Drug Abuse

Policy Alcohol and Other Drugs

Patricia G. Erickson 1

C. A. Ottaway 2

INTRODUCTION AND HISTORICAL OVERVIEW

This is the first policy contribution to the Annual Review, and our initial view, therefore, will be more broad than just the last one or two years. Twenty-five years of public concern, debate, and reaction have followed the wave of illicit drug use that began in the late 1960s. The resulting policy from this era has been a Gordian knotlike entanglement, but the 1990s has ushered in a new era of potentially clearer objectives. While many aspects of drug policy analysis in the field of addictions have tended to be substancespecific (e.g., Beaglehole, 1991; Dorn & South, 1987; Nadelmann, 1989; Room, 1991; Single, 1984; Skretting, 1993), driven by the differing legal status of various drugs, a critical aspect of recent developments has been a persistent move towards an integrated approach to psychoactive substances in general. Principal factors underlying this shift have been a unifying perspective provided by "the new public health" approach (e.g., Ashton & Seymour, 1988; Single, Erickson, Skirrow, & Solomon, 1992; Wallack, 1984) and the articulation of policy alternatives centered in the harm reduction/harm minimization perspective of drug use and addictions problems (Heather, Wodak, Nadelmann, & O’Hare, 1993; O’Hare, Newcombe, Matthews, Buning, & Drucker, 1992).

Bearing in mind current trends in the development of public health initiatives which are moving toward harm reduction approaches aimed at both licit and illicit drugs, in this chapter we (a) trace the threads of traditional policy development, (b) consider the principles of public health policy and harm reduction, and (c) consider the possibility of relating these approaches to more traditional policies, particularly those relating to illicit drugs. We also examine the potential limitations public health and harm reduction approaches may encounter in dealing with social problems related to substance abuse. Finally, we discuss future directions for research and evaluation of existing policies and programs.

The accompanying reprinted articles indicate the important role that research can play in informing public policy decision-making on a variety of drug use and addictions issues. Their scope is broad: health care costs in alcoholism treatment, drug use as a risk factor in pregnancy, mental illness, and HIV transmission. These diverse topics illustrate the complex canvas of drug use and addiction problems touched by the policy brush.

The evolution of an integrated public health approach is well illustrated by the activities of the World Health Organization (WHO), especially the report (1993) of its 28^th Expert Committee on Drug Dependence. The effort of the latest WHO group is very important because it reflects an international perspective on a number of issues, including drug policy, provided by experts from a number of countries. The 1974 WHO report broke new ground by treating psychoactive substances, both legal and illegal, in a coherent way and by adopting a comprehensive framework for "preventing problems associated with the use of psychoactive dependence producing drugs" (WHO, 1974). This strong public health emphasis was reiterated and expanded with an explicit "harm reduction" rationale in the most recent report:

The committee considered the different types of drug use and drug-related problems in the population as a whole, including the total range of patterns of use and the associated health risks.... This idea is now seen as applicable to all psychoactive drugs and implies that, in order to reduce the risk of harm, preventive strategies must be directed not only to those with the highest levels of consumption but also to those with less heavy patterns of use.... In the harm minimization approach, attention is directed to the careful scrutiny of all prevention and treatment strategies in terms of their intended and unintended effects on levels of drug-related harm. (WHO, 1993, pp. 2-3)

First, let us examine the three principal models that have dominated drug policy discourse in

the 20^th century. These are legalization, regulation, and prohibition. Manifestations of all three have been displayed throughout the 1900s, and the law has been used in each in attempts to enforce public health goals. Legalization, or free market availability, was the dominant mode at the turn of the century. Also in place early on was regulation, in the form of a "medicines control" policy in many countries in which the agents of distribution were physicians and pharmacists (Erickson, 1992a; Musto, 1991). With the advent of the complete ban imposed by "narcotic" drug prohibition in most Western nations by the Hague Convention of 1912, drug policy began a protracted course of criminalization that still holds sway (Erickson & Cheung, 1992). A1though a concern with prevention at the community level was never completely absent from the formative era of drug policy development, it was overridden by moralistic concerns with defining the individual drug user’s behaviour as "bad" and seriously deviant (Berridge, 1993; Erickson, 1990; Smart, 1984).

