Overdose Data," Center for Disease Control and Prevention (CDC), .

Center for 21st Century Security and Intelligence Latin America Initiative

2

an assessment of recent changes in drug use and drug policies in the united states

entire 2014 State of the State address to heroin and prescription drug abuse, it intensified public discussion about the opioid problem throughout the country.12

In the short run, there is little reason to believe that drugs are going to become less of an issue in the United States. High-profile discussions will likely continue as states, including California and Massachusetts, will probably vote on marijuana legalization in 2016, marijuana prohibition could become an issue in the 2016 presidential election, and countries in Latin America and the Caribbean seriously debate drug policy. There will also be series of well-publicized events leading up to and occurring at the 2016 Special Session of the United Nations General Assembly on the World Drug Problem (UNGASS 2016).

No one knows what the United States will do at UNGASS 2016, but it is useful to review the current landscape and recent policy changes as background for such speculations. The next section of this paper discusses trends in U.S. drug consumption, production, and trafficking, highlighting the striking finding that consumption of cocaine in the U.S. dropped 50 percent between 2006 and 2010. Indeed, according to Caulkins et al., this downturn "competes with the 2001 Australian heroin drought as the greatest `success' in modern recorded drug history at the population level."13 This is followed by an overview of U.S. drug policies and four noteworthy changes to drug policies in the United States. The paper concludes with thoughts about the international conventions and UNGASS 2016.

Drug Consumption, Production, and Trafficking in the United States

Consumption

Since the price for illegal drugs jumps dramatically once they enter the United States, most of the money spent at the retail level goes to domestic traffickers and suppliers. Figure 1 shows that aggregate U.S. expenditures on cocaine, heroin, marijuana, and methamphetamine were generally stable over the period 2000-2010 at roughly $100 billion per annum; however, there was a seismic shift in the composition of expenditures.14 The value of the retail illicit market for marijuana increased by one-third between 2004 and 2010, while the value of the cocaine market was cut in half over the decade, and fell by nearly onethird between 2006 and 2010.

Cocaine. From the mid-1980s to the mid-2000s, the market for cocaine was the largest of all illicit drugs in the United States. Though consumption peaked in the early-1990s, in 2000 the market was still worth roughly $60 billion in today's dollars. However, the market declined rapidly in value, and even more so in quantity consumed. Between 2000 and 2006, total quantity consumed remained around 300 metric tons (mt) of pure cocaine (e.g., 2 kilograms of adulterated cocaine that is 50 percent pure cocaine counts as 1 pure kilogram). Yet the size of the market in real dollar terms fell by over 20 percent, and over the next five years consumption dropped by 50 percent and expenditures fell by another 34 percent.15

12 Katharine Seelye, "In Annual Speech, Vermont Governor Shifts Focus to Drug Abuse," New York Times, January 8, 2014, . com/2014/01/09/us/in-annual-speech-vermont-governor-shifts-focus-to-drug-abuse.html.

13 Jonathan P. Caulkins et al., "Cocaine's Fall and Marijuana's Rise: Questions and Insights Based on New Estimates of Consumption and Expenditures in US Drug Markets," Addiction (2014), doi: .

14 Office of National Drug Control Policy (ONDCP), What America's Users Spend on Illegal Drugs, 2000?2010 (Washington, DC: Executive Office of the President, 2014), .

15 Ibid; and Beau Kilmer et al., How Big is the U.S. Market for Illegal Drugs? RAND Corporation Research Briefs, no. RB-9770-ONDCP (Santa Monica, CA: RAND Corporation, 2014), .

