What is “Harm reduction”?

They say the difference between a policy and a crusade is that a policy has to be judged by its results, but a crusade is only judged by how good it makes it supporters feel. On that basis drug prohibition is a successful crusade but a failed policy.

Prohibition of selected drugs has been around for several decades but despite increased efforts and costs it has not managed to achieve its stated goal, to end use of these drugs. Judging by past experience it will never reach it, or even come close. This lack of success is not because we aren’t doing enough. Instead, it’s because we’ve been doing the wrong things. We’ve been doing things that we thought would send messages but otherwise weren’t really very effective. We are not directing our limited resources into the most effective way of handling the problem. We are ignoring evidence of ongoing failure because we would rather not face our taboos.

The simple idea of harm reduction is to do whatever works best, measured by the total amount of harm as its outcome.

The law of unintended consequences

This little story is said to have happend in Eastern Europe. Civil servants were found to be using lots of pencils. It was assumed they were stealing them for personal use at home. The administration decided to put a stop to it. One new pencil was only to be issued if one old pencil stub was returned. To their surprize pencil usage increased even more: Instead of being able to take four new pencils home the civil servants now had to cut up a fifth pencil to make four stubs first. The lesson is that sometimes the attempted solution creates responses that are worse than the original problem. It’s not what we attempt to achieve that matters but what we actually achieve.

Drug law enforcement initially set out to protect people from problems involving drugs by making certain substances legally unavailable. However, enforcement of such drug laws can lead users to switch to other, more dangerous drugs. It leads to huge, uncounted costs to society from criminalisation, from the spread of infectuous diseases by behaviour encouraged by illegality. It expands opportunities for violent criminals. Drug money allows gangs to recruit more criminals. It is their life blood. So much money to be made with things that are illegal will corrupt law enforcement and all security branches of the government. Abusers will shy away from seeking help for fear of getting arrested. Users will lack safety advice and controlled product quality. Black market dealers sell to buyers of all ages, and they often sell many kinds of drugs. Whatever health risks there are from a drug, they will always increase if the drug is banned and in proportion to how hard the law is enforced.

When such things happen, the actual outcome of what was a well-meaning policy leads us away from the goal of protecting society. It has happened many times: During alcohol prohibition in the USA people switched from beer and wine to more easily concealed hard liquor and mafia gangs violently fought over a black market. People died or went blind from bad liquour. When opium smoking was eradicated in South-East Asia it caused a switch to intravenously injected heroin abuse which became a wave that spread HIV and AIDS. Addicts are younger than ever. In Japan where marijuana is treated no different from harder drugs many young people who experiment with drugs do not use less harmful cannabis as in more cannabis-tolerant countries but try far more dangerous solvents or amphetamines because these are more readily available. The harder you try to stop marijuana, the harder the drugs that people will use instead!

In the last decades, an alternative approach to dealing with the drugs problem has gained support in many countries. This approach, called “harm reduction”, does not simply try to reduce drug availability at all costs but also considers the damage done by drug law enforcement and any responses to it by the drug users and sellers. It takes into account the law of unintended consequences.

If total eradication of currrently prohibited drugs is an unrealistic goal then we need to find a way to live with the availability of drugs, striving to minimize harm caused by both drug use itself and by the direct and indirect effects of our policies meant to discourage drug use. Just like doctors who often have to prescribe medicines that can have undesireable side effects, we have to weigh the benefit of different “treatments” for the “disease” versus the potential harm from these “treatments” so as to pick one policy that offers the greatest amount of benefit at the least damage to society.

Harm reduction is not just a theory. It has been put into practise by the Dutch government and parliament since 1976. The Dutch can buy cannabis in coffee shops. Decriminalisation has not lead to increased drug use. Problems with hard drugs are much lower than in France or Germany. The Dutch economy is the most productive in Europe.

Harm reduction and marijuana

Some might say, even if alcohol and nicotine cause significant health damage, that is no argument to legalise marijuana. “We have enough problems with two legal drugs, we don’t need another one.” According to this thinking, if marijuana were made legal again, more people would use it and the harm from increased marijuana use would come in addition to existing harm from legal drugs and this should be prevented at any cost. Though this argument sounds plausible at first, there really are many problems with it, since it ignores many important aspects of the situation:

1. It doesn’t matter how many different legal substances are available, what matters is how to minimize harm from them. It makes no sense to coerce people to use more harmful drugs instead of letting them use less harmful ones, no matter which one is used by more people already.