For decades, little questioning of this predominant policy of prohibition occurred, other than the treatment debate for opiate users in the 1950s and the cannabis decriminalization movement of the 1970s (Giffen, Endicott, & Lambert, 1991). The lines between legalizers and prohibitionists were not drawn clearly again until the American drug policy debates of the 1980s, but even then some overlap occurred due to blurring of objectives and strategies (Nadelmann, 1993). Some de facto forms of regulation, in the guise of controlled availability of opiates and cannabis, were being cautiously piloted in the Netherlands; Merseyside, England; and South Australia (Heather et al., 1993). Since the UN treaty the Single Convention on Narcotic Drugs, 1961, decreed international prohibition, signatories could pursue alternatives only on an unofficial or highly limited basis.

As aspects of these three drug policy models are still very much in play in national and international laws, treaties, and practices, it is essential to be clear regarding their defining features. These models diverge on two interacting dimensions — namely, the rules governing availability and the types of consequences which may follow from violating these rules. The negative outcomes are viewed in terms either of health or of criminal justice and other enforcement costs. A traditional approach in drug policy has been to consider that the stricter the controls, the lower the health consequences but the higher the criminalization costs. In contrast, when controls on availability are lax, criminal justice and other enforcement costs are presumed to decline at the expense of increased health costs. (As a matter of terminology, forms of legal regulation can be subsumed under legalization, while decriminalization [i.e., lowering penalties] presumes prohibition.)

Legalization, or a legal drug market, can be characterized as a system in which no criminal offence accrues to the use or exchange of psychoactive substances and there is a legal source of supply (Stevenson, 1990). Governments permit production, manufacture, and sale of a product with few restrictions other than those generally applied to consumer goods, but may apply taxation to production and/or distribution processes. Implicit in such an approach is that users of the substances are free to exercise choice in a free market and that producers compete for their business and attempt to maximize profits. In this model of an open legal substance market some proponents suggest that strong forces of individual and corporate self-interest would tend to restrain and restrict the undesirable consequences of drug use (Stevenson, 1990). It has also been suggested that a more moderate form of a legalized market in which regulation of availability is exerted might be less likely to increase the more harmful expressions of drug use (Nadelmann, 1989). It is well recognized, however, that the established and relatively unfettered market in tobacco and a modestly regulated one in alcohol have produced a considerable toll on the health of users and a major societal burden in many countries (Beaglehole, 1991; Goldstein & Kalant, 1990). An important lesson for public health-directed policy would appear to be that when commonly desired commodities such as psychoactive drugs are legal, cheap, and easily obtainable, increasing numbers of people will use them, with potentially accumulating health costs (Beauchamp, 1990).

In contrast, a substance prohibitionist model envisages a system of extreme and enforced control over both substance use and availability. Such a model aims at eradication of use and availability and is upheld by the force of criminal law. Interdiction and coercion thereby become principal objectives of this model (Erickson, 1992a; Heath, 1992). Since the purpose of policy in this model is the suppression of all access and consumption of the forbidden substance, one of its justice instruments is the criminalization of all substance-related activities. An aggressive pursuit of such a model is usually termed a "drug war" (Mosher & Yanagisako, 1991), but the application of prohibitionist policies even in less severe forms usually imposes extensive individual, social, and economic costs in both the health and the criminal justice spheres (Mosher & Yanagisako, 1991; Nadelmann, 1989).

It needs to be recognized, however, that this stance need not be accompanied by vigorous enforcement: The key defining features of prohibitionist policies are the absence of legal availability and the potential of criminal sanctions (Erickson, 1992b). For example, the medical provision of methadone or heroin maintenance in the U.K., the institutionalized nonenforcement of cannabis law in the Netherlands, as well as the execution of drug traffickers in Malaysia and mandatory minimum sentences for drug possession in the U.S., are individual practices, associated with markedly different enforcement behaviours, but all within the bounds of their particular national prohibition policies (Marks, 1991; "Harsh Rockefeller Laws," 1993).

Thus, a vital feature is how substance-related legal interventions are applied in a particular social and political context. Substance regulation involves legal controls on availability that can stop short of criminal sanctions so that some level of consumption activity is permissible within certain limits (Erickson, 1992a). Some balancing of health costs with the necessity of rule enforcement may be seen as a reasonable trade-off of individual and economic interests in access not excess (Kleiman, 1992). In substance regulation, such as applied to therapeutic pharmaceuticals, the agents of social control are the inspectors physicians, and government officials rather than police, prosecutors, and judges.