Center for 21st Century Security and Intelligence Latin America Initiative

3

an assessment of recent changes in drug use and drug policies in the united states

Figure 1. Annual Spending on the Major Illegal Drugs in the United States: Relatively Stable Levels but Changing Composition (in 2010 dollars)

$160

$140

$120

$100

$80

$60

$40

$20

$0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: ONDCP, 2014

Marijuana Heroin Meth Cocaine

Figure 2 shows that the number of "chronic" cocaine users (a term defined by the federal government as those using at least four times in the prior month) was generally flat between 2000 and 2006, but declined rapidly from 2006 to 2010.16 Data on consumption and use-related harms since 2010 are inconsistent. The rate of cocaine treatment admissions continued on an uninterrupted downward trajectory,

but emergency department visits from 2011 matched 2010 levels, and accidental overdose deaths involving cocaine rose by over 20 percent to 4,700 between 2010 and 2013.17 Past-month use estimates from the National Survey on Drug Use and Health (NSDUH) household survey, which largely captures non-dependent users, hovered around 2010 levels between 2011 and 2013.18

16 ONDCP, What America's Users Spend on Illegal Drugs, 2000?2010. 17 CDC, Multiple Cause of Death Files 1999-2013 (Atlanta, GA: CDC, 2014), . Data are from the Multiple

Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics. Using CDC WONDER mortality data, we define cause of death based on the multiple cause of death (MCD) ICD-10 codes for cocaine (T40.5), heroin (T40.1), methamphetamine, and other psychostimulants with abuse potential (T43.6), and prescription painkillers (the sum of T40.2, T40.3, and T40.4) with accidental poisoning as the underlying cause of death (X40-X49). These counts represent all cases where each drug is listed as a cause of death; the CDC notes that any single death may have up to 20 causes. 18 Substance Abuse and Mental Health Services Administration (SAMHSA), National Survey on Drug Use and Health, 2010 (Ann Arbor, MI: InterUniversity Consortium for Political and Social Research [ICPSR], 2010), doi: ; SAMHSA, National Survey on Drug Use and Health, 2011 (Ann Arbor, MI: Inter-University Consortium for Political and Social Research, 2011), doi: ICPSR34481.v3; and SAMHSA, National Survey on Drug Use and Health, 2013 (Ann Arbor, MI: ICPSR, 2013), doi: ICPSR35509.v1.

Center for 21st Century Security and Intelligence Latin America Initiative

4

an assessment of recent changes in drug use and drug policies in the united states

Figure 2. Indicators of Cocaine Use in the United States, 2000-2013 200

160

120

80

40

0 2000 2001 2002 2003 2004 2005 2006 2008 2007 2009 2010 2011 2012 2013

Chronic Users Past month users (NSDUH) Accidental overdoses (CDC)

Treatment admissions (TEDS; Primary) ED visits (DAWN)

Sources: ONDCP, 2014; Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS), 2000-2012; SAMHSA, National Survey on Drug Use and Health (NSDUH), 2002-2013; SAMHSA, Drug Abuse Warning Network (DAWN), 2004-2011; CDC, 2014

A recent article offered four possible hypotheses for the decline in U.S. cocaine consumption: a decrease in Colombian coca available for cocaine production; the crackdown and violence in Mexico; an increase in non-U.S. demand for cocaine; and a decrease in U.S. demand for cocaine.19 The authors suspected that some combination of supply-side factors likely accounted for much of the U.S. decline, but do not make any statements about the roles of particular supply-side phenomena. They also noted that these

hypotheses are neither exhaustive nor mutually exclusive, and at least two other explanations have also been offered: increased interdiction efforts in Colombia20 and precursor chemical controls by the United States.21

At this point it is not possible to say how much of the decline in U.S. cocaine consumption can be attributed to policy decisions. In fact, there may have been a "perfect storm" with the rapid increase in manual

19 Caulkins et al., "Cocaine's Fall and Marijuana's Rise." 20 Daniel Mej?a, Plan Colombia: An Analysis of Effectiveness and Costs (Washington, DC: Brookings Institution, 2015). 21 James K. Cunningham, Russell C. Callaghan, and Lon-Mu Liu, "US Federal Cocaine Essential ("Precursor") Chemical Regulation Impacts on US

Cocaine Availability: An Intervention Time Series Analysis With Temporal Replication," Addiction 110, no. 5 (2015): 805-20, doi: . org/10.1111/add.12839. Ongoing work by Peter Reuter considers the possibility of a positive feedback loop as enforcement against sellers became more intense as a result of the initial demand drop.

