This post has come about because over at Crooked Timber I was outed as one of the authors on this paper, while defending the prohibition of heroin (I’m the third author on that paper, and have a brace like it[1]). I don’t usually like to reveal my identity on the internet, because … well, because the internet is a dangerous place, and also it seems a bit pretentious. But since it came up on that thread, and I didn’t want to do a threadjack (the OP was about “zombie economics,” not “zombie drug policy”), I thought I’d give the definitive Faustusnotes position on the Legalization of Heroin.

First though, in the interests of all this clarity of identity, I thought I’d add that I’m currently teaching this topic in a special lecture at Ritsumeikan Asia Pacific University, on the special topic of Global Crime and Public Health, in which I get to add some of my own theories about the importance of governance and corruption in modern drug policy. My views, of course, don’t represent those of the University or my colleagues, though I sincerely hope that they do reflect those of my students by the end of the course[2] . Also, Professor Quiggin, the author of the original post at Crooked Timber, has a couple of posts about prohibition at his own blog that express a common problem many on the civil libertarian side of politics (whether right or left) have with drug prohibition – even if we accept it is practically a good idea, how can we justify it when we don’t prohibit alcohol or tobacco? I’ll try to answer that on practical grounds in this post as well.

As a final point, I should add that my views don’t represent those of my co-authors, though I think we agree in the main on most of these issues, but it would be wise to assume we differ in various small ways about details of the wide range of issues that fall within the rubric of modern drug policy.

The harm reduction vs. prohibition debate and the war on drugs

As with a lot of modern policy debate, the drug “debate” has been poisoned by the involvement of the US on the prohibition side of things. US prohibition policy – the so-called “war on drugs” – is much tougher and harsher than that in action in other countries of the developed world, and involves a whole series of abuses of freedom that don’t really occur in the rest of the developed world. The US also lacks a coherent national harm reduction policy, which means that the worst effects of the drug trade on its prime victims (the drug users) is not ameliorated or softened effectively by health or welfare agencies. I find when discussing the issue of whether drugs should be legalized that it is best to completely ignore the US experience of prohibiting heroin and cocaine, because it has been done in such a cruel and heartless way that it really doesn’t represent what can be achieved.

It’s also important to ignore the distinction between harm reduction and prohibition, and to assume for a moment that they can a) work side by side, and b) aim for the same goal (improvements in health). We can, at least in theory, argue for prohibition on the basis of its benefits for health.

For the benefit of my American reader(s), harm reduction is a suite of practical policies aimed at reducing the damage drug use does, without attempting to judge the behaviour, and based on the assumption that harmful behaviour occurs regardless of our judgments and even where it is illegal. Because harm reduction doesn’t explicitly try to stop the underlying activity, many people think of it as a kind of “gateway policy” for drug legalization, but in my experience this is a pretty big mistake. Harm reduction is typically represented by policies like Needle Syringe Programs (dispensing free needles), free availability of methadone treatment, and sometimes more radical experiments like medically supervised injecting centres[3] or medical prescription of heroin[4]. Many harm reduction practices do actually attempt to change behaviour, reduce drug use or stop drug use (that’s pretty much what methadone is designed to do), so the claim that harm reduction as a policy suite condones drug use is a bit shallow.

Prohibition, on the other hand, is an attempt to stop the use of drugs, typically by banning their production, sale and/or use. Prohibition has recognized negative effects, the main ones being (and these are all important):

  • Criminalization of drug users for their personal behaviour, which generally doesn’t harm others
  • Invasion of the rights of non- drug users as part of police activity
  • Stigmatization of drug users
  • Significant public health effects deriving from the need of users to keep their use secret

Note that stigmatization is important in the era of HIV. Stigmatized people don’t seek health care. This means that there is a risk they will unknowingly spread HIV. Thus stigmatization is practically an important issue even if you, personally, think that the stigma is deserved.

Why Prohibit Heroin?

Heroin, particularly, needs to be prohibited for a simple reason – it is extremely dangerous when used as an injectable drug. It is dangerous for two simple reasons, and neither of these reasons will go away just because the substance is legal. These are:

