Citation: JAMA, The Journal of the American Medical Association, May 20, 1992 v267 n19 p2573(2) Title: Government extinguishes marijuana access, advocates smell politics. (Medical News & Perspectives) Authors: Cotton, Paul ============================================================================== Full Text COPYRIGHT American Medical Association 1992 THE US Public Health Service is snuffing out new applications for marijuana to be smoked as a form of therapy. Critics contend that politics, not science, is behind the decision. They say that, by denying access to what may be a useful treatment, officials are allowing some of the nation's sickest patients to be taken hostage in the war on drugs. However, arguing that risks are great and benefits unproven, officials have moved to reject 28 applications for marijuana therapy that had been approved under a compassionate-use program. Thirteen patients already receiving marijuana for glaucoma, acquired immunodeficiency syndrome (AIDS), and nausea related to cancer chemotherapy will continue to do so. The Public Health Service acknowledges the timing of this latest action was influenced by a deluge of applications from patients with AIDS. They had, with the Alliance for Cannabis Therapeutics in Washington, DC, figured out how to cut what had been a cumbersome application that could take up to 50 hours to complete down to a Food and Drug Administration-approved form that could be filled out in less than 1 hour. Anecdotal evidence suggests that marijuana, apparently through appetite stimulation, may slow or even reverse weight loss in patients with human immunodeficiency virus-related wasting syndrome, for which there now is no approved therapy. Preliminary studies suggesting a similar effect for dronabinol (Marinol, Roxane Laboratories Inc [Boehringer Ingelheim Corp], Columbus, Ohio), an oral preparation of marijuana's primary active ingredient, [[Delta].sup.9]-tetrahydrocannabinol (THC), increased interest in smokable marijuana. This is because it is more quickly and readily absorbed than the oral preparation and, according to marijuana therapy advocates, is easier for patients themselves to titrate in order to avoid the mind-altering side effects. But the compassionate access program was sending a "bad signal," says James O. Mason, MD, DrPH, assistant secretary for health in the US Department of Health and Human Services and head of the Public Health Service. He says that giving marijuana out as medicine might create the "perception that this stuff can't be so bad." Responding, Robert Randall, president, Alliance for Cannabis Therapeutics, says: "Mason seems to be more interested in ideological signals than in the welfare of desperately ill people." Mark Kleiman, PhD, an associate professor of public policy at Harvard University, Cambridge, Mass, adds: "I'm mostly a hawk in the war on drugs, but this is gibberish." Kleiman says that "fact sheets" released with the Public Health Service decision (describing the dangers and alternatives to marijuana therapy) are "a mix of things that are simply misleading, unpersuasive, or that completely concede the case" for compassionate access. "My field is drug enforcement," he says, "and, in my professional opinion, it [medical marijuana] just doesn't matter with respect to how much marijuana abuse there is." Weak Data All Around Unfortunately, there are very few well-controlled studies to document either marijuana smoking's risks or benefits. "The really striking thing" about marijuana research is its poor quality, says Steven Karch, MD, editor of the Forensic Drug Abuse Advisor. Studies that suggest benefit often have not been well controlled, he says. The few apparently well-done epidemiologic studies have failed to confirm dangers predicted on the basis of in vitro findings, especially of damage to the immune system. "In vitro studies should not be the basis for making decisions like this," says Karch, who is director of research at the University Medical Center of Southern Nevada, Las Vegas, a clinical facility of the University of Nevada School of Medicine, Reno. "I find the whole thing really disturbing because it's a political decision, it's not medical." John P. Morgan, MD, associate professor of pharmacology at the Mount Sinai School of Medicine, City University of New York, and author of the latest Merck Manual's chapter on marijuana, says a US government-funded study in Jamaica found no detrimental effect on general health from marijuana. The Multicenter AIDS Cohort Study, which has followed nearly 5000 homosexual and bisexual men since 1984, also finds no correlation between use of marijuana and immune status or speed of human immunodeficiency virus disease progression (JAMA. 1989;261:3424-3429). Another ongoing longitudinal study has been looking for 4 years now at how psychosocial and behavioral factors and immune changes relate to human immunodeficiency virus infection risk in 373 inner-city teenagers in Newark, NJ. Investigators have found in twice-yearly drug screens that marijuana use, regardless of the amount, does not correlate to any immune system changes. However, marijuana users do tend to have "risk-taking personalities" and are more likely to engage in other behaviors that increase risk for such infection, says Stephen Keller, PhD, professor of psychiatry, University