A long history of drug tolerance

In his talk, he began by sketching the history of drug regulation, pointing out that just a hundred years ago, in the 19th Century, psycho-active drugs were legal in almost all countries. These would include opium and related opiates, coca and, cannabis (also called ganja and marijuana), just like tobacco and alcohol. The situation existing then was in fact quite typical of the long history, where for thousands of years, some psycho-active drugs even had religious significance.

"In the 19th century, the biggest users of opiates in the United States were middle-aged white women," Nadelmann pointed out. All kinds of formulations were available from the local drug store, widely recommended by doctors for variety of ailments. "Even when some individuals showed that health problems could surface through overuse, nobody thought to make it illegal."

Up to the turn of the century, the popular fizzy drink Coca-Cola contained coca in its recipe.

What propelled the change in attitudes from then to now? There is the assumption, Nadelmann said, that there is a logical basis why tobacco and alcohol are legal while other drugs are not. However, if one looks hard at the history, there is a virtual absence of scientific information behind the adoption of prohibition. "The answer has to do NOT with what effects the prohibited drugs had, but with WHO used these drugs."

"The first anti-opium laws emerged in Nevada in the 1870s and 80s, and were directed specifically at Chinese migrants." Large numbers of Chinese labourers were brought into the Western United States during that period to build the trans-continental railways, following the California Gold Rush (which also attracted a lot of Chinese). They used to work 70-80 hours of back-breaking labour a week, and on their day off, would relax with opium.

There was lurid panic about the spread of opium dens and the fear of white women being seduced into them. Coupled with the fear of "yellow hordes" invading the United States, the anti-opium laws were an indirect measure to keep migrants under control.

The first anti-cocaine laws in the US emerged in the South. Afro-American men were the main users of cocaine, and this bred the fear among the Whites of their former slaves losing control: "And what will become of our white women???"

Likewise, the first anti-cannabis (marijuana) laws were directed against Mexican migrants in the Southwest.

Even the infamous attempt to prohibit alcohol in the 1920s followed the same pattern, borne out of ethnic prejudice by what Nadelmann called the "White White Americans" (those descended from English and Northern European stock) who were the earlier migrants to America, against the "Not-so-White Europeans" mainly from Italy and Greece who were flooding into the US at the time. The Southern Europeans brought a wine-drinking culture. The sudden interest in banning alcohol reflected fears of "what's happening to the character of our country?"

 
Opium in Asia

Crossing the Pacific to Asia, the chief drug issue in the 19th and early 20th centuries was that of opium use in China and among migrant Chinese communities in other countries.

"But when you look at India at the same time," said Nadelmann, "opium was used as pervasively as in China, yet it was not regarded as a problem."

What made opium a problem for the Chinese government and intelligentsia therefore was more political than social. Opium represented enslavement by Britain. The Chinese saw it as a means by European powers to weaken Chinese society. "It was, and remains, a national nightmare."

The difference in attitudes between India and China towards opium is analogous to how Northern and Southern Europeans see alcohol today. The Scandinavian countries see alcohol as a scourge and take a highly moralistic tone towards it, while the Southern Europeans celebrate "vino" culture.

The politics of opium was further stoked by the involvement of the US in Asia. It goaded the Chinese government over it, seeing it as a way to undercut the influence of the British. It was also in line with the character of US foreign policy, to take a missionary approach to many international issues.

Interestingly, it was opium use that today offers nuggets of data. Nadelmann cited a study about the effects of prohibition – I believe he mentioned that the data came from the then US-administered Philippines – that showed what results from prohibition.

Before the new law took effect, there was an opium licensing system where opium dens could operate in a regulated way (Colonial Singapore had such a system too). After this was abolished and opium totally criminalised, two effects could be seen: firstly, there was a reduction of older people smoking opium; secondly, after a few years, there was a jump in heroin production and consumption, especially among young people.

I didn't fully catch the follow-on sentences by Nadelmann on these, but I believe he explained that the reason why that happened was that a ban made it imperative to concentrate the product into a small, but highly potent form, making it easier to transport. A purer form of the product in turn increased the likelihood of abuse. Illegality also created a black market with its cash windfall to invest in production and distribution.

I believe Nadelmann's point was that where social problems had been relatively mild and contained, it soon went out of control.

In the second part of his talk, Nadelmann described the current situation, with special reference to the differences in approach among countries. The US, he said "is far and away the leading incarcerator in the world" with about half a million people behind bars for violating a drug law. Each year, some 2 million people are arrested for this reason and in some cities, 50 percent of Black men have been through the criminal justice system.

The US takes a punitive approach, with almost total reliance on policing to deal with the problem. Worldwide, this approach would have been the dominant one about 2 decades ago, and it certainly resembles the case in Singapore. In fact, Singapore is even more extreme, using the death penalty, whereas in the US, almost no one is executed for drug offences.

A poppy field in Afghanisation. The country is probably the leading source of heroin worldwide

 
From the 1980s on, there has been a new direction. Led by the Netherlands and other European countries, it is health-driven, focussed on reducing personal and social harm rather than eradication -- the "harm reduction strategy". Worldwide, this could now be said to be the main approach and in that sense, Singapore is a far outlier.

With heroin, the response has been to offer methadone as replacement and to set up needle-exchange programs to reduce infection risks. There has also been a move towards removing laws against retail and possession with respect to soft drugs.

The World Health Organisation, Nadelmann said, did a 19-country assessment of coca and cocaine in the 1990s.Its conclusion was that chewing coca leaf (a traditional practice among Andean highlanders) had no identifiable health consequences; in fact the coca leaf provided vitamins. As well, the large majority of cocaine users do not become addicted to it. But guess what happened? The US forced the WHO to suppress the report.

Coming back to methadone replacement for heroin, Nadelmann argued that it is analogous to using a nicotine patch for smokers. The health consequences of nicotine itself is minimal, except perhaps on the cardio-vascular system. The health downside of smoking comes from inhaling all the other substances associated with cigarettes.

Like a nicotine patch or nicotine gum, with methadone, one may remain dependent on it, but it does not cause damage to the heart, lungs, etc that heroin does. More importantly, these persons are able to function in society, holding jobs, etc. Nadelmann pointed out that a methadone user cannot be told apart in a crowd.

At the same time, legalised methadone removes the black market problem.

Better yet, for some people, methadone, like a nicotine patch, can represent a way to gradually ending dependency on the drug. People may not succeed at the first try, but some persist and eventually do.

Today, this harm reduction approach is spreading across many countries. Nadelmann observed with surprise that a senior official in China told him that the country's aim was to have 500,000 people in methadone programs. In Iran, an ayatollah in the Ministry of Justice issued a fatwa 4 years ago permitting methadone and needle exchange. Malaysia too has a methadone program and similar steps are being taken in India, Indonesia and Central Asia.

This approach is missing in Korea, Singapore and Philippines (Note by Yawning Bread: It struck me that these are the 3 Asian countries most strongly influenced by moralistic American Christianity)

 
The threat of HIV

The harm reduction approach is relatively new to Asia. Five years ago, no one would want to talk about it. The chief reason why people are now taking it seriously, he said, is due to the threat of Aids, since one of the leading routes for HIV infection is the sharing of needles.

A new report by the World Health Organisation released this week put the total number of people living with HIV/Aids worldwide at 33 million. While two-thirds are in Subsaharan countries, some one-fifth are in Asia.

About one-half of injecting drug users (IDUs) are also found in Asia. IDU accounts for nearly half of all new HIV infections on this continent. That's how connected the drug policy issue is with HIV.

If you look at HIV registers, said Nadelmann, some 44 percent of HIV-positive cases in China are IDU. The figures for Vietnam, Indonesia and Malaysia are 52, 54 and 72 percent respectively.

His point was that the threat of HIV magnifies the problems of drug abuse. If a policy of punitive eradication is not working, but instead driving the drug problem underground, it is time to switch course.

 
Question time

During question time, someone who, from the sound of his question appeared to be from the Central Narcotics Bureau, pointed out that Singapore had tried a drug-replacement program with Subutex. In the end, drug users abused it and doctors were sucked into a web of corruption.

Nadelmann replied by saying that much depends on the design and execution of a drug replacement program. Some work badly, and some work well. He didn't elaborate on what would distinguish the two.

He also pointed out that even if, under a punitive regime, "we catch and imprison every drug user, the recidivism rate is very high." In contrast, methadone replacement is sustainable in the longer term, and delivers economically productive people.

I asked two questions.

The first was whether in a country like Singapore where the drug problem was already relatively small, albeit due to measures that are highly punitive and therefore morally troubling, would it make any sense to adopt a softer strategy? Wouldn't drug use increase as a result of a change in strategy?

Nadelmann said the experience of Australia suggested that any increase would be minimal. When Australia changed to a harm reduction strategy, IDUs were well under 1 percent. The new strategy has not seen increased abuse; at the same time, it delivered many social and health benefits. This is in addition to sidelining the protection rackets and the black market and all the harmful social effects of underground money sloshing about.

The Swiss did a cost benefit analysis of a heroin prescription trial, and they found it quite positive too.

He asked whether our fears might be analogous to objections against sex education. Some people argue that providing sex education increases sexual activity among teenagers. But where's the evidence? In contrast, what evidence there is, relates to the harm reduction that sex education provides.

Another example of how the punitive approach may be blindsided was that fact-wise, cannabis is less dangerous than alcohol and tobacco, yet there is no debate on this as to the policy response.

My second question was whether proposals to legalise small possession and consumption necessitated a more thorough review of the criminalisation of production and distribution. Wouldn't half-measures result in highly schizophrenic situations?

In reply, Nadelmann said policy-making can never be purist; it has to balance various costs and benefits. The most optimal result may well be a complex mix of limited access and regulated supply, varying from one type of psycho-active substance to another. Even a very limited legal supply with tightly controlled channels may be enough to do the trick, yielding substantial improvements in public health and eliminating people's reliance on the black market. There may be no need to legalise wholesale.

As a parting shot, he reminded the audience that an intelligent response to the drug problem required that we not only focus on the harmful consequences of drug use, but also, we must think about the harmful social consequences of the policy we choose.

© Yawning Bread