2. If one really believes that total prohibition and jails are the best way to prevent abuse and one recognizes that alcohol is one of the most frequently abused drugs then one would have to argue that being found in possession of alcohol should put you into jail. Yet nobody is arguing for alcohol prohibition, because the USA tried it and it didn’t work.
3. Laws that seek to control availability through prohibition are misguided and ineffective. Availability is not really the decisive factor in drug use since rising demand will lead to higher prices which usually attract more suppliers, as economics Nobel prize winner Milton Friedman has long pointed out. As long as there is enough demand for drugs availability will always catch up, no matter what new laws we pass.
4. In a free country prohibition could never wipe out the use of prohibited substances, since prohibition-inflated prices will always attract criminals looking for easy profits. As borders are crossed, prices go up more than a 100 times. It is estimated that if the government of Mexico could intercept 50% of all cocaine this would only increase drug prices in the USA by 3%. An intercept rate of 50% is impossible to achieve. Law enforcement usually intercepts less than a tenth of the drugs that are produced or smuggled into a country while over 90% of the drugs reach the profitable black market, earning criminals a fortune. 8% of all world trade dollars are made on illegal drugs, bigger than all the car exports. We know from experience that alcohol prohibition did not stop Americans from drinking, but it created a rich source of income to violent gangsters such as Al Capone.
5. A single marijuana plant produces enough seeds to grow thousands of new plants. It is as easy to grow as maize (corn) or tomatoes and yet in Japan it usually sells for twice the price of gold. It doesn’t matter how illegal this plant has become, as long as illegal marijuana production is so easy and profitable it will be impossible to stop, no matter how much tax payer’s money is spent on arresting users. Even after 53 years of cannabis prohibition, the plant grows wild in many parts of the country, as it has done for thousands of years.
6. If we want to to discourage excessive marijuana use or use by adolescents we don’t have to make it illegal, we can simply make it expensive. Rising tobacco taxes have motivated many a cigarette smoker to give up smoking, and marijuana is less addictive than tobacco. The government could sell marijuana in licensed stores (not supermarkets) and tax it like it taxes beer and cigarettes. It could sell grow licences for personal use to adults. This would also make available more money for drug treatment and health education, paid for by drug users and not by other taxpayers.
7. People who are really interested in drugs other than alcohol and nicotine will go ahead and try them, whether they are prohibited or not. This is especially true for young people who are naturally curious and not as capable of judging the legal risks as well as older people are. Punishing those who are only experimenting with a drug and who would mostly grow out of it very soon is counterproductive, especially when the direct health risks of the drug are as moderate as in the case of marijuana.
8. It is questionable if legalisation would lead to any significant increase in use. If prohibition worked then the Netherlands, where cannabis use has been tolerated by the police for almost a quarter of a century (since 1976), should have higher rates of use than next-door Germany or America. This is not the case. Use rates amongst the Dutch are similar to rates amongst Germans. In the USA, where some people serve lifes sentences without possibility of parole for growing marijuana, the rate of use is 6.4% versus only 3% in the more tolerant Netherlands. That’s because the Dutch spend more of their drug policy money on health-care based policies that work and not on police and prisons that are ineffective.
9. Drug use is affected far more by social attitudes, fashions and information than by laws. Marijuana use is relatively low in Japan not because it’s illegal but primarily because most people still think it is an addictive narcotic like opium or heroin. As more people discover that this is not the case use will probably rise (as it has been gradually rising for over 30 years), whether marijuana is legalised or not. Japanese marijuana seizures increased six-fold from 1998 to 1999. Drug laws don’t control use, they react to it. The end of alcohol prohibition in the USA was preceeded by 13 years of rising illegal alcohol use. It is likely that before marijuana is legalised or tolerated in Japan again its use would already have stabilized at the rate at which it which it will be consumed without criminal penalties.
10. A drug policy that keeps marijuana illegal can not talk honestly about the risks of nicotine and alcohol, for fear of either showing the risks from marijuana as benign by comparison or exposing its own hypocrisy. Legalisation is a chance to better treat or drug problems #1 and #2, nicotine and alcohol. Legalisation will not happen without public debates about the risks of all drugs. This will make people more aware of the abuse potential and harm from currently legal drugs. We would have a chance to explain that “legal” is not the same as “harmless”. Even if marijuana use were to become more common after legalisation, the most likely side-effect of that would be a drop in alcohol and tobacco consumption as people become aware that these are also drugs that carry risks.
11. Not only would people be more careful with the currently legal drugs, they would also have less incentive to use them as much. People smoke fewer joints than cigarettes and can’t handle much alcohol when they smoke cannabis. Many cannabis users virtually give up alcohol altogether. In many societies where cannabis use is common (such as the Brahmins of India, Islamic societies and amongst the Rastafarians of Jamaica) alcohol is either banned or frowned upon. Since alcohol abuse is far more harmful to people’s health than excessive marijuana use the net result of this switch would be beneficial.
12. Tough laws and propaganda against cannabis encourage abuse of other, far more harmful drugs. By making marijuana available through legally tolerated sales outlets where minimum age laws can be enforced, people who want to try the drug will no longer need to enter an unregulated black market where gangsters will try to sell hard drugs to customers of all ages. If young people in Japan were honestly informed that solvents are far more toxic than marijuana and that stimulant drugs such as amphetamines are far more addictive and harmful than marijuana and if marijuana was available without fear of prosecution then this could help reduce the widespread abuse of easily obtained solvents (which cause brain damage) and of dangerous stimulant drugs.
13. Even if legal marijuana would not reduce harm from other legal or illegal drugs, prohibition itself causes harm. Users who get caught lose their freedom, their jobs and their incomes. Jailed users don’t pay taxes but instead have to be guarded, housed and fed at taxpayers’ expenses. Prisoners in the USA cost between $20,000-$100,000 per year to house and feed (¥2,300,000-11,500,000), more than studying at the best universities of the country. Jailing people is one of the most expensive ways of dealing with a problem, which is why it should be reserved for the more serious crimes. Giving young people a criminal record for drugs does far more damage to their future careers than the experimental drug use itself normally would.
14. The amount of money we can spend on a drugs policy is limited. We should spend it on something that actually works. The drug war doesn’t work. You can not solve a public health problem using criminal law enforcment. There is no evidence that prohibition is a cost effective method of limiting or reducing drug-related damage.
    • The USA boosted its federal drug prohibition budget from $65 million in 1969 to $1 billion in 1980, to $17 billion in 1998, with virtually no impact on drug use, which fell and rose independently. Even though over last few years arrest rates went up in both the USA and Japan, hard drugs have become cheaper in both countries. [1]