 

 

CURRENT STATUS

In the l990s, a number of factors beyond public health concerns have helped to move illicit drug policy considerations out of the impasse of the 1970s and 1980s and have promoted an integrated approach. Many of these factors have global significance. One major factor, identified by several investigations (Flynn, 1993), is the enormous growth in the world supply of psychoactive drugs. Both developed and developing countries have been affected, and somewhat ironically, the global expansion of free market ideals has led to increased, largely unregulated commerce in licit drugs, often at the expense of public health concerns (WHO, 1993).

Other factors are also important. Efforts to stem the proliferation of the illicit market in many countries primarily have taken the form of increased resources for enforcement, increased penalties, and new offences geared to the crossborder trafficker as well as the local grower, seller, and user. Concomitantly, the need for fiscal restraint has become apparent in the face of mounting national deficits. The lack of a medical-scientific rationale underlying the current legal status of many different drugs has also become more widely recognized. The traditional supply-directed strategies of interdiction, buttressed by sophisticated technologies, have been found to be ineffective in eliminating, or even curtailing, the international drug trade and thus have had little impact on local consumption (Caulkins, Crawford, & Reuter, 1993; DiNardo, 1993; Kennedy, Reuter, & Riley, 1993). The AIDS epidemic, fueled in part by needle-sharing among injection drug users in many countries, illustrates the potential harm of marginalizing such users (O’Hare et al., 1992). The growth of the health promotion movement and the provision of integrated treatment services for polydrug users have also been manifested in many countries (Single et al., 1992). The outcome has been a convergence in issues and policy-making regarding psychoactive substances internationally (Heather et al., 1993; Single et al., 1992).

A part of this convergence is illustrated by the articulation of a public health-based approach known as "harm reduction/minimization." Since this approach to the problems of drug use and addiction has features that distinguish it from the classic medical-epidemiological public health tradition, as well as from the legalization/ prohibition dichotomy, it is important to trace these developments and consider its unique contribution.

Before the classic "purple book" report of 1975, Alcohol Policies in Public Health Perspective (Bruun et al., 1975), proponents of public health views of addictions were lonely voices in the free market wilderness, and until the past 20 years, research on addictions problems from a public health perspective had very little influence on alcohol or tobacco policy (Beauchamp, 1990; Room, 1991). Furthermore, prohibition directed illicit drug policies, walled in the criminal justice fortress of punishment and deterrence, have been remote from public health concerns (Erickson, 1990; Jonas, 1989).

The term public health implies government action on behalf of the community "to avoid disease and threats to the health and welfare of individuals and the community at large" (Duffy, 1993, p. 200). In the evolution of public health concerns, the earlier preoccupation with the control of sanitation and the prevention of contagious disease have been supplemented by the notion that policies and practices should actively promote health within a broad environmental perspective (Ashton & Seymour, 1988; Duffy, 1993). Further, it is recognized that the prevention of many traditional infectious diseases is a different category of problem than that associated with voluntary human behaviours such as drug use (Room, 1974). Moreover, the notion of a singular and universal prevention measure— akin to vaccination—that may lead to the eradication of substance use is probably not realistic (Room, 1974).

In general, policy is a plan of action pursued by government, but more sociologically, policy is the official practice of social control by the state (Black, 1989; see also Albrecht & Jackson, 1985; Brownstein, 1991; Nagel, 1980). Critical steps in policy implementation are concerned with analysis and advice. Policy analysis can contribute to the new public health objectives of prevention, health protection, and health promotion by searching for the most effective ways, among various options, of achieving the desired outcome.

A public health-centered policy differs from the current dominant policy of criminalization in several ways. One difference is the emphasis it places on the achievement of pragmatic outcomes rather than symbolic or moral messages to the community. If laws are used to achieve public health aims, examples of coercive strategies might involve quarantine for infectious diseases, destruction of diary herds to stop the spread of tuberculosis, or raids on crack houses to stem the transmission of sexually transmitted diseases (STDs). A single-minded deterrence approach that relies solely on punishment is likely to be viewed as counterproductive by public health strategists; rather, other less coercive measures will be invoked as well. Widespread milk testing and early identification and treatment of those exposed were also vital to the success of antituberculosis efforts. Universal vaccination of school-age children against childhood illnesses is another example. Public health arguments have led to restrictions on alcohol and tobacco advertising along with campaigns in the media to promote healthy behaviours and lifestyles in many countries.

