The U.S. Drug Policy Landscape

Insights and Opportunities for Improving the View

by Beau Kilmer, Jonathan P. Caulkins, Rosalie Liccardo Pacula, Peter Reuter

This Article

RAND Health Quarterly, 2012; 2(3):2

Abstract

Discussions about reducing the harms associated with drug use and antidrug policies are often politicized, infused with questionable data, and unproductive. This article provides an overview of a nonpartisan primer that should be of interest to those who are new to the field of drug policy, as well as those who have been working in the trenches. It begins with an overview of problems and policies related to illegal drugs in the United States, including the nonmedical use of prescription drugs. It then discusses the efficacy of U.S. drug policies and programs, including long-standing issues that deserve additional attention. Next, the article lists the major funders of research and analysis in the area and describes their priorities. By highlighting the issues that receive most of the funding, this discussion identifies where gaps remain. Comparing these needs, old and new, to the current funding patterns suggests eight opportunities to improve understanding of drug problems and drug policies in the United States: (1) sponsor young scholars and strengthen the infrastructure of the field, (2) accelerate the diffusion of good ideas and reliable information to decisionmakers, (3) replicate and evaluate cutting-edge programs in an expedited fashion, (4) support nonpartisan research on marijuana policy, (5) investigate ways to reduce drug-related violence in Mexico and Central America, (6) improve understanding of the markets for diverted pharmaceuticals, (7) help build and sustain comprehensive community prevention efforts, and (8) develop more sensible sentencing policies that reduce the excessive levels of incarceration for drug offenses and address the extreme racial disparities.

For more information, see RAND OP-393-MCF at https://www.rand.org/pubs/occasional_papers/OP393.html

Full Text

Three topics dominate discussions of drug policy in the United States: legalizing marijuana for medical and nonmedical purposes, the violence in Mexico, and the increase in prescription drug abuse. While these issues now capture policymaker and media attention, other important drug-related problems and questions, such as the extraordinarily high levels of incarceration for drug offenses, still need to be considered.

This article provides an overview of a nonpartisan primer on drug use and drug policy in the United States. It aims to bring those new to drug policy up to speed and to suggest where researchers and potential research funders could focus their efforts to make strong contributions to the field.

Overview of Drug Use and Drug Policies in the United States

More than 40 million Americans use cocaine, heroin, marijuana, methamphetamine, hallucinogens, or prescription drugs for nonmedical purposes each year, with roughly half consuming only marijuana. In the last five years, marijuana use—particularly daily use—has increased, and cocaine use has declined. As homicides associated with flagrant street markets for crack have declined, there has been a sharp rise in deaths associated with prescription drugs. A more recent policy challenge involves new substances, often referred to as designer drugs or “legal highs,” because they are—at least initially—not covered by existing prohibitions.

The Obama administration estimated that federal spending on drug control would reach about $26 billion in 2012, divided into prevention, treatment, domestic law enforcement, international law enforcement, and interdiction; the proportion of spending allocated to prevention and treatment has increased since 2008 but remains below one-half. Large amounts of money are also spent by states (e.g., corrections, treatment), local governments (e.g., policing, school-based prevention), and the private sector (e.g., funding media-based prevention campaigns) on policies and programs related to drug use. It is likely that state and local governments spend more on drug control than does the federal government, and that this spending is even more enforcement-oriented than the federal drug budget.

This primer discusses two recent and important changes to U.S. drug policy at the federal level. The first is the passage of the Patient Protection and Affordable Care Act, which is expected to expand insurance coverage to tens of millions of individuals who do not have it now. This will help extend prevention and early intervention services, provide incentives for coordinating primary care, and enhance community-based treatment options. Another change is the federal response to medical marijuana, which is evolving. Federal authorities have never made a priority of targeting patients or their caregivers for simply possessing medical marijuana. What has changed over time has been the federal response to those supplying medical marijuana. Over the last two years, federal prosecutors have stepped up their efforts to shut down dispensaries.

The Efficacy of U.S. Drug Policies and Programs

It has been customary to distinguish four or five categories (“pillars”) of interventions: domestic law enforcement, international supply-side reduction efforts, treatment, prevention, and (outside of the United States) harm reduction. However, this traditional categorization fails in two important respects. First, it imagines that law enforcement is synonymous with supply control, but law enforcement agencies do more than try to reduce drug supply. Second, significant harms revolve around drug markets, and law enforcement is the lead agency for addressing those. Given these issues, this paper distinguishes between supply reduction, management of market harms, treatment, other interventions with dependent users, and prevention.

Based on the available evidence, the authors highlight a number of long-standing topics meriting additional attention, such as being more strategic about the use of incarceration for easily replaced functionaries, expanding nontraditional approaches to dealing with dependence, and improving understanding of the dynamics of drug epidemics to evaluate whether there are “global” lessons or differential experiences.

What Is the Drug Policy Research Funding Landscape, and Where Are the Gaps?

The bulk of drug-related research is sponsored by the National Institutes of Health and, in particular, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. Other government agencies include the Substance Abuse and Mental Health Services Administration, the U.S. Veterans Health Administration, the White House Office of National Drug Control Policy, and the U.S. Department of Justice Office of Justice Programs. For various reasons, little of that funding addresses strategic policy choices.

As a result, foundations have played a major role in drug policy research. The Robert Wood Johnson Foundation remains the largest source of nongovernment support for objective research in the area of drug policy, but its support has decreased since the end of its Substance Abuse Policy Research Program (SAPRP) in 2009. The Open Society Foundations have also been a significant contributor, with an emphasis on projects that support human rights, harm reduction, and the liberalization of drug laws.

Much of the focus has been on biomedical research, with little-to-no funding for big-picture research—either comprehensive evaluations that look at successful ideas and strategies or novel promising approaches, grounded in the understanding that drug problems do not affect every city, every family, or every nation in the same way. Moreover, there are diminishing returns in the areas that have been traditionally studied, compared with the low-hanging fruit that remains in areas that have been neglected. Indeed, largely missing from the landscape is analysis and evaluation of the drug control strategy that has dominated government budgets and rhetoric for decades: law enforcement, both domestic and international. With the end of SAPRP in 2009, there is a need for a new, sustained source for funding of science that objectively and systematically considers overarching policy objectives and/or politically unpopular alternatives.

What Are the Opportunities to Influence the Drug Policy Field?

Comparing the needs, old and new, to the current funding patterns, suggests eight salient opportunities to improve understanding of drug problems and drug policies:

  1. Sponsor young scholars and strengthen the infrastructure of the field.
  2. Accelerate the diffusion of good ideas and reliable information to decisionmakers.
  3. Replicate and evaluate cutting-edge programs in an expedited fashion.
  4. Support nonpartisan research on marijuana policy.
  5. Investigate ways to reduce drug-related violence in Mexico and Central America.
  6. Improve understanding of the markets for diverted pharmaceuticals.
  7. Help build and sustain comprehensive community prevention efforts.
  8. Develop more sensible sentencing policies that reduce the excessive levels of incarceration for drug offenses and address the extreme racial disparities.

This research was sponsored by the John D. and Catherine T. MacArthur Foundation and was conducted within the RAND Drug Policy Research Center, a joint endeavor of RAND Health and RAND Infrastructure, Safety, and Environment.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.