of Medicine and Dentistry of New Jersey, Newark. Shortly after the Public Health Service decision, Robert C. Bonner, the Drug Enforcement Administration administrator, issued a 46-page ruling that also said marijuana "has no currently accepted medical applications," and so must remain a Schedule I controlled substance. Bonner issued the ruling because the US Court of Appeals for the District of Columbia circuit had ordered the Drug Enforcement Administration to clarify its 1989 ruling that marijuana has no accepted medical use. That 1989 ruling was made despite the opposite conclusion being reached the year before by one of the agency's administrative law judges who had held extensive hearings on the issue. Judge Francis L. Young wrote in 1988 that marijuana "has been accepted as capable of relieving the distress of great numbers of very ill people, and doing so Young said the law "requires the transfer marijuana from Schedule I to Schedule II," along with drugs like morphine that have both high potential for abuse and for medical utility. Young said the argument that making marijuana a Schedule II drug will "send a signal that marijuana is okay generally for recreational use ... is specious. It presents no valid reason for refraining from taking an action required by law in light of the evidence. "The fear of sending such a signal cannot be permitted to override the legitimate need, amply demonstrated in this record [from the hearings he had held] of countless sufferers for the relief marijuana can provide when prescribed by a physician in a legitimate case." Bonner, however, apparently discounted most of this testimony of marijuana's potential benefit. "Any mind-altering drug that produces euphoria can make a sick person think he feels better," says Bonner in the current ruling. Perceptions of benefit "may be based on rationalizations caused by drug dependence, not on any medical benefits caused by the drug." Bonner says that, "beyond doubt, the claims that marijuana is medicine are false, dangerous, and cruel. Sick men, women, and children can be fooled by these claims and experiment with the drug. Instead of being helped, they risk serious side effects." He suggests long-time users "may eventually get cancer, glaucoma, multiple sclerosis, and other diseases." He also says that marijuana is likely to be more cancer-causing than tobacco, damages brain cells, causes lung problems such as bronchitis and emphysema, and may weaken lung antibacterial defenses. However, he provides no documentation. The dangers of and alternatives to marijuana are discussed in five "fact sheets" issued at the time of the Public Health Service decision by the National Institute of Allergy and Infectious Diseases, the National Institute of Neurological and Communicative Disorders and Stroke, the National Institute of Dental Research, the National Cancer Institute, and the National Eye Institute, all part of the National Institutes of Health, Bethesda, Md. These fact sheets note that there are more than 400 compounds in marijuana smoke including carcinogens, and that contamination of marijuana with Salmonella and fungal spores has been reported. These "would be a concern for anyone, but especially for patients with compromised immune systems," they conclude. The inability to standardize dosage with marijuana smoking is also said to be a significant problem. Steve Schnittman, MD, chief of the National Institute of Allergy and Infectious Diseases' AIDS Division medical branch, says that is a reason why his institute has plans to study only oral dronabinol despite patients' reports that marijuana smoking is more effective and easier for them to control. With the oral form, "we have much more control over what exactly people are receiving," he says. Institute officials say megestrol acetate (Megace, Bristol Myers Squibb, Evansville, Ind), though not yet approved as therapy for human immunodeficiency virus-wasting, provided benefit to two thirds of patients with AIDS-related weight loss and anorexia in a placebo-controlled trial with 278 subjects. The institute itself is sponsoring further clinical study of dronabinol, but officials say studies suggesting benefit so far have been less well controlled than those for megestrol. Institute officials acknowledge that marijuana smoking "results in higher plasma levels of THC" than does oral administration. But they say that deep inhalation may be impractical or unacceptable to nonsmoking patients, and that the rapid onset of altered mental status "may be disconcerting." Smoking Better? Those arguments have marijuana therapy advocates fuming. "They need any kind of excuse," complains Morgan. "Smoking is probably much better than oral administration, and is unquestionably helpful to patients with AIDS." Mark Harrington, AIDS Coalition to Unleash Power (ACT-UP), New York, says: "It's clear the government's war on drugs is taking precedence over any kind of medical rationality." The argument that side effects outweigh benefit, he says, "is as spurious for this indication as it is for withholding morphine from people suffering extreme pain. The evidence is not there." Harrington says access is being denied to an agent that "could really improve the quality of [patients'] lives, and if it can enable them to eat more, it may even extend their