Although long-term goals are important in public health policy, the most emphasis is placed, when a choice must be made, on ameliorating or preventing immediate harm rather than focussing on a less tangible distant hazard. Similarly, approbation of socially deviant behaviour is superceded in public health policy by a less judgemental concern for the reduction of adverse consequences. For example, providing condoms to prisoners to limit the spread of STD has been introduced in some jurisdictions (Des Jarlais & Friedman, 1993; Duffy, 1993; Friedman, 1993; WHO, 1993). Public health approaches thus emphasize a broad range of strategies.

Under strictly enforced prohibition models, criminal sanctions focussed on the detection and punishment of offenders are paramount. There is no boundary between private and public substance use behaviours, and harm to the user associated with the administration of the Illegal substance is irrelevant. Since no use is permissible, any particular circumstances of the "crime" have little bearing on individual culpability in criminal justice processing. The traditional outcomes of law enforcement (arrests, convictions, seizures, sentences), however, can have many unintended consequences that are counterproductive and may themselves be harmful in a number of ways (Erickson, 1993a; Single et al., 1992). Aggressive application of the criminal law extends the boundaries of acceptable infringement on the individual’s liberty and rights (Marx, 1988). The usual justification provided by government is that it is serving the interests of general and specific deterrence among potential and actual offenders, but the thrust of 20 years of deterrence research has demonstrated few benefits associated with prosecution of illicit drug activity (Erickson, 1980, 1992a; Reuter, 1988). The symbolic/moralizing function of the criminal law, nevertheless, remains a potent force in "sending the correct message"— namely, retribution — to those who would flaunt it (Erickson, 1992a).

How, then, can an integrated, contemporary public health perspective be expressed specifically in the psychoactive substance use context? Acknowledgement must be made of Scandinavian alcohol researcher Kettil Bruun’s pioneering work to bring discussions of control policy for licit and illicit drugs into the same frame of reference. He saw clearly that the result of taking a public health approach would tend to encourage increasing the controls on tobacco and alcohol but decreasing controls on illicit drugs (R. Room, personal communication, 1993).

Other early efforts have focussed on controls on alcohol availability (Bruun et al., 1975) and public education and discussion of the hazards of smoking tobacco (Beauchamp, 1990). The impetus for illicit drugs was the provision of methadone and needle exchange programs for injection drug users, particularly in response to the AIDS epidemic (Berridge, 1993; Des Jarlais & Friedman, 1993). The theme which has come to the fore is that of "harm reduction" or "harm minimization" (Heather et al., 1993; O’Hare et al., 1992). While this terminology has been associated with alcohol since 1970 (Room, 1974), it has taken a higher profile in the 1990s with the establishment of annual international harm reduction conferences. Evidence and examples of an integrated approach are provided in recent work involving the provision of nicotine patches for cigarette smokers (Russell, 1993) and "controlled drinking" rather than abstinence for some of those at risk for alcohol problems (Heather, 1993).

Harm reduction does not involve advocacy of a particular legal policy (Strang, 1993). Instead, it asks practical questions about what types and features of policies are effective for reducing the harms associated with particular types of drug use behaviours. This follows the lead of alcohol policy analysis which emphasizes the disaggregation of alcohol-related problems into manageable components that can be addressed by specific strategies (Room, 1991). As Room says, "a conceptualization like minimization, which legitimizes small steps and half measures, will tend to be more useful [than one sweeping major measure]" (Room, 1974, p. 13). Flexibility of response is the keynote (Erickson, 1993b). Thus, harm reduction principles can be incorporated into existing drug policies, without waiting for major legislative initiatives. Many examples of harm reduction can be evoked, from needle exchange programs in prisons, low potency preparations, safe use instruction, and price hikes, to nicotine patches and vitamin-enriched beer. It is evident, however, that regulation provides more scope for harm reduction than the other two alternatives, while also meeting public health objectives. Another major contribution of the harm reduction perspective is to direct attention to the careful scrutiny of all prevention and treatment strategies in terms of their intended and unintended effects on levels of drug-related harm

(WHO, 1994).

Harm reduction, then, owes its roots and origins to the public health tradition, but has been refined and adapted within the areas of both licit and illicit psychoactive drug use (Erickson, 1992b; Heather et al., 1993; Room, 1974). The more medical aspects of the tradition have been deemphasized, while incorporating more psychological-social-cultural dimensions. Agent, host, and environment have been redeployed as drug, set, and setting (Zinberg, 1984). What are the defining principles of this perspective? Since it is still "hatching," the final contours and colourings are still to be witnessed. All those associated with its nurture have not yet reached consensus (Strang, 1993), but some common elements of definition have emerged.

