We likely did not see this disease process due to our small sample size, as Layden et al reported ARDS development in several of their examined cases.In our series, we did not evaluate the pathologic pulmonary changes in different patients. In other case reports, different pathophysiologic patterns of pulmonary involvement, in the form of diffuse alveolar hemorrhage, exogenous lipoid pneumonia, acute eosinophilic pneumonia, or hypersensitivity pneumonitis have been identified.Although the mechanism of EVALI is not clearly understood, the CDC suggests the use of steroids for treatment.According to a series of patients in Illinois, 51% of those patients had improvement in symptoms after the administration of steroids.6 In another study, patients showed clinical and radiological improvement following the use of antibiotics and steroids.In our study, six patients received steroids and six patients received antibiotics; three of those patients followed up in clinics with normal spirometry. But this evidence is not sufficient to establish that use of steroids or antibiotics is beneficial in EVALI. There are several limitations of our study. First, because it was a retrospective chart review we could not establish causation. Second, all data may not have been recorded on all patients . We might have missed some if the ICD-10 codes were not correct on the chart. Only three had documented follow-up, so we don’t know whether the other four had any comorbidities after their hospitalization. Third, we had a small number of patients. Fourth, this was a single-center study; so results may not be generalizable to other hospitals with different patient demographics.Psychoactive drugs are an especially rich topic for criminological scholarship. The topic is inherently multidisciplinary,vertical cannabis involving neuroscience, psychology, cultural anthropology, history, microeconomics, and moral philosophy.
And drug policy instruments extend beyond the usual arsenal to include social work, medicine, psychotherapy, social support groups, drug maintenance clinics, and mass media campaigns. In order to cover such a vast topic in a limited space, it is necessary to be selective, making some general observations and pointing the reader to good secondary sources. We focus primarily on the currently illicit psychoactives, giving little attention to alcohol or tobacco. We trust that every educated reader will be familiar with the arguments for analyzing licits and illicits together, and we assure skeptics that we will not neglect the core question of how prohibition shapes drug behavior and drug outcomes. We also limit our scope to policies and outcomes in the United States. We do this with some reluctance, because there is much more innovation in drug policy in Canada, Australia, and Western Europe than in the US, including experimentation with safe injection rooms, methadone buses, retail cannabis outlets, and government provided heroin . Most readers will have at least a passing familiarity with traditional scholarly ways of framing the topic, such as drug use as a “victimless” crime; the failure of drug prohibition and the merits of legalization; the relative merits of supply-side vs. demand-side programs;the “punitive paradigm” vs. the “public health paradigm”; and neurochemical reasons why drugs are a unique social problem. We would not contend that any of these framings are “wrong” or misguided, just that they have become overly simplistic clichés that can stultify our thinking. We will use an analytical framework that we hope will provide a fresher and more pragmatic perspective on the topic. We will also try to avoid some hydraulic assumptions often implicit in drug policy debates; e.g., the assumption that if one approach has lots of problems, another approach will work better, or that if we cut back our funding of one program , we will end up spending more on another . It is not necessarily the case that any of our drug policy instruments, optimally deployed, will dramatically change our drug problems.
Drug policies might not even be the most effective government responses, relative to, say, universal health care or improved education . And offering more of anything that works modestly well doesn’t guarantee we’ll do even better. After briefly sketching out a framework for thinking about drugs, we then use it to interpret some major findings on drug use, drug harms, and drug policies. We then close by calling attention to some emerging issues that are likely to force us to do some new thinking and move beyond the clichés of late 20th century drug rhetoric. The central empirical claim of this chapter is that existing policies have discouragingly modest effects on our drug problems. Our central normative claim is that we can advance our understanding of drug policies and outcomes by moving beyond a nearly exclusive reliance on the number of drug users as a metric for success . There are often important gains we can make in reducing the quantities that users consume and the harm that their use causes . Framing drug policy in language of supply- vs. demand-side programs reflects the increasing diffusion of economic thinking from the business place to other domains of American life. The idea is that some interventions involve supply while others involve demand , and that there is a drug control budget pie that can be sliced along these lines. But there are some drawbacks to this framing. As Murphy has documented, the notion that we can simply shift monies from one portion of a federal drug budget to another is naïve; there is no single allocating authority, and the “budget” is a mythical post-hoc construction assembled from a variety of conflicting sources and entities. The alternative idea of a “public health” framing of drug policy is refreshing, but in practice it tends to devolve to the “demand reduction” frame. Instead, we will try to keep the focus on strategies, rather than tactics; goals rather than programs. Our framework for doing so is sketched here and is developed in greater detail elsewhere Our perspective will not appeal to everyone. In particular, our framework is irrelevant for people who hold that certain moral beliefs trump any consideration of consequences. There are two such deontological positions.
