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The Public Health Approach to the Drug Problem*

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"Either this nation will kill racism, or racism will kill this nation." (S. Jonas, Aug., 2018)

And this statement applies in particular to the way in which the so-called "Drug War" has been carried out since it was invented by Richard Nixon.


1. Introduction

In the late 1980s, as the "Drug War" was becoming conducted ever-more fiercely, with the rampant incarceration of users and minor dealers, a movement to oppose it was beginning to be developed. I heard about it and started attending annual meetings of the "drug policy reform movement." There was a major focus on marijuana legalization, which I certainly supported, since for most users marijuana was (and is) the least harmful of the potentially addicting drugs. Indeed, to this day many (if not most) marijuana users do not become addicted in the biochemical sense (as most users of nicotine in tobacco products do) but rather become simply "social users," as most regular consumers of alcoholic beverages are. My focus, in terms of the health of the public, was on seeing all the potentially addictive drugs as a unity, starting with the two major killers, tobacco and alcohol. However, those who focused on marijuana legalization (that is the majority of participants in the "drug [policy reform movement" at the time,) were not interested in pursuing my concept and the program that would/could have been developed from it.

2. Some Basic Facts about the Pathology Associated with the Addictive Drugs

As a group, the addictive substances can be described as the Recreational Mood-Altering Drugs, i.e., the "RMADs." Of the group, currently, tobacco kills about 480,000 persons per year, including about 41,000 non-smokers exposed to second-hand smoke, while alcohol kills about 95,000 persons per year In terms of the opioids, in recent years overdose deaths from both the illegal and prescription opioids have been on the rise, spiking to 88,000 during the COVID-19 Pandemic. It is not known how many of these deaths occurred because the users simply did not know the doses that they were taking, but presumably it was a significant number, since a) non-prescription sales of prescription drugs are not regulated and b) there is no evidence that a significant number of such deaths were in fact the result of suicide.

As is well-known, a major cause of this rise has been the OxyContin/oxycodone/fentanyl epidemic fueled by Perdue Pharma. Since 1996, there have been approximately 450,000 deaths from users'-opioid-overdose (New York Times, 4/13/21, Jennifer Szalai, p. C1). It is not known how many of these deaths were due to OxyContin use, but successful legal actions against its production by Perdue Pharma which produced it, and the Sackler family that owned the company, indicate that a significant proportion were.

3. Indeed the "Drug War" has never worked as intended (that is to vastly diminish if not wipe out the use of the "illegal" RMADs). As has been the case in recent years as well the use of the illicits has varied little over time since the "Drug War" was commenced by the Nixon Administration in 1971.

4. Thus despite the lack of interest on the part of the bulk of the participants in the "drug policy reform movement," I did start thinking once again of developing a public health approach to the drug problem, going well beyond the lessons taught by the communicable disease model. I was eventually asked to contribute a chapter on it to what became the standard text on the whole field, edited by Dr. Joyce Lowinson and entitled simply Substance Abuse. (My contribution was, serially, "The Public Health Approach to the Prevention of Substance Abuse," chapter 70 in Lowinson, J., et al, Eds., Substance Abuse: A Comprehensive Textbook, 2nd ed., Baltimore, MD: Williams and Wilkins, 1992; chapter 77 in the 3rd ed., Baltimore, MD: Williams and Wilkins, 1997; and chap. 79 in the 4th ed., Baltimore, MD: Lippincott Williams and Wilkins, 2004.)

5. After a long time-gap, I eventually published the concept in a journal article, "Ending the 'Drug War'; Solving the Drug Problem: The Public Health Approach," Journal of Preventive Medicine, Vol. 1, No. 2:8, 2016 (, and then in a book Ending the "Drug War"; Solving the Drug Problem: The Public Health Approach which was subsequently published in a softcover book edition by Scholars' Press, a German company (Saarbrucken, Deutschland, although the book was published in English; see Note 1, below).

6. The principal elements of the Public Health Approach to the Drug Problem are as follows:

1. The Drug Problem is a Unity, not a Duality, i.e., the "legals" and the "illegals." As noted, it starts with the two most widely used addictive drugs, ethyl alcohol in alcoholic beverages and nicotine in tobacco products. Currently tobacco products kill about 480,000 people per year while alcohol kills about 95,000.