First, harm reduction is not dogmatic or moralistic, but gives allegiance to policies and programs which demonstrate pragmatic benefits in reducing drug-related harm. This has been illustrated by the pressing need to stop HIV transmission among injection drug users (Des Jarlais & Friedman, 1993). Second, for harm reduction, abstinence, or the total prevention of ah drug use or cessation of use, is not the single objective of policies and programs. Together these illustrate the third point that harm reduction is multidimensional: A range of methods is drawn upon in order to achieve specific goals, and these are available simultaneously, to fit the continuum of drug use and problems. As a fourth feature, it is recognized that various kinds of social harms, such as divisiveness (by age, race, class), stigmatization, and the reinforcing of deviance, are aggravated by criminalization and require the provision of harm-reducing alternatives (Erickson, 1992a). Fifth, the reintegration of illicit drug users into society, while they may need assistance, will be enhanced by recognition that they are capable of participating in the decisions about their own lives and the social dialogue surrounding drug issues (Cheung & Erickson, in press; Des Jarlais & Friedman, 1993).

While research and evaluation of harm reduction approaches for illicit drugs are still at an early stage, some studies have been done that are highly relevant to its future as a framework in

which to shape a more viable policy option. The three topics that will be highlighted here are de facto decriminalization, the potential of informal controls in limiting harmful drug use behaviour, and alternatives to abstinence as a treatment/program goal.

The first topic considers changes in the sanctions addressed to sellers and users. Legal suppression of availability of substances under prohibitionist models is virtually always accompanied by illicit markets in which no direct regulation by government or product quality control by competing producers is possible. The legal prohibition of substance availability, however, is sometimes presented as a "public health" measure that prevents general access by the population and minimizes consumption by keeping prices high (Goode, 1993; Macdonald, 1981). Any success of this concept, however, is undemonstrated. What has been learned from the "drug war" of the past decade, especially that against cocaine, is that prices can drop even while purity rises. Moreover, people who desire prohibited drugs usually continue to obtain them, particularly those among the most disadvantaged groups in the population (Erickson & Cheung, 1992; Nadelmann, 1989).

Indeed, there is less control over an illicit market than a legally regulated one, where the government can determine price, purity, and who obtains drugs under what conditions (Erickson, 1992a; WHO, 1993). The threat of criminal sanctions usually serves as a check on use mainly among the prudent, self-regulation-oriented and predominantly middle class members of society—that is, those who are least likely to indulge in the most harmful patterns in any event (Goode, 1993). Thus, from a harm reduction perspective, the notion of strict control in a prohibitionist scheme is largely illusory. There is some containment of the problem, but more often marginalization of the problem, and at high additional social costs (Goode, 1993).

It is very difficult to predict the potential consequences of adoption of a given form of legal regulation of substance availability (MacCoun, 1993). The precise nature and extent of illicit drug activity is difficult to ascertain for a baseline assessment, due to the "hidden" and stigmatized nature of the activities (Sutton & Maynard, 1993). Furthermore, there is virtually no direct experience with a shift to free market legalization of the currently illicit drugs to offer as a contrast to existing cost estimates (Wagstaff, 1987). Examination of the situation at the turn of the century when these substances were readily available can offer certain insights, but probably has limited relevance to the present (Musto, 1991).

Since substance prohibition models offer little flexibility and few precedents to examine variation in legal control of illicit drugs, few conclusions can be made. Nevertheless, some differentiation of response to cannabis has occurred that offers some insights (Morgan, Riley, & Chesher, 1993). Experiences in the U.S., Canada, Australia, and the Netherlands have been evaluated. The American "decriminalization" (i.e., penalty reduction, not elimination) experience of the 1970s, when levels of cannabis use reached their peak, showed that use levels did not increase more in states that lowered penalties compared to states that did not (Single, 1989). In perhaps the most complex series of legal changes, the community of Ann Arbor, Michigan went through five revisions of legal penalties within a short time, fluctuating between more and less severe, without any concomitant change in cannabis use as tracked longitudinally (Single, 1989). Since Canada has not charged its federal drug laws since 1969, it can serve as a comparison case study for the U.S. (Erickson, 1992b). Cannabis use levels went through the same overall trends in Canada, rising until 1979 and then dropping, without any parallel changes in drug law and the dominant policy of criminalization (Erickson, 1980, 1992b).