  • Transmission of Blood Borne Viruses (BBVIs): particularly HIV and Hepatitis C (HCV). HCV is now the single biggest cause of liver transplant in Australia, surpassing alcohol-related liver damage, so it’s an extremely costly and unpleasant disease. HIV is a bullet that the developed world largely dodged by good luck and very rapid implementation of harm reduction policy. BBVIs are primarily spread in the developed world through needle sharing by IDUs (in fact, it’s the only way to transfer HCV). To give a sense of how endemic these diseases can be, HCV was around in Australian IDUs in the 70s, before the implementation of NSP and harm reduction policies. Its current prevalence in IDUs is about 60%, and in US areas without NSP it is up above 90%. HIV in Australian IDUs is low, less than 1% in fact, and this is almost entirely due to the provision of clean needles to IDUs before the disease became widespread.
  • Overdose: Heroin kills its users, randomly, and rapidly. During the late 1990s in Australia heroin became one of the top killers of young people, with nearly 1000 deaths in 1999. Although overdose is associated with using other central nervous system depressants (especially alcohol and benzodiazepines), the epidemiology of overdose is still not clear and there is pretty strong evidence of at least some randomness in the death rate – autopsies suggest that people who have died from overdose have similar levels of residual heroin in their system to those who didn’t, whether or not they had other substances at the time of death. OD is a random risk that heroin users face.

If heroin were legalized, it would become much more widely available and the rates of BBVIs and HCV would surely climb. There are clear reasons why this will happen, but before I describe them, anyone who has read this far should ask themselves these three questions:

  • Have you ever got drunker than you expected from a couple of beers, or experienced greater effects from the amount of alcohol consumed than you expected? i.e. is your experience of alcohol’s potency the same every time you drink the same alcohol?
  • Have you ever had unsafe sex when you fully intended to have safe sex, had the condoms with you, and knew the risks? Do you know people who have done this?
  • Have you, your partner, or a completely reasonable and sane person you know, ever experienced an unplanned pregnancy? Do you think those people knew the risks? Do you think that the high teen pregnancy rate in the UK is entirely related to lack of availability of condoms?

I present these questions in support of the unasked questions about the behaviour that will flow from legalization. Legalization is not a panacaea that will instantly solve all our drug use problems, and turn previously chaotic, criminally involved addicts into beautiful people. It just means more people will be at risk of these mistakes.

The consequences of legalization

The two main consequences of legalization of heroin are an increase in overdose deaths and an increase in the prevalence of BBVIs. These, I think, are inevitable, because of the reality of injecting drug use.

Increase in Overdose Deaths: heroin does not kill users because it is cut with bad stuff, as many claim. It kills users because it randomly kills people. Some people claim that steady purity will prevent this from happening, because users will know how much they’re taking, but this isn’t necessarily the case. We don’t know the biological causes of overdose clearly, and we don’t clearly understand the relationship between heroin purity and overdose. I am sure it’s well understood in medical settings, but people won’t be injecting heroin in a medical setting – they’ll be injecting it in their loungeroom, with their friends, in the same context that people drink alcohol now. The effects won’t be controlled, and peoples’ behaviour is not so straightforward. There will be people who misjudge the time since they last had a drink, or how drunk they “think” they are, or who think the first shot just isn’t enough and don’t wait long enough for the second one, or who’re feeling particularly nasty today, or… then there will be people (presumably those who map to the 30% of ODs whose residual levels of morphine are lower than in OD survivors) who just die randomly. There will also be people who’ve tried to give up, and come back for a shot but forget their tolerance has gone down; people coming out of gaol or the army or a long overseas trip.

Increase in BBVIs: HCV is not a rare disease that IDUs get through crazy mistakes. It’s an environmental hazard that happens to people who are IDUs. It happens because people shoot up in silly situations, like the toilet behind the restaurant, or the party with 5 of their mates, or 6 times today during a cocaine binge, or… I once watched 10 people in a room at a house party injecting speed, all sharing the drug from the same bag by the light of a couple of candles, most of them drunk, music loud, people passing around various objects, bags, spoons, water… in this situation needles get misplaced easily, people think they’re using their own but they’re not… with 60% prevalence of a virus, this becomes a significant risk of its spread.

It’s also not the case that IDUs in Australia share needles because of the illegality of the drug. Most IDUs in Australia have regular, reliable and uninterrupted access to clean needles and don’t have to share, and sharing rates are generally low. Nonetheless, prevalence of HCV is high. This is because when the majority of people in your community have a disease that is linked to the main behaviour that defines your community, that disease becomes an environmental hazard, rather than an avoidable medical condition (like HIV).

Addiction: The other thing that will happen if the drug is legalized is a lot of people will try it and become addicted. We have evidence from the Vietnam war that when the drug is available young men will try it; if legal in Australia and easily purchased, the number of people trying it will increase and with it the pool of addicted people. Addiction to heroin is associated with poverty – you can’t shoot up 3 times a day and hold down many forms of work. Addiction to heroin is also associated with loss of children (through neglect) and family. Unless the legally available drug is very cheap, it will also lead to crime – an addicted person will be having to spend upwards of $30 a day on their habit, which is worse than most serious smokers do. Having lost their job and family support, where will this money come from?