2. There should be single national policy of dealing with drug addiction. Making one group of addictive drugs legal and the other illegal has simply led to many more problems than those, which are serious enough, arising from the use of the addictive drugs., like that of mass incarceration (Alexander, Michelle, The New Jim Crow, The New Press, 2012.)

3. Substance abuse is a problem with a natural history, sometimes, if not often, starting in childhood.

4. THE universally harmful drug is nicotine in tobacco products.

5. There is a spectrum of harmfulness and of safe use for most addictive drugs (nicotine being one major exception --- "meth" being the other).

6. Legalization of the Public Health Approach is not the focus; solving the drug problem is.

7. "Moral suasion" is of limited use, although it can work in certain circumstances.

8. There is a group of standard public health approaches which can be very effective: education, taxation on legal sales, limitation of advertising (I prefer banning), limiting availability for legal sales: the concept of "The Package Store," pricing (very effective in diminishing cigarette sales).

9. There is a major assault on the "Drug Culture," beginning a ban on all advertising of the currently "legals" and other forms of pro drug-use advertising.

10. The use of "Alcoholics Anonymous"-like programs.

11. Ending mass incarceration for minor "drug crimes," which would with legalization would virtually disappear anyway.

12. A comprehensive public education campaign, modelled on the one that has been successful in dealing with cigarette smoking.

13. A comprehensive school health education program. In the Public Health Approach model, drug-use education programs for dealing with any of the addictive/habit-forming drugs would likely be more successful than they are at present because the message wold be a consistent one, unlike it is currently, that is that some drugs are "good" or at least "OK" while others are "bad," which objectively makes no sense.

14. As far as treatment programs are concerned, again consistency of approach would great assist their successful development.

15. As for the current status of crop subsidy and price-support programs for the legals, I am not familiar with it/them, but in the PHA they wold be ended.

16. There could be further development in liability law dealing with purveyors of/dealers in all of the addictive/habituating drugs.

17. As for sales, ALL of the addicting/potentially-habituating drugs would be sold, legally, from what in some states have been traditionally called "Package Stores." For those drugs which are currently causing a serious number of overdose deaths this is especially important, because we know that most overdose deaths are a result of the user simply not knowing just how much drug-substance is in the packet/pill he/she just bought.

18. Finally, law enforcement would have an important role, but not the current one of imprisoning minor users/sellers. Rather it would focus on: a) dealing with black markets; b) dealing with violations of advertising/promotion/prescribing policy/laws; c) dealing with liability suits under a broadened concept of what constitutes liability in this field (see what has happened to the Sackler family, currently offering $4.275 billion to settle thousands of lawsuits that have been filed against Perdue Pharma [NYT, Szalai, 4-13-21]); d) dealing with criminal/harmful behavior resulting from the use of the covered substances.


1. The original sources for this column are:

Jonas, S., Ending the Drug War; Solving the Drug Problem: The Public Health Approach, Saarbrucken, Deutschland: Scholar's Press, 2016

Jonas, S., "Ending the Drug War: The Public Health Approach to the Drug Problem," Journal of Preventive Medicine, Vol. 1, No. 2:8, p. 1.

Jonas, S., "Public Health Approaches" (to the drug problem, Chap. 77 in Lowinson, J.H., et al, Substance Abuse: A Comprehensive Textbook, Baltimore, MD: Williams & Wilkins, 1997).

*2. The text for the paper on which this column is based was drawn from: Jonas, S., Outline for a presentation on the topic "Is Heroin Addiction a Communicable Disease?" Hawaii Addiction Conference, Addictions Division, Dept. of Psychiatry, Burns School of Medicine, Honolulu, Hawaii, April 16, 2021.


(Article changed on May 13, 2021 at 9:55 AM EDT)

(Article changed on May 15, 2021 at 5:34 PM EDT)

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Steven Jonas, MD, MPH, MS is a Professor Emeritus of Preventive Medicine at StonyBrookMedicine (NY) and author/co-author/editor/co-editor of over 35 books. In addition to his position on OpEdNews as a "Trusted Author, he is a Senior (more...)
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