More dramatic changes have occurred in Australia and the Netherlands. A ticketing system for small amounts of cannabis has been in effect in the state of South Australia since 1987. If the fine is paid within the prescribed period, no court appearance is required and no criminal record results; rates of cannabis use in that state have not increased or differed significantly from other parts of Australia without this ticketing provision (Morgan et al., 1993). In the Netherlands, the approach to cannabis has been termed "institutionalized nonenforcement" (Currie, 1993). Here, licensed coffee shops can sell small amounts of cannabis products, along with food and beverages (excluding alcohol) without police interference. The police role is to monitor and to ensure that rules against selling to minors or engaging in "hard" drug activities are not broken. This unusual practice of what is still, officially, a prohibition system, since 1976 has not resulted in increases in cannabis use among

young people (Morgan et al., 1993). On the other hand, annual use levels have remained quite stable, though at low levels, instead of dropping off, as has occurred in many other Western countries in the 1980s (Sandwijk, Cohen, & Musterd, 1991). One interpretation of this trend is that experimentation has continued at fairly constant levels, but the proportion of regular users has not expanded.

Given the considerable individual and social costs which accrue to cannabis enforcement, the limited deterrent benefits of criminalization, and the relatively low health risks associated with cannabis use (Erickson, 1980, 1990), this substance would seem to be a prime candidate for harm reduction efforts. These could range from greatly diminished enforcement or nonenforcement of current laws to possible forms of legal regulation. It is often asserted that liberalization would result, necessarily, in cannabis being marketed in the same way as alcohol and tobacco have in the past, and would soon incur comparable health and other social costs. However, as described earlier, the absence of strict regulatory controls over these licit substances in most countries hardly exemplifies a public health-based policy (Beaglehole, 1991; Wallack, 1984; WHO, 1993), and the argument seems spurious. The challenge for cannabis reform might be to establish and evaluate a new direction in public health policy centered on the principles of harm reduction.

A powerful but often unappreciated check on the excessive or hazardous use of drugs is that of informal social controls, our second example of harm reduction research (Heath, 1992). These consist of all the pressures, guidance, hints, gossip, and sometimes outright disapproval of behaviour that occur in daily interaction with peers, family, and others in social networks (Black, 1989). In fact, these socially grounded controls play a much more important part in most people’s decisions about drug use than do the more remote and rarely applied threats of criminal punishment (Erickson, 1992a). It is also clear that informal controls are most effective when synchronous with widespread public attitudes and the existing regulatory scheme. Current public health thinking tends to emphasize the potentially mutually reinforcing effect of health conscious popular sentiment and fairly strict regulation. Informal controls may be enhanced by the public dialogue that results from attempts to shape public opinion in favor of more health-supporting behaviours (Beauchamp, 1990). The overwhelming evidence of major declines in the use of tobacco products in most Western nations, without resort to criminalization, shows the combined power of health messages and popular disapproval in conjunction with price increases and restrictions on public smoking. At the same time, the expansion of tobacco markets in developing countries underlines the importance of implementing controls over availability, in conjunction with education, in order to minimize future harm (WHO, 1993).

Several recent studies of illicit drug users have also demonstrated the importance of informal controls within drug user groups (Grund, Kaplan, & de Vries, 1993; Waldorf, Reinarman, & Murphy, 1991). Users actively engage in establishing norms of "safe" use and the avoidance of the pitfalls of excessive use within extended social groups. For example, perception of high risks of crack cocaine use is a major factor that users communicate to would-be users; they also build their own harm reduction practices through the covert sharing of perceived knowledge (Erickson, 1993b). The example of even the most "addictive" illicit drug, cocaine, casts doubt on the implicit prohibitionist view that the properties of the drug are more important than the characteristics of the user and social context, or set and setting (Zinberg, 1984). These studies show the important ways that users can learn to control use and how they maintain, lose, and regain control. The implication for policy is that honest and open information, easier to promote under some form of regulation than the ban of prohibition, may accelerate or reinforce the sharing of harm-reducing advice in user groups. As well, these studies support choosing the least harmful policy of no or minimal intervention unless the drug use behaviour clearly justifies the need to prevent a greater harm.