Center for 21st Century Security and Intelligence Latin America Initiative

5

an assessment of recent changes in drug use and drug policies in the united states

eradication, increase in Colombian interdiction, reduced availability of sodium permanganate, instability in Mexico, and an increase in non-U.S. demand. Together, these events may have had more of an effect on cocaine consumption in the United States than any event would have had on its own, but this is very much an open question.

Marijuana. Approximately $40 billion was spent on marijuana in 2010, and more than 20 million people in the U.S. consume marijuana each month.22 The number of self-reported past-month marijuana users was flat from 2002 to 2007, but rose significantly from 2007 through 2013 (Figure 3). However, counts of these so-called "current" users paint a picture that is at best incomplete, if not misleading, because consumption is dominated by daily/near-daily users; their numbers were growing much more rapidly and

are now up seven-fold since the nadir in the early 1990s.23 While changes in public sentiment about marijuana and medical marijuana laws (especially those that allow dispensaries) likely account for some of the increase,24 decreases in the cost per hour of marijuana intoxication could also play a role.25 Changing public perceptions about marijuana could also contribute by making survey respondents more honest about their consumption. Yet considering that the number of daily/near-daily users increased much more than the other past-month users, this is unlikely to be the major contributor.

Methamphetamine. Consumption estimates for methamphetamine contain significant uncertainty due to a lack of data covering non-urban areas where methamphetamine tends to be more common. Nevertheless, the overarching trends across treatment

Figure 3. Self-Reported Marijuana Use Rose Rapidly Between 2007 and 2013 20

18

16

Past-month Users in Millions

14

12

20-30 days

10

8

6-19 days

6 3-5 days

4

2

1-2 days

0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: SAMHSA NSDUH, 2002-2013

22 ONDCP, What America's Users Spend on Illegal Drugs, 2000?2010. 23 Caulkins et al., "Cocaine's Fall and Marijuana's Rise"; and Jonathan P. Caulkins, e-mail communication with Beau Kilmer, February 24, 2015. 24 D. Mark Anderson and Daniel I. Rees, "Medical Marijuana Laws, Traffic Fatalities, and Alcohol Consumption," Journal of Law and Economics 56,

no. 2 (2011): 333-369, ; and Rosalie L. Pacula et al., "Assessing the Effects of Medical Marijuana Laws on Marijuana Use: The Devil is in the Details," Journal of Policy Analysis and Management 34, no. 1 (2015): 7-31, doi: . 25 Caulkins et al., "Cocaine's Fall and Marijuana's Rise."

Center for 21st Century Security and Intelligence Latin America Initiative

6

an assessment of recent changes in drug use and drug policies in the united states

Figure 4. Indicators of Methamphetamine Use in the United States, 2000-2013 400

300

200

100

0 2000 2001 2002 2003 2004 2005 2006 2008 2007 2009 2010 2011 2012 2013

Chronic Users Past month users (NSDUH) Accidental overdoses (CDC)

Treatment admissions (TEDS; Primary) ED visits (DAWN)

Sources: ONDCP, 2014; SAMHSA TEDS, 2000-2012; SAMHSA NSDUH, 2002-2013; SAMHSA DAWN, 2004-2011; CDC, 2014

admissions, emergency department admits, and household respondents suggest that the estimated steep decline in users beginning circa 2005 may have abated or even reversed around the end of the 2000s (Figure 4). Evidence of a large increase in psychostimulant overdose deaths is consistent with that assertion, but we cannot rule out the possibility that the increase is attributable to a psychostimulant other than methamphetamine.26

Heroin. Figure 5 shows that the number of chronic heroin users was generally flat over from 2000 to 2010, but there appeared to be an uptick beginning in 2008.27 The small increases seen in 2009 and 2010 continue into present day based on data on treatment admissions and emergency department visits. Most striking is the large increase in accidental overdoses involving heroin, which appear to have almost tripled from 2010 to 2013.

