Drug policy: striking the right balance

Stimulus functions of caffeine in humans: relation to dependence potential

The interoceptive stimulus functions common to drugs of dependence include positive subjective effects, discriminative functions, and reinforcing functions. Data from studies measuring these stimulus functions constitute the objective assessment of a drug's dependence potential. This paper reviews the subjective effects, discriminative stimulus, and reinforcing stimulus functions of caffeine in humans to assess the dependence potential of caffeine. The stimulus effects of caffeine are compared with those of d-amphetamine, a prototypic CNS stimulant that has been studied under similar conditions, to evaluate the relative dependence potential of caffeine. Finally, caffeine's effects are evaluated in terms of generally accepted criteria for defining drug dependence. It is concluded that caffeine partially meets the primary criteria of drug dependence: 1) the majority of caffeine use is highly controlled, but not compulsive; 2) caffeine is psychoactive; and 3) caffeine functions as a reinforcer under certain conditions in humans, but not in animals. Caffeine thus has limited dependence potential. Additionally, although caffeine shares stimulus functions with d-amphetamine, it does so under limited conditions and should be considered to have a relatively lower dependence potential.

Needle sharing in The Netherlands: an ethnographic analysis

BACKGROUND

Needle sharing has been reported to be the main cause of the rapid spread of the human immunodeficiency virus (HIV) among injecting drug users. Risk behaviors such as needle sharing are, however, the end result of complicated interaction patterns in drug user networks, which have their specific rules and rituals, and larger social structures and official drug policy.

METHODS

To study these interaction patterns we examined the drug administration rituals of heroin addicts in Rotterdam, The Netherlands. Intensive ethnographic descriptions were collected by participant observation.

RESULTS

In less than 10% of the observed self-injections unsafe syringes were used. In 68% of the self-injections new, sterile syringes were used. Needle sharing as a planned sequence was not observed. Sharing was determined primarily by the availability of syringes, experience with the injecting ritual, and drug craving. In all observed needle-sharing events, subjects were aware of the risks involved and undertook efforts to clean the injection equipment.

CONCLUSIONS

In contrast to psychological approaches aimed at reducing individual "risk behavior," these findings suggest that HIV prevention can be made more effective if active drug injectors are organized to help themselves and their peers prevent high-risk exchange situations.

Heroin addiction: neurobiology, pharmacology, and policy

The neurobiology of drug addiction is being clarified. Research is revealing the anatomic pathways of primary drug reinforcement (reward) in the brain and the molecular architecture of the receptors on which addictive drugs act. All addictive drugs mimic (or occasionally block) the actions of some neurotransmitter; in the case of heroin or methadone an endogenous opioid, probably beta-endorphin. The groundwork is being laid for understanding Dole and Nyswander's "metabolic disease" concept as a concrete neurochemical abnormality of the endogenous opioid system. Thus, a stronger basis is developing for regarding methadone maintenance as a means of replacing a neurohormonal deficiency. Three practical conclusions that can be drawn from this model are: (1) methadone dosage must be adequate (never less than 50-80 mg); (2) it should be more widely accepted that some patients may require lifelong methadone maintenance; and (3) longer-acting, better stabilizing methadone congeners, such as LAAM and its metabolites, should be brought into general use.

Criminal justice and the drug-abusing offender: policy issues of coerced treatment

Criminal justice populations, including arrestees, probationers, inmates and parolees, have become increasingly involved with drugs of abuse. These numbers have seriously impacted the criminal justice system from enforcement to the courts, corrections, and subsequent legal supervision agencies. Prevalence of substance abuse in these populations is reported, as well as the effectiveness of community-based and corrections-based treatment in effecting behavioral changes to reduce drug demand. The characteristics of successful intervention programs are described and an ideal model proposed for better integrating community treatment and criminal justice intervention efforts.

Medicalizing the drug war

Recent findings in the field of psychopharmacology pertain to the abuse of drugs and alcohol among criminal offenders and have implications for new management techniques. Drugs of abuse exert their effects on areas of the brain responsible for pleasure, providing a powerful reinforcement for drug usage. Furthermore, there is a prevalence of psychological, psychiatric and social dysfunctions that antedate drug use which are identifiable at an early age. It is suggested that drugs of abuse differentially influence users via these biological, psychological and social mechanisms, reinforcing the development of serious and chronic abuse in a vulnerable subgroup. Studies of drug abuse specially indicate that within this subgroup, antisocial behavior precedes and exacerbates drug abuse, and multiple risk factors contribute to the concomitant development of criminality and drug abuse. Early detection and comprehensive treatment of underlying disorders that may both precipitate and result from drug abuse promise to improve possibilities for prevention and reducing relapse rates. Furthermore, the inclusion of pharmacologic treatments may further enhance the success of conventional drug treatments. This article proposes that incorporating scientific data and medicalizing our approach to drug abuse is essential to win the war against drugs.