One is the libertarian belief that ingesting psychoactive substances is our birthright. At the other extreme is legal moralism – the belief that drug intoxication is intrinsically immoral. Based on an extensive analysis of drug policy rhetoric ,cannabis hydroponic set up we conclude that few people are strict libertarians or pure legal moralists with respect to drugs. Most people who argue that either drug use or drug prohibition is immoral usually cite empirical arguments in support of their positions. MacCoun and Reuter offered a thought experiment that can help people identify where they stand with respect to consequentialism. At this point, we bid pure libertarians and legal moralists adieu. For the consequentialists, we suggest three broad goals: Prevalence reduction , quantity reduction , and micro harm reduction . Practices and concepts most readily identified with prevalence reduction include abstinence, prevention, deterrence, and incapacitation. Practices and concepts most readily identified with harm reduction include safe-use and safe-sex educational materials, needle exchanges, and the free distribution of condoms to students . Traditional discussions of prevention, treatment, deterrence, and incapacitation focus almost exclusively on the first category, with the implicit assumption that the best way to eliminate harm is to eliminate prevalence — turning users into non-users. This is logically correct, but not very realistic. Prevalence reduction may be employed in the hope of reducing drug-related harms, but because it directly targets use, any influence on harm is indirect. Harm reduction directly targets harms; any influence on use is indirect. From an analytic standpoint, all three strategies contribute to a broader goal, macro harm reduction . For tangible harms, Macro Harm = Micro Harm x Prevalence x Quantity, summed across types of harm . The strategies are potentially in tension, particularly if efforts to reduce prevalence increase harm , if efforts to reduce quantity discourage abstinence , or if efforts to reduce average harm encourage the prevalence or quantity . Thus, any drug policy intervention should be evaluated with respect to all all three criteria – prevalence reduction, quantity reduction, and harm reduction – because all three contribute to the reduction of total drug harm. Note that our use of “harm reduction” is unusual here, in that we are not referring to specific “harm reduction” programs like needle exchange, but rather to a goal that is served – well or poorly – by any intervention. For that reason, we will discuss harm reduction in the context of traditional interventions like policing, prevention, and treatment. Why is psychoactive drug use a crime? And is there a sensible answer that also explains why tobacco and alcohol are on one side of the legal threshold, while marijuana, cocaine, the opiates, and the psychedelics are on the other? One way of tackling this question is historical, and there are a number of outstanding histories of roles played by race, class, and economic interests in the evolution of drug, tobacco, and alcohol control . Another approach is philosophical. If we were starting a society from scratch, which substances, if any, would we prohibit? The traditional first cut at this question uses John Stuart Mill’s harm principle: “That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.”
MacCoun, Reuter, and Schelling listed nearly 50 different categories of drug-related harm, falling into three clusters: Health, social and economic functioning, safety and public order, and criminal justice. Many are quantifiable, at least in principle , but others are not . The authors attempted to categorized these harms with respect to two questions: Who is the primary bearer of the harm? And, what is the primary source of the harm? None of the harms could be confidently categorized as the exclusive burden of the user; in every category of harm there was a compelling case that others also suffered the harms. Thus, the notion that drug use is a “victimless crime” seems untenable. These harms to others meet the Mills criterion, but that hardly nails down the case for prohibition. MacCoun, Reuter, and Schelling argued that for over half of the harm categories, the primary source of the harm was either the illegal status of the drug, or the enforcement of that law, at least under the current prohibition regime. . The notion that prohibition and its enforcement are partially responsible for drug harms is perhaps best illustrated by examining the relationship between an offender’s illicit drug use and his or her involvement in other crimes. A considerable literature on this relationship suggests the following conclusions . Drug use can promote other crimes; criminality can promote drug use; and/or both can be promoted by environmental, situational, dispositional, and/or biological “third variables.” All three pathways have empirical support in at least some settings and populations. But these causal influences are probabilistic, not deterministic. Most drug users are not otherwise involved in serious crime. Finally, the drug-crime link varies across individuals, over time within an individual’s development, across situations, and possibly over time periods . Like many things in life that are bounded at zero, the frequency distribution of drug consumption has a positively skewed log-normal shape . If one plots the proportion of all users as a function of quantity consumed , most users pile up on the low side of the quantity distribution, but the plot will have a long narrow right tail representing a small proportion of user who use very large quantities. As a result, the harmful consequences of substance use are not uniform, but are disproportionately concentrated among the heaviest users. Everingham and Rydell used these features to explain why cocaine-related harms remained high even as total prevalence was dropping; one sees a similar logic today in methamphetamine statistics. There is a sophisticated treatment of these distributional features and their implications for the targeting of interventions , but far less little discussion in the illicit drug literature . Another distributional consideration is how drug use and drug harms are distributed across geographic, class, and ethnic lines. African Americans use illicit drugs at a rate similar to European Americans, but they bear a disproportionate share of the law enforcement risk and market related violence.