Many people try heroin and don’t become addicted, but those who do become addicted typically see their lives fall apart around them. We don’t need to expand the pool of people to whom this applies.

Australia’s Prohibition Success

In January 2001 Australia experienced a sudden reduction in the availability of heroin, that led to a marked change in the heroin markets and drove a lot of young people and new users out of the heroin market, probably permanently. There was a sustained 60% reduction in heroin deaths, 70% reduction in ambulance attendances at overdose, and a 15% reduction in cocaine possession offences. There was no long term increase in acquisitive crime, prostitution offences or BBVIs. New entrants to methadone increased, indicating people trying to leave the market; it’s likely that the overall number of new and young users permanently declined. This was a huge public health gain with very little downside, and it occurred through a sustained campaign of harm reduction and prohibition that ramped up, and improved, with the 1997 release of the National Drug Strategy (under the conservative government of John Howard). Increased treatment places, novel harm reduction policies, and improved health services to IDUs, meant that they were sheltered from the worst effects of the shortage; improved coordination of federal customs and police, improved intelligence-gathering and coordination of local police, and significant reductions in police corruption, meant that drug importation stopped being profitable, and the supply side of the market collapsed.

Our argument (in the paper linked above) is that harm reduction was a key part of this success of prohibition, both in reducing demand for heroin (through methadone treatment) and in protecting users from the worst of the effects of prohibition when it happened. The long term reforms of sex work and police behaviour towards petty crime also helped with this – in my opinion, on a local level we saw the lessons of the Inquiry into Aboriginal Deaths in Custody, the Wood Royal Commission into Police Corruption[5], the National Drug Strategy and the Drug Courts all coming together in 2000/2001 to destroy the viability of the market for heroin.

Why we Prohibit Heroin but not Alcohol

There is understandable concern that it’s hard to support prohibiting heroin but not alcohol; and that the bad historical lessons of the latter should inform our decision to try the former. But in fact the two drugs are completely different, and there are practical reasons why even if we wanted to prohibit alcohol we can’t. John Quiggin touches on these in his posts on prohibition, but I think he misses the point a little. We can’t prohibit alcohol for many practical reasons that don’t apply to heroin:

  • It has a long-standing tradition of use, that isn’t just window-dressing. Alcohol is an important part of our culture, not something we can just wish away, with a role in festivals and the bonds of social life
  • The raw materials are accessible to anyone – they’re in shops down the road
  • The production process is well understood and can be done in a back yard, so the prohibition is trivial to avoid
  • Declaring alcohol illegal means that the people charged with enforcing the law will be declared criminal overnight, unless they stop a long-term habit (Police do like a drink)
  • There is an existing industry with a significant role in society – not something that ever applied to heroin

In addition, we know that alcohol can be used safely, while heroin can’t. So it’s really hard to put up a justification for banning alcohol “for the protection of the user,” while we can do so for heroin. Now, many people object to banning a substance if the only victim is the user, which is why we only ban substances we are sure you can’t use safely; or substances that affect others as well as the user. This applies in spades for heroin, which has no safe level of use, is highly addictive, and whose habitual users commit significant amounts of crime to fund their habit. Heroin is a public order as well as a personal health problem, and the possibility that legalizing it will suddenly cause all those public order problems to disappear rather than worsen is really something that we don’t need to take a risk and find out – especially since we have perfectly good policies in place to prevent prohibition from becoming the vicious, poisonous political problem that is in the US.

A Final Note on Narco-States

It is my firm opinion that drug dealing does not destroy nations (like Columbia or Guinea-Bissau). Rather, states in the process of collapse become havens for drug dealers, which in turn destabilizes parts of those states, and leads to massive corruption problems that further fragment the states. Australia grows lots of opium, but you don’t see Tasmania turning into a narco state. This is because we have a strong state, that can control crime in its borders. There is no causal process from drug dealing to failed states; it’s the other way around.

Conclusion

On civil liberties grounds alone no substance should be banned if it is just bad for the user. But if the drug is randomly fatal, causes addiction and poverty of the kind that inevitably leads people to be tempted to commit crime, and is associated with a significant public health problem like HCV or HIV, then it should be banned if it is possible to do so. It is practically possible to prohibit heroin, we have shown it can be done and that harm reduction can prevent such prohibition from being a threat to health; so I think we should maintain heroin’s illegal status, and do all we can to prevent its production, importation, and use. It should, in short, remain illegal.

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fn1: including an interesting test of the relative importance of long-term epidemic trends in the heroin market, compared to a sudden shock; and a general method for statistical analysis of imperfectly-dated natural experiments

fn2: Said facetiously, of course…

fn3: One of which I had a small part in helping to set up

fn4: Which I support

fn5: Which I think was hugely important for police corruption in Australia