The 1960s, 1970s, and 1980s were periods of dramatic change in drug use: the spread of marijuana, the heroin epidemic, the explosion in cocaine initiation in the 1970s, and the spread of crack and street markets in the 1980s. By comparison, the last 10 to 15 years have seen few dramatic developments. America's drug problem has settled, superficially at least, into a time of stability or, at most, predictable change: Usage has been steady or down some, initiation has rebounded, but there has been nothing as dramatic as the propagation of the cocaine epidemic. This stability in drug problems is mirrored by an even longer-standing stability in drug policy, in which America's primary response to illicit-drug use has been an emphasis on enforcement and punishment.
Together, stability in problems and in policy has fostered inattention to the future. This inattention is reinforced by the lack of vested interests in the future of drug policy and problems. Politicians have short time horizons, and researchers write only about what they are sure of, so they say little about the future. Importantly, in the illicit-drug arena there is no legitimate industry to support the bevy of consultants who generate alternative futures in other policy domains, e.g., defense, energy, transportation.
A focus on the present may be proper if drug problems and policy are static over the long term, but they are not. The stability of the past decade or more is an exception. Epidemics of drug use in the United States occurred not only in the 1960s, 1970s, and 1980s, but also as far back as the late 19th century. American drug policy was quite different a hundred years ago, and in recent years it has changed rapidly in other developed countries.
Are there reasons to think drug problems and policy could change rapidly again over the next 5 to 20 years? We believe so. In this issue paper, we lay out some reasons behind our belief and its implications for current policy.
The following is based on the deliberations of a colloquium, "Drug Use and Drug Policy Futures," held at RAND in August 2002. The colloquium was attended by scholars from RAND and other institutions. It was supported with discretionary funds provided to the Drug Policy Research Center by The Ford Foundation.
Why might we expect drug problems and policy to be quite different in the future from what they are now? We break the reasons into three categories:
- "Drivers," or factors influencing drug problems and policy, which could grow stronger or weaker.
- Assumptions about the future context that could fail.
- "Wild cards," or unexpected developments that could change the course of problems and policy.
Naturally, there are many such drivers, assumptions, and wild cards, and many were discussed over the course of the colloquium. Those presented here were selected by colloquium participants as significant, plausible, and representative of a range of types of influence on drug use.
Note that in the following we are not attempting to forecast any one specific drug problem or policy future as the most likely. We show, instead, that there is a range of possibilities that may represent departures from current trends. Note also that, in the case of policy changes, we take no position concerning whether such changes are desirable but merely seek to argue that the future may be more fluid than the recent past.
Many factors influencing drug problems and policy could grow stronger or weaker in the coming years and drive problems and policy off their current course. We focus here on long-standing factors external to drug use that shape key aspects of drug use and related problems, factors whose future course seems reasonably predictable but whose effects on drug use are uncertain or underappreciated. These factors include the following:
Moral Codes of Conduct. The last 40 years have been marked by a shift from absolutist, religiously inspired moral codes of conduct to individualist, relativist, secular values. This shift has influenced virtually every aspect of policy related to the government's role as moral arbiter; these include rules about sexual behavior, abortion, and gambling. The shift has not extended so dramatically to illicit-drug policy, at least not yet. Drug policy and problems are likely to be strongly affected by how long the exception regarding drugs holds out.
Cigarette smokers are more likely to use marijuana than nonsmokers. If that relationship reflects causality and not just coincidence, and if tobacco use keeps falling, marijuana use could also fall.
Licit-Substance Use Trends. Trends in the use of licit substances may affect the use of illicit drugs. For example, tobacco use has been decreasing as cigarette prices, stigma, and legal restrictions on use have risen. Cigarette smokers are more likely to use marijuana than are nonsmokers. If that relationship reflects causality and not just coincidence, and if tobacco use keeps falling, marijuana use could also fall. Likewise, it is worth noting the illicit use of licit substances like oxycodone. Such use is a large and growing part of the illicit-drug use problem in the United States.
The Influence of Interest Groups. The evolution of drug policy can be influenced by the political acumen (or inexperience) of interest groups. The movement for the reform of drug laws has long been marginalized but has recently become more organized and effective. As the movement has focused on medical-marijuana use, it has drawn more support, including major financial contributions. With the latter have come greater organizational strength and the potential for subsequent influence on policy formation beyond the medical-marijuana issue.