lives. The National Cancer Institute's fact sheet states that scientists there "believe marijuana-related compounds probably are not as effective" as other antiemetics in patients suffering nausea after chemotherapy. However, it says marijuana-related compounds "can be useful" when nausea is not controlled by other antiemetics. Institute officials say that while "THC is more readily and quickly absorbed" from marijuana smoke, "for the most part" smoking is "no more effective" than oral preparations. Mary McCabe, RN, an institute clinical trials specialist, says that increasing numbers of other effective antiemetic regimens, such as ondansetron hydrochloride injections (Zofran, Glaxo Pharmaceuticals, Research Triangle Park, NC), have diminished the need for compassionate access to smokable marijuana. When asked about patients who remain refractory to these other antiemetics, she said that "on a personal basis you would like to offer them whatever could be made available," adding that "the actual call of whether it should be available" is not up to the institute. Still, some oncologists apparently disagree with the Public Health Service. A survey completed by 1035 members of the American Society of Clinical Oncology found that 48% of those responding would prescribe marijuana to some patients if it were legal, and 44% said they had recommended its illegal use to control emesis in at least one cancer patient undergoing chemotherapy (J Clin Oncol. 1991;9:1314-1319). The authors caution that the survey response rate of 43% makes it difficult to determine how accurately its results reflect opinion among oncologists. They suggest the survey demonstrates that oncologists' experience with marijuana is more extensive and opinions more favorable "than the regulatory authorities appear to have believed." They add: "It appears that current regulations create the somewhat anomalous situation that a substantial fraction of all practicing oncologists at least occasionally commit an act--counseling a patient to acquire and use a controlled substance--that constitutes a crime and that at least in principle could lead to the revocation of their licenses." The National Institute of Neurological Disorders and Stroke says the anecdotal reports of marijuana relieving pain and spasticity in patients with multiple sclerosis "have not been studied in an organized way." The National Eye Institute says that while marijuana does lower intraocular pressure, its studies have not shown that the pressure is lowered enough to to prevent optic nerve damage from glaucoma. And it warns that the long-term usage required to treat glaucoma puts the patient at risk of respiratory system damage. Morgan concedes that pulmonary damage is likely. However, he says he has never seen "a convincing report of pulmonary cancer or any evidence of chronic obstructive pulmonary disease or emphysema in marijuana smokers" who did not also use tobacco. He adds that the doses used to treat other diseases are probably not great enough to make the risk significant. "Criminalization is insane," says Morgan. "I do not advocate marijuana use, but I am absolutely convinced this is a valuable therapeutic agent which cannot be studied now because of the current political climate."--by Paul Cotton ----------------------------------------------------------------------------- Citation: The Economist, March 28, 1992 v322 n7752 pA23(2) Title: The last smoke: medical marijuana. (American Survey) ============================================================================== Full Text COPYRIGHT Economist Newspaper Ltd. (UK) 1992 MEDICINES often produce side-effects. Sometimes they are physically unpleasant. Many doctors consider marijuana effective in relieving the nausea of chemotherapy, treating glaucoma and helping AIDS patients gain weight. It too has discomforting side-effects, but these are not physical. They are political. On March 18th the Drug Enforcement Agency (DEA) rejected the pleas of medical-marijuana advocates to reclassify the drug so that it could be prescribed by doctors. At present, marijuana is grouped with the most disapproved-of drugs, such as LSD and heroin; cocaine and morphine, just as illegal, may be used medically. Two weeks earlier, the Public Health Service (PHS) had said it was curtailing a tiny "compassionate use" programme that supplies marijuana, despite the law, to 13 patients. They will go on getting their joints; no one else will. The decisions come after a year of to-ing and fro-ing. Last June the PHS hinted it might limit the compassionate-use programme because of a surge of applications from AIDS patients. After loud protests from AIDS activists, the PHS decided to review its policy. Pressure on the DEA came from elsewhere. In 1988 a federal administrative-law judge recommended that marijuana be reclassified. The DEA disagreed, saying the drug had no "currently accepted medical use". Last April a federal appeals court ordered the agency to think again. Now the government has in effect abandoned the "current acceptance" standard. It had little choice. A recent study by two Harvard drug-policy researchers found that almost half of 1,035 oncologists surveyed said they would prescribe marijuana if it were legal. Indeed, 44% of them said they had advised patients to smoke pot despite the possibility of prosecