Public Health and Recreational Drugs

My 56 yearn of experience as physician has led me to conclude that we need to blur the distinction between legal and illegal drugs. For instance, it is clear that nicotine as a motive for exposure to the tobacco that accompanies it is more harmfu1 than pure, uncontaminated heroin in reliable doses. The grip of the habit in each case is quite similar. We have made great strides in reducing the number of smokers in the United States with special credit for this progress going to Surgeons General Luther Terry and C. Everett Koop. Considering the unintended consequences (such as bootleggers) of attempts to prohibit alcohol, education is a more effective deterrent than prohibition in the long run., but the fact that tobacco is a legal substance confuses the courts with the idea of "commercial free speech". Some blurring of this "legality" of tobacco seems entirely appropriate because advertising tobacco is comparable in its public health consequences to advertising heroin. Compare the public health result to the delay in incarcerating typhoid Mary 100 years ago. Typhoid Mary was a carrier of typhoid fever who insisted on continuing to work as a food handler until she had caused one hundred thirty-some deaths from typhoid fever. Her 'epidemic' ceased when special laws were passed in New York state permitting her to be jailed. Do we need to limit tobacco sales to certain government licensed stores to help control tobacco use by minors? We already have such stores for alcoholic beverages.

Treating heroin addiction as a public health problem is likely to be more successful than treating nicotine addiction because of the well-known experience with methadone maintenance. We need outreach to poor heroin addicts instead of waiting lists. A daily dose of methadone for former heroin addicts blunts their drug craving and eliminates withdrawal symptoms for years if necessary The longest acting drugs in all categories of addicting drugs are the least habit-forming.

The problem of cocaine is more difficult because of the lack of a long-term substitute to blunt withdrawal cravings. Some urgent research about cocaine receptors, long acting agonists and antagonists is needed. Meanwhile, maybe some stop gap products comparable to nicotine chewing gum, patches and inhalers might be commercially viable if cocaine were less “illegal". After all, we are succeeding with nicotine mitigation without long acting agonists or antagonists.

Addiction to caffeine is scarcely a public health problem because of its lesser toxicity. But should we permit adding caffeine to food as an aid in marketing soft drinks? Even if caffeine should turn out to benefit some children, it is unlikely that the net effect would benefit this population considering the empty calories and escalating obesity. Following are some suggestions regarding caffeine addiction: 1) Only permit promotion of products that contain caffeine naturally such as coffee, tea, cola nuts and matte’. 2) Prohibit selective breeding of those natural sources to increase caffeine content when this is the sole motive (as recently came to light concerning Brazilian tobacco). 3) Require labeling that specifies the actual content of caffeine in the product, not just that caffeine has been added.

Basically we have been talking about harm reduction. Another very important item of harm reduction is to eliminate sharing needles. This is currently not widely implemented because of "sending the wrong message." Mature consideration tells us the message, "We don't care if you get AIDS, because of our puritanical hang-ups" is an even more wrong message. There are other examples where promoting public health goals to solve medical problems has been successful, but the puritanical approach has failed. Venereal disease is one salient example and elimination of excess mortality by decriminalizing abortion is another. Incidentally, in the 19th century criminalizing of induced abortions was a public health measure because at that time any induced abortion was much more dangerous to the mother than a completed pregnancy.

In conclusion, I would like to emphasize that my support for blurring the distinction between legal and illegal drugs does not imply condoning criminal activity motivated by drug use such as purse snatching, sales of illegal drugs, or doctors or pharmacists diverting legal drugs. But we urgently need a new approach. The "Drug War" supplies criminal elements with enormous revenues, a corrupting influence on society. Spending obscene amounts of money jailing nonviolent addicts (as opposed to drug dealers) is not a public health measure. These moneys would better be spent on treatment of addictions and other public health benefits. Some of those jailed for long periods for simple possession of marijuana would actually be good citizens or even good parents, if they were not in jail (marijuana does not foster violence in users as does alcohol).

John A. Frantz M.D. See also: Public Health, Public Costs and Public Benefits under Economics and Politics

June 6, 2002

There is no addicting drug in fingernail clippings.

The horns of a dilemma are usually on the same bull. (Spanish Proverb)