    • If we want to solve this problem we need to concentrate our resources where they are most needed. Cannabis is not physically addictive. Few users develop a psychological dependence. There are fewer problem users amongst cannabis users than amongst users of legal drugs. We should target our resources not on specific substances but on specific people. First we should make accurate information available. Most people avoid bad risks if they are given enough information. To those who still run into health or other problems we should then offer help, whether they abuse alcohol, methamphetamine, nicotine or even cannabis. Chances are, if all the effects of drug abuse were out in the open, it would encourage people to be more careful and it would make it easier for those who need help to get help.

What can we do about drug abuse?

If drug use is increasing then that is for a number of factors, such as changing values, cultural influences, personal experiences in people’s lives. Drug use is just a symptom of other causes, some of which are very difficult to address. It should not surprize us that attempts to treat the symptoms have little effect when the root causes are left untreated.

Our modern consumer society encourages materialism, stress, fast-paced lives, intense competition and it leads to a loss of traditional values and of religion. However, many of the changes have positive effects too and in any case are difficult if not impossible to undo.

When people look for explanations to difficult problems, especially problems that they have no first hand knowledge of, then it is easier to find an excuse, a scape goat to blame the problem on. In medieval Europe epidemics were blamed on the Jews and all sorts of evil was blamed on “witches” who were burnt alive. Nowadays it’s much easier to blame plants or chemicals than to think about the way we work, raise our children and how we entertain ourselves and then to change the way we live. That’s why drugs have become such a convenient scapegoat for the evils of society all over the world. The existence of drugs is an excuse for not fixing the real problems, and as long as people are afraid they will give up more of their freedoms.

It is part of human nature to seek altered states of consciousness, either through drugs, sex, physical activity or religion. As long as there is pain, boredom or curiosity there will also be drugs. We should accept that as a fact rather than seeking a drug free utopia.

Total prohibition of virtually all drugs other than alcohol and tobacco is not the least harmful drug policy because it ignores the individual properties of each legal or illegal drug, the frequency at which they are used and the damage done by enforcement.

1. We should recognize the difference between use and abuse, appropriate and inapropriate settings, adolescent and adult use and less harmful or more harmful drugs. We need a more intelligent drug policy that considers more than just the chemistry of a substance.
2. We should regulate various drugs (including alcohol and tobacco) in appropriate ways so as to minimize harm. What works for cannabis may not work for amphetamines, cocaine or heroin. Different approaches may be needed for different drugs. Being afraid of legalising harder drugs is no good reason to keep arresting marijuana users who hurt no one.
3. We need a policy that’s based on science and facts, not prejudice and lies. The tolerant Dutch approach is a better model to follow than the American policy of “zero tolerance”, which is just another word for intolerance.

Here is some information about specific drugs in Japan:

Marijuana:
The “Hemp in Japan” library
How many marijuana users are there in Japan?
How expensive is marijuana in Japan?
The Hemp Control Law

Other drugs:
Alcohol
Nicotine (Tobacco)
Amphetamines (Speed)
Caffeine (Coffee)
OGD report 1997/98 on Japan

[1] “While the federal budget to fight drugs went from one and a half billion dollars a year up to 16 billion dollars a year, the price of one gram of pure cocaine fell from $300 in 1981 to $100 in 1997. For heroin the price fell from $3,500 to $1,100.”

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See also:
Hemp in religion, for fibre, food and fuel, as medicine
Marijuana prices in Japan, How many users, The Hemp Control Law