The importance of the larger policy setting in shaping the application of informal controls is aptly described by Grund, Stern, Kaplan, Adriaans, and Drucker (1992), reprinted in this volume. For effective harm reduction in preventing HIV transmission, it is essential to learn about the roles and rituals surrounding both drug use and sexual behaviour in order to devise relevant and appropriate interventions and support to injection drug users and their partners. Ethnographic research has made a major contribution in this area.

The third topic, briefly, is to consider the risk continuum rather than abstinence. The ban on possession and, therefore, use of illicit drugs renders difficult, if not impossible, the public support of any addictions programs that do not require and promote abstinence. Thus health care professionals are often in the uneasy situation of knowing that their clients are continuing to use illicit drugs and that reduced use might be a considerable if officially unacceptable achievement. Of course, even the desirability of abstinence as a program goal has been hotly contested for the licit drugs as well (Heather, 1993; Russell, 1993). Nevertheless, the problem is particularly acute for the illicit ones. Many users cannot be attracted into programs that insist on abstinence (Erickson, 1993b). Again, little evaluation of controlled availability of drugs, other than methadone, has been possible. A harm reduction program in Merseyside, England (Marks, 1991) has demonstrated the ability to attract a range of drug users who have been way of conventional programs By offering a range of substances, carefully monitored, this program has resulted in healthier drug users with a lower rate of HIV infection than other parts of the U.K.

CONCLUSION AND FUTURE DIRECTIONS

The history of drug policy and the slow evolution to a new integrated public health perspective of harm reduction have been reviewed. There are a few early initiatives that enable some assessment of the harm reduction framework for illicit drugs. Continued assessment should be directed at expanding the knowledge base for illicit drug policy in a manner analogous to the considerable body of policy-related alcohol research (Bucholz & Robbins, 1989). It is important to better understand substance use behaviours and to establish guidelines for determining what related "harms" can and should be "reduced." We need to know what level of the harmful outcomes (i.e., individual, local community, or society) is to be the focus of the strategy, and these strategies, in turn, should be grounded firmly in empirical research on behaviour interventions. We must be mindful of the risk that a potentially popular term such as "harm reduction" may be embraced as a policy or program rubric without necessarily the commitment or the resources to implement it in an effective form (Erickson, 1992b).

The current expansion of a public health centered approach to drug policy in many countries provides a sharp contrast to the debate between legalization and prohibition. Policy derived from a new public health perspective, and aimed at the reduction of harm associated with the use of psychoactive substances, can provide important new opportunities for community based programs. These would potentially be of benefit to both drug-using and non-drug-using members within the larger community, as well as to health care providers.

Although these approaches can provide important new opportunities, they also carry with them important new responsibilities. One of these is the responsibility to choose strategies and methods which are potentially effective, and to explicitly evaluate their effectiveness. An allied responsibility is that of choosing interventions that will be most effective within that particular culture/community where "harm" is to be minimized. This suggests a program of incremental policy and intervention initiatives where new approaches that are introduced have clearly testable criteria for their desired outcomes. Then, continued evaluation procedures can be used to enhance and maintain those programs with demonstrable effectiveness based on external validation.

The use of psychoactive drugs has a complex natural history with a diversity of behaviours. The spectrum spans exploratory or casual use, intensive or compulsive use, and dependent or addictive use (Bozarth, 1990;’Erickson, 1993b; Kalant, 1989; Waldorf et al., 1991). Within different regions of this behavioural spectrum, opportunities for minimizing harm differ. Subsets of interventions need to be designed and tested for their specific effectiveness within a more defined region of drug use behaviour. This approach also allows for the possibility that less or even no intervention would be the preferred option for some behaviours.

If the use of psychoactive substances is seen within a larger context of the social, biological and pharmacological interactions that evolve a drug use proceeds from the experimental to the compulsive end of the spectrum, then it become of great importance to investigate and identify the key steps or control points through which the most leverage for harm-reducing intervention can be applied.

Whether crucial questions about the etiology and effective treatment of the most harmful expressions of substance use are answered in the near future or not, the use of psychoactive drugs is likely to continue in virtually all of the world’s societies. So long as this is so, a fundamental problem for policy development and analysis is: How do we minimize the harm that is associated with the use of psychoactive substances and the attempts to control use? It may seem tempting to cut through the Gordian knot of illicit drug policy with the sword of outright legalization. This review has argued that a process designed around public health-centered policies of judicious regulation has the most potential for eventually untying the knot with the least harmful outcomes for the individual and society.

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