Illicit Drug Experience Among the Voting Populace. Both the electorate and its chosen leaders are becoming more experienced with illicit drugs as the years pass. People born after 1945 went through young adulthood during a time in which illicit-drug use was much more common and accepted than did people born before 1940. As time goes on, the former group becomes a larger proportion of the body politic. That proportion has now reached a majority of the voting population. The consequences of this are difficult to predict, but the result could be policies that differentiate more between different substances.
State Versus Federal Laws. The 50 states provide a diverse testing ground for different policies, and some have already shown willingness to experiment with drug policy, as with medical-marijuana policy in California and Arizona. This experimentation creates tension between the federal government and the innovating states. At some point, a case pitting federal control against state prerogatives may come before the U.S. Supreme Court, and it is plausible that the decision will have significant consequences for subsequent drug policy.
Counterterrorism's Effects. The war on terrorism could influence the implementation of drug policies and trends in drug use. Further terrorist attacks might increase the stigmatization associated with drug use if the attacks were linked to the drug trade. Greater attention to border control has reportedly increased the quantity of drugs interdicted, but large reassignments of law enforcement and Coast Guard resources to counterterrorist duties (e.g., moving agents to the Canadian border) may take a toll on enforcement pressure against drug traffickers.
The Globalization of Trade. Powerful economic factors have been working in directions opposite to the tighter borders suggested by the war on terrorism. The globalization of trade has contributed to the availability of drugs and complicated their control. Lower customs barriers mean easier smuggling, and drugs are no exception to globalization's worldwide diversification of markets; more drugs are more globally available than was the case 20 years ago, and that trend can be expected to continue.
Associations with Violent Crime. In the United States, violent crime has been associated with drug use, both in the minds of the public and in reality. The clearest instance of this connection was the simultaneous increase in the violent-crime rate and the explosion of the crack epidemic between the mid-1980s and the early 1990s. The reduction of violent crime since then has made it easier to talk about alternatives to the criminal justice approach to drug policy. The violent-crime rate is likely to rebound at some point. If it does so at the same time that "softer" approaches to drug policy are being implemented, there could be a backlash against such approaches, regardless of the true cause of the crime increase.
Maintained Assumptions That Are Vulnerable to Challenge
Drug problems and policy can track a familiar course over the next 5 to 20 years only if certain assumptions supporting the current trends are maintained. Some of those assumptions seem safe, such as a belief that the volume of legitimate cross-border trade will continue to be very large relative to drug smuggling, making it difficult to "seal the borders." The drivers discussed above would generally fall into the "safe" category if restated as assumptions, e.g., "Violent crime will continue to be associated with drug use." Colloquium participants judged other assumptions that have been valid in the past to be more vulnerable to reversal, or at least more vulnerable than is commonly assumed. These vulnerable assumptions, phrased as questions, include the following:
If ecstasy prices drop or if methamphetamine use in the eastern United States catches up to levels in the Southwest, the United States will face the contagious spread of an important drug, with consequent stresses on the enforcement and treatment systems.
Will the Current "Big Three" Illicit Drugs Continue to Dominate Drug Problems? Cocaine, heroin, and marijuana have collectively accounted for most illicit-drug use in the United States, and most of the associated addiction, morbidity, mortality, and crime. Even today, despite so much concern about ecstasy and methamphetamine, the big three are thought to account for close to 90 percent of spending on illicit drugs. Yet ecstasy prices will probably drop, very possibly triggering expanded use. Likewise, if methamphetamine use in the eastern United States catches up to levels in the Southwest, that drug could at the national level surpass heroin as a generator of use, crime, and spending. To the extent that either occurs, the United States will face the contagious spread of an important drug (as opposed to the current endemic status of the big three), with consequent stresses on the enforcement and treatment systems.
Will Policy Continue to Treat Different Illegal Drugs Much the Same? The most obvious candidate for differential treatment is marijuana. While laws against using and particularly selling marijuana are strict in most jurisdictions, enforcement in many has been more lax than that for other drugs. Medical-marijuana laws may be the foot in the door toward codifying that distinction. Several of the drivers listed above could push policy further toward differentiation. If that happens, will marijuana be uniquely distinguished from the common, expensive, "hard" drugs (cocaine, heroin, and methamphetamine), or will exceptions be made for other substances too?
Will Expanded Investment in Drug Treatment Continue to Be Unpopular? Treatment's low status among politically favored remedies to the drug problem is partly the result of a prevailing tacit perception that it doesn't work. A strong effectiveness argument cannot be made to counter the moralist contention that providing treatment simply grants favors to criminals. There is reason to believe, however, that treatment's performance may improve. There seems to be something of a trend among treatment providers from a social welfare paradigm to a health care model. Concomitantly, pressure to adopt evidence-based practices has been growing. As a result, the provider community is becoming more professionalized; as that proceeds, the prospects for shifting addiction treatment into the medical mainstream will get brighter. Should treatment quality improve, its political support could increase as well. Indeed, there has been increasing political support for treating substance abuse as a chronic disease instead of as (or as well as) a crime reflecting moral failure.
Will Political Support for Strict Prohibition Among the Public at Large Remain Stable? This assumption may fail if credible options to the current regime are developed and publicized. Indeed, both the medical-marijuana initiatives and public-opinion polls suggest that the public attitude toward drug policy is considerably more nuanced than are the statements of most politicians, at least at the federal level. Conventional wisdom holds that nuance does not play well on television and that hard-on-drugs sound bites are less risky than soft. Conceivably that could change, at least in some states.
Will Racial and Ethnic Minorities Remain Divided on the Question of Strictness? The drug war has been fought predominantly in minority communities, where sentiments have been mixed. There have been support for enforcement against street corner drug sellers and calls for greater police attention to such crimes. There have also, in some quarters, been resistance to methadone maintenance and support for approaches based on abstinence only. However, there is also resentment over the number of minorities incarcerated on drug offenses, a number greatly disproportionate to their use of drugs. It is difficult to say how far the sentencing disproportionality can be pushed before it results in a collapse of minority support for antidrug efforts. The situation is not helped by a number of regulations and laws making educational, welfare, housing, and other benefits less available to former drug offenders and their families.
Will Incarceration (or the Threat Thereof) Continue as the Mainstay of Prohibition? Some alternative policies have been implemented, e.g., drug courts and California's Proposition 36, which mandates treatment for persons convicted of simple use or possession. But drug courts can process only a small fraction of drug offenders, and it is too early to evaluate the success of the new California law. One interesting potential innovation goes under the rubric of "coerced abstinence." Under this scheme, probationers and parolees would be required to stay clean or face a progressively harsher series of penalties. How they stayed off drugs would be up to them, but presumably, demand for treatment would increase. The current incarceration-focused system is in all likelihood operating beyond the point of diminishing returns, so some carefully thought-out variations might reduce drug use at lower government cost. The success of any such variation in one jurisdiction could encourage others to experiment or imitate.
If the drug future is to resemble the present, it must be tacitly presumed that the broader world of the future will look much like the present one. This is unlikely to be the case, particularly in technological terms. It is very hard to predict what specific changes will occur, but it is relatively safe to predict that some kind of change will occur. We use the term "wild cards" for these low-probability, high-consequence developments and offer a few plausible examples to illustrate the concept.
It is possible that a scientific breakthrough will result in a treatment model that is dramatically more effective than those currently employed or contemplated. In that case, policy could shift from a focus on addiction to a focus on intoxication.
Developments in Neuroscience. It seems almost certain that over the next two decades there will be dramatic developments in neuroscience, including not just passive understanding but also the ability to engineer different drugs and interactions between drugs and the brain. What, if any, implications this will have for illicit-drug use, control, or policy is hard to forecast. It is possible, however, that a scientific breakthrough will result in a treatment model, perhaps one based on medication, that is dramatically more effective than those currently employed or contemplated. In that case, policy could shift from a focus on addiction to a focus on intoxication. It is also possible, however, that it is the manufacturers of illicit drugs who will be able to profit from research. New drugs may be invented that will mimic the benefits of current ones without their dangers, at least in the short run.
A Celebrity Incident. In the 1980s, Len Bias's death focused public attention on the perils of cocaine and may have convinced many people who would otherwise have tried cocaine not to do so. Ecstasy has been enjoying a reputation as a "soft" drug much the way cocaine did in the 1970s, when cocaine initiation was high and growing. An overdose death of a celebrity such as a pop star from a club drug could change that, possibly with significant effect on initiation. Conversely, an equally well-known individual (or his or her child) could suffer grievous harm from enforcement action against what proved to be minor drug offenses (e.g., he or she, while in jail for a simple possession charge, could be raped by an individual infected with HIV). In such a case, public support for a more nuanced drug policy could crystallize in a way that politicians could not ignore.
