As a clinical psychiatrist I have worked with hundreds of substance abusers and their families, and I’m convinced now, more than ever, that we need to legalize drugs. Sound like a contradiction? It isn't. The main reason people fear drug legalization is because they're devoted to the disease model of substance abuse. Simply put, most people believe that if we legalize drugs—including the “gateway” drug marijuana—we’ll experience an epidemic of out-of-control drug addiction that will shake the foundations of civilization.
My soon to be released book, Blowing Smoke: Rethinking the War on Drugs without Prohibition and Rehab (Rowman & Littlefield, February 2012), traces the history of the disease model and argues that its roots are political not scientific, and that the model paradoxically enables substance abuse. Current neuroscientific knowledge does not support the disease model; it only shows why quitting can be hard. Human nature is more resourceful than the disease model allows, which is why prohibition laws won't stop the flow of drugs, and multiple trips through rehab won't stop consumption.
While early drug control laws, like the Harrison Narcotics Tax Act (1914) and the Marihuana Tax Act (1937), were aimed at immigrants and minorities, modern prohibition laws are based on the disease model. Prohibition is believed to be a public health initiative. The disease model informs the United Nations’ Single Convention on Narcotic Drugs (1961), which is the legal basis for the war on drugs throughout the world. The thinking behind the treaty is straightforward: if drug abuse is a disease, then drugs are pathogens that need to be banned. The U.S. implemented this treaty through the Controlled Substance Act (1970).
The disease model was part of a larger cultural trend in the mid twentieth century that began to view the masses as weak and in need of enlightened protection from the political and scientific elite. This view didn't arise from the massess, it was passed down from the elites, who were certain that they knew what was best for everyone else. During this time Americans also lost the right to self-medicate. Most medicines today are “by prescription only." Prior to 1951, you could walk into any pharmacy and buy almost anything you wanted, with the exception of those drugs controlled by the tax acts.
So what is it about the disease model that enables substance abuse? Drug rehab teaches addicts that they have a genetic brain disease and that they aren’t responsible for their behavior; the sick-role entitles addicts to a wide range of welfare and disability benefits; disease model-inspired prohibition laws create a forbidden-fruit élan; and the model creates a set of expectations that does nothing to foster moderation: drugs will fry your brain, you’ll lose the ability to control yourself and you’ll likely commit crimes to support your habit. That many drug users behave like this is true enough, but the reason has less to do with the chemical properties of drugs than with the expectations and enabling that society delivers courtesy of the disease model.
Blowing Smoke argues that the only way to effectively manage the drug problem is to meet human nature head-on: embrace drug use as a cultural norm and let informal cultural controls reinforce responsible use. Quitting isn't necessary, only moderation. Doctors can't change addicts, but addicts can change themselves, and they're more likely do so when family members and friends help them experience uncomfortable consequences for irresponsible consumption. Want to help drug addicts? Then help them face painful consequences for irresponsible use.
While repealing prohibition laws would eliminate the violence associated with the drug trade, harm reduction efforts that seek to shift control to the medical profession would be misguided. If we legalize drugs and continue to treat drug abuse like a disease, irresponsible use will continue to grow and many reasonable people would start calling for a return to prohibition.
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