26 CDC, Multiple Cause of Death Files 1999-2013. Accidental overdose deaths due to heroin and psychostimulants including methamphetamine both grew by approximately 40 percent between 2012 and 2013. For heroin, this was the third straight year of 35 percent or higher year-over-year growth and represents nearly a tripling of overdose deaths from 2,794 in 2010 to 7,838 in 2013. This is unprecedented in the WONDER data going back to 1999, and an area of immediate concern for drug and public health policy research and intervention, especially in light of the plateau in prescription opioid overdoses over the same period after rapid growth in the preceding decade. The increase in deaths also appears to be acute among women 3544 years of age (3.5-fold growth over 2010-2013) and in the northeast (3.8-fold growth).

27 The erratic trends in household survey figures circa 2005 underscore how futile it is to try to track heroin use with general population surveys; indeed, the actual number of daily and near-daily heroin users was more than 15 times (one million versus 60,000) what would be estimated by the U.S. household survey. Beau Kilmer and Jonathan P. Caulkins, "Hard Drugs Demand Solid Understanding," USA Today, March 8, 2014, . story/opinion/2014/03/08/heroin-abuse-hoffman-research-column/6134337/.

Center for 21st Century Security and Intelligence Latin America Initiative

7

an assessment of recent changes in drug use and drug policies in the united states

Figure 5. Indicators of Heroin Use in the United States, 2000-2013 500

400

300

200

100

0 2000 2001 2002 2003 2004 2005 2006 2008 2007 2009 2010 2011 2012 2013

Chronic heroin users Past month users (NSDUH) Accidental overdoses (CDC)

Treatment admissions (TEDS; Primary) ED visits (DAWN) Methadone admissions (NSSATS)

Sources: ONDCP, 2014; SAMHSA TEDS, 2000-2012; SAMHSA NSDUH, 2002-2013; SAMHSA DAWN, 2004-2011; SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2000-2011; CDC, 2014

Though the causes of the upturn in use are unclear, evidence increasingly suggests that dependent nonmedical use of prescription opioids has led to an increase in heroin use.28 One hypothesis is that some who become dependent on painkillers eventually substitute cheaper heroin for more expensive--and increasingly harder to acquire--pills. Additional evidence of chemical tolerance toward opioid painkillers may also push users

to heroin to maintain intoxication.29 Another conjecture is that suppliers may be pushing heroin more heavily in light of the drops in demand for cocaine and falling profitability for illicit marijuana.30

Nonmedical use of prescription opioids. The prevalence of nonmedical use of prescription opioid painkillers has been relatively flat over the past decade,

28 Stephen E. Lankenau et al., "Initiation Into Prescription Opioid Misuse Amongst Young Injection Drug Users," International Journal of Drug Policy 23, no. 1 (2012): 37-44, doi: ; K. Michelle Peavy et al., "`Hooked On' Prescription-Type Opiates Prior To Using Heroin: Results From A Survey Of Syringe Exchange Clients," Journal of Psychoactive Drugs 44, no. 3 (2012): 259-65, doi: 10.1080/02791072.2012.704591; and Cristopher M. Jones, Karin A. Mack, and Leonard J. Paulozzi, "Pharmaceutical Overdose Deaths, United States," Journal of the American Medical Association 309, no. 7 (2013): 657-659, doi: .

29 Kieran A. Slevin and Michael A. Ashburn, "Primary Care Physician Opinion Survey on FDA Opioid Risk Evaluation and Mitigation Strategies," Journal of Opioid Management 7, no. 2 (2011): 109-15.

30 Nick Miroff, "Tracing the U.S. Heroin Surge Back South of the Border as Mexican Cannabis Output Falls," Washington Post, April 6, 2014, . world/tracing-the-us-heroin-surge-back-south-of-the-border-as-mexican-cannabis-output-falls/2014/04/06/58dfc590-21234cc6-b664-1e5948960576_story.html.

Center for 21st Century Security and Intelligence Latin America Initiative

8

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download