An Epidemic of a Performance-Enhancing Drug. Some currently illicit drugs first spread as legal substances with one or more purported benefits besides euphoria. Indeed, in some cases the substances did in fact bring real benefits. However, these drugs were subsequently banned when use led to abuse or adverse side effects were discovered. This could happen again. That is, it is not only currently illicit drugs such as ecstasy and methamphetamine that might emerge as problem drugs of the future. It could also be some current or yet-to-be-invented drug that is intended to help people improve memory, lose weight, or treat attention deficit disorder, depression, or some other mental or behavioral condition. The case of Viagra® shows how quickly the use of performance-enhancing drugs can spread, and there are any number of instances of drugs that have been approved by the FDA but subsequently discovered to have adverse side effects.
Technological Progress in Drug Testing. A means of testing may be developed that is cheap, quick, and not as intrusive as urine sampling. What if, for example, the presence of drugs could be determined through a patch placed on the arm for a few minutes? What if the patch simultaneously tested for other health indicators? Such a diagnostic tool might prove difficult for parents to resist. It might also break down some of the resistance on privacy grounds to widespread drug testing, e.g., as part of routine physical exams. This could affect not only drug use, but also drug policy inasmuch as it might shift some sanctioning activity from the criminal justice system to parents, employers, coaches, and other screeners.
It is worth bearing in mind while considering technological advances that they must not only be made in the laboratory but implemented in society. If policies (or jurisdictional turf defenses) do not promote implementation or work to discourage it, any benefits will remain theoretical. It is possible, for example, that much more effective treatment for addiction might encounter objections on moral grounds in some quarters, e.g., that alleviating the curse of addiction could make it harder to resist the temptation to indulge in intoxication. A similar argument has been quite effective in greatly limiting the establishment of policies favoring, or even allowing, needle exchange.
Implications for Today
The colloquium demonstrated that a semistructured approach to thinking about the future of drug problems and policy could yield some interesting alternative visions. These visions and the approach generating them have implications for current policy. Put another way, current decisions regarding drug policy should be informed by a broad range of possible futures. It was not part of this exercise to infer a comprehensive set of policy implications from the futures envisioned, but we briefly describe here the different types of implications that might be drawn and some examples illustrating their importance.
To begin, recognizing the approach of pleasant surprises cannot hurt, and predicting the advent of unpleasant ones can only help. The latter, in particular, could focus attention on elements of drug policy or other influences that, if addressed now, could reduce the chances of an unwanted turn of events. For example, prevention might receive greater investment today if a future epidemic of some new drug were judged more likely than a slow decay to endemic levels of the current drugs. It might be wise to change prevailing prevention messages if it was believed that a "performance-enhancing drug gone bad" were a significant risk.
The value of futures analysis, however, is not limited to the avoidance of unpleasant surprises. By playing out specific scenarios to their ultimate consequences, policymakers could also identify complex issues that will arise whose eventual resolution could benefit from immediate attention. For instance, predictions of coming conflict between state and federal laws suggest initiating now a comprehensive discussion of federalism vis-à-vis drug policy, rather than doing so piecemeal as individual aspects of this issue are raised in the courts.
Another good example brought up above is the possibility that policy will no longer continue to treat all drugs the same. We ask whether, in the event of more tolerance of marijuana use, drugs in the "middle" between marijuana and the obviously hard three (cocaine, heroin, and methamphetamine) will be classed as soft or hard. This is not an academic question. It has important implications for enforcement costs and for the course of future drug use and harms. Now is the time to start thinking about whether mescaline, ecstasy, or peyote should be treated more like marijuana or cocaine in the event that popular pressure forces a sharper distinction between marijuana and cocaine policy. Otherwise, the classification of mescaline and other drugs could be based on politics instead of on a careful assessment of the harms caused by the drugs and by enforcement of laws restricting their use.
The benefits of a look into the future could also accrue to politicians and interest groups holding particular views on drug policy. To the extent that the drug reform movement is gaining strength by focusing on medical marijuana, hard-liners may wish to cede some ground on that issue. Doing so could undermine the accumulation of political and organizational capital that could subsequently be focused on lifting sanctions for recreational use. Similar logic could be applied to mandatory minimum sentences that have racially disparate impact. Conversely, if one thought that an adverse celebrity incident with marijuana were inevitable, it might make sense to fight to keep strict prohibition in place, rather than retreat to a less rigid but more defensible fallback position.
These few examples suggest that the approach to futures analysis taken in the RAND colloquium could be of real value in reviewing current drug policy. Thus, inferring a comprehensive set of policy implications from the futures envisioned here would be a useful next step. More generally, the examples offered here suggest that everyone could be better off in the long run if the time and attention devoted to analyzing past trends and the current situation were supplemented by more formal attention to the future.