Phillip S. Smith, Writer/Editor

This chewy, provocative, interdisciplinary collaboration by a group of academic experts at the University of Utah appears formidable at first glance, but turns out to be remarkably rewarding. In what they bill as a search for justice when it comes to drugs, the authors delve deep into the fundamental theoretical questions at the center of the debates over drugs -- What is addiction? What is harm? -- as well as the history of how we got to where we are and how we can get to a better place. Their search for justice in drug policy takes them to some very interesting places and takes the reader on a fascinating ride.

[inline:drugsandjustice.jpg align=right]Embracing as their starting point the Aristotelian principle that justice means "like cases are treated alike," the authors insist that if we are to develop a "consistent, coherent, and comprehensive" policy toward drugs we must begin by examining the totality of the drug universe -- pharmaceuticals, over the counter (OTC) drugs, illegal drugs, sports enhancement drugs, "common use" drugs (alcohol, caffeine, and tobacco), religious use drugs (peyote, iboga, ayahuasca), and alternative and herbal medications.

The fact that we treat cocaine one way, Ritalin another, and the herbal supplement ephedra yet another is, the authors argue, an historical artifact, the result of complex social and political processes that have little to do with a rational approach to the universe of substances that affect the mind and/or body. Part of our problem, the authors suggest, is that the very division of these substances into the various categories listed above creates enclaves, or "silos," of knowledge, one for prescription drugs, one for illegal drugs, one for OTC drugs. Regulated (to a greater or lesser degree) by different agencies and studied by differing, increasingly specialized, academic and professional disciplines, different categories of drugs become different, unknown universes for those outside the specialty.

Such effects can occur even with drug categories. Consider prescription opioid pain relievers and their users. While pain management specialists and addiction medicine specialists both study the opioids and their effects on their users, their very specializations impel one to see a patient seeking relief and the other to an addict seeking drugs.

And just what is addiction, anyway? The authors accept the consensus that addiction does indeed exist, even if it proves to be a remarkably slippery concept. The pain medicine/addiction medicine field has one definition (the AAPM/APS/ASAM Consensus Definition), the psychiatric profession has another (the Diagnostic and Statistical Manual [DSM] diagnosis) -- and they don't necessarily agree. In a fascinating intellectual exercise, the authors compare the cases of two men, both professional, both successful. One is a hard-core coffee drinker who thinks about coffee all the time, relies on it to get his work done, and suffers withdrawal headaches and grogginess if he doesn't get his fix. The other has been using cocaine every weekend for the past two years without any great ill effect. Neither has done any appreciable harm to others because of his drug use.

Under the definitions of the pain docs, our coffee drinking friend is an addict; under the definitions of the DSM, he isn't. In fact, he doesn't even qualify for the less serious diagnosis of "substance abuse." Our weekend warrior cocaine user, on the other hand, does not qualify as an addict under either the consensus definition or the DSM, although he could qualify as the less serious "substance abuser."

The most widely used professional definitions of addiction can't agree about our coffee drinking friend, while they do agree that the cocaine user is not an addict. Equally strangely (or perhaps not), both definitions of addiction define the coffee drinker as having the more serious problem than the cocaine user.

Yet the coffee drinker goes about his business unimpeded, while the cocaine user faces the prospect of arrest and imprisonment. In both cases, the drug users are not harming others and only arguably harming themselves. This suggest, the authors write, that we are not treating like cases alike.

Another core conceptual problem the authors grapple with is the notion of harm. It is, after all, the notion of preventing harm -- to drug users or others or both -- that drives much of drug policy. Justice requires the application of the Millsian Harm Principle, that we are free to do as we choose absent harm to others, but teasing out just what constitutes harm is not as clear-cut as it might seem. Again, our definitions of harm are often based on our "siloed" perspectives and by foregrounding or backgrounding. With illicit drugs, harms are foregrounded and any benefits are hidden in the shadows. (I'm reminded of the scary anti-drug propaganda efforts with their lists of the dire and hideous consequences of using the substances in question. If this stuff is so terrible, why on earth is anyone using it?) The same sort of differing perspective takes place between pain docs and addiction docs; one sees an Oxycontin tablet and thinks of its value as a pain reliever; the other look at it and sees its addictive potential.

Recognizing the problems that still adhere to such key notions in drug policy as addiction and harm, as well as many other complications, the authors nonetheless attempt to posit other, more just, models of drug policy. They construct a policy continuum, with "Drug Anarchism" on one end and "Total Drug Prohibition" on the other, but those are merely ideal types, extremes, unlikely to ever be implemented. More plausible, they suggest, are three alternatives to out present shambolic (inconsistent, incoherent, non-comprehensive) set of drug policies: The Autonomist approach, the Medical Model approach, and the Centralized Superregulatory Approach. One would, absent harm to others, leave drug-taking decisions in the hands of competent adults, one would defer them to pharmacists and "drug trainers," and one would reconstitute our current differing systems of drug regulation into a single system regulated by a single bureaucratic entity, much like the Department of Homeland Security for drugs.

"Drugs and Justice" might appear a daunting jaunt through theory and philosophy, but the authors are very good at bringing things back down to earth. They present numerous case studies to illustrate the various quandaries and dilemmas facing those seeking a just drug policy. It's one thing to pontificate on the philosophy of harm; it's quite another to explore the issues around whether it is just or proper to subject a productive heroin user to a drug court where he must choose between his freedom and his drug of choice.

Throughout this work, the authors are careful to not take sides. But on the last page of the text, they make some recommendations. The most significant is this: "We must make significant changes, not just cosmetic prunings, in the way we treat drugs -- all drugs. This means scrapping many of the laws on the books and starting over."

There is a lot of meat in these pages. And for those with a serious interest in drug policy, broadly defined, it's a pretty tasty treat. This book should be read not only by all those specialists in their silos, but by policymakers seeking a better way forward. Sadly, it's more likely to be read mainly by grad students.