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Drug Misuse and Social Cost

The debate about illicit drugs is set to run and run. There are many voices calling for drug legalisation, and more equally vociferously opposed. These arguments all too often rely upon concepts of freedom of the individual compared with protection of society, and rarely is evidence of harm or lack of harm brought forward as arguments on either side.

The biggest problem for those wishing to use evidence is the paucity of good research.

Reinstating the British System

John Marks, a psychiatrist from Cheshire and Merseyside, has long campaigned for the prescription of heroin for addicts (the British System) [1]. He does not call for wholesale legalisation. Rather he makes the point that to afford black market prices, addicts buy more than they need, adulterate it, and sell the extra to finance their own habits.

This results in a gigantic pyramid selling system in which the major input of cash comes from criminal activity. Where drug abuse is prevalent the proportion of criminal activity ascribed to drugs is seldom lower than 50% and may be 80%.

Thus a heroin habit of one gram per day costing £50 amounts to £15,000 a year. Marks comments that the total amount stolen to support the habit of the estimated 100,000 addicts in the UK is as much as £1.5 billion. This may be a serious underestimate - a car radio with a retail price of £100 is unlikely to raise even 20% of that for the criminal. The retail value of the amount needed to be stolen to support the heroin habit of 100,000 addicts could easily be £7.5 billion or more.

The British system involved addicts getting a ration of their drug of addiction from a GP, and in 1967 when this ended, there were 659 notified addicts, compared with the 100,000 estimated now. In Widnes, Merseyside, where the system continues to operate, there is no infection from HIV, no drug-related deaths and a 96% reduction in acquisitive crime [2].

Even more interesting is a 92% reduction in the incidence of addiction.

These are dramatic claims. While not obtained from RCTs, they are certainly worth further detailed attention.

Drugs and driving

Road accidents are a major cause of preventable deaths in younger age groups. Driving under the influence of intoxicating drugs other than alcohol may be an important cause of traffic injuries. Just how important it is in Memphis, Tennessee (population 690,000) has been highlighted by a detailed report in the New England Journal of Medicine [3].

Motorists stopped for careless driving in the USA usually undergo standard field sobriety tests to assess balance and the ability to follow simple instructions, and these, as well as smell of alcohol, can be used as the basis of an arrest. This study did not look at drivers who were primarily suspected of driving under the influence of alcohol, but rather those in which there was some impairment but no overt alcohol use.

These drivers were referred to a mobile 'drug van' (a converted ambulance), where the sobriety tests were repeated and videotaped, and where they were asked to supply a urine sample in a special toilet (possible under Tennessee law), and where the urine sample could be tested for cocaine and marijuana metabolites using a field immunoassay system.

All the drivers had been stopped for reckless driving - more than 20 mph over the speed limit, driving on the wrong side of the road, at high speed through red lights or stop signs, at night without lights, or passing dangerously.

In 46 nights 175 subjects were stopped; 97% were men, predominantly in their late teens to early 30s. Moderate or extreme intoxication was shown by 68%.

Urine samples were obtained from 150, and the results are shown in the figure. Marijuana or cocaine metabolites, or both, were detected at levels of 100 ng/mL or 300 ng/mL, respectively, in 14% of those who had only mild signs of intoxication, compared with 85% in those with moderate or extreme intoxication. Overall, 59% of those tested were positive for these drugs.

The most important comparison given in the paper was that during the period of the study there were 111 arrests for driving under the influence of drugs compared with only six in a comparable period in the previous year - and five of those followed serious accidents.

This was not a study of incidence, but is usual with drug-related incidence studies, objective testing almost always reveals a much higher incidence than previously thought.

It is common for individuals, whether in medicine, education or government, to deny that drug problems exist. Unless that judgement is backed with objective testing, such information is worthless.

The study also highlights a key part of the legalisation debate which has received little attention. Unlike alcohol, psychoactive compounds like cannabinoids can remain in the body for very long periods, and have lingering effects long after the primary `high' has disappeared. So driving, or working, or even being at home with impaired judgement can affect the lives of others. Freeing up drug use is likely to mean tightening up on testing.

References:

  1. J Marks. Drug misuse and social cost. British Journal of Hospital Medicine 1994 52: 65-6.
  2. J Marks. The north wind and the sun. Proceedings of the Royal College of Physicians of Edinburgh 1991 21: 319-27.
  3. D Brookoff, CS Cook, C Williams, CS Mann. Testing reckless drivers for cocaine and marijuana. New England Journal of Medicine 1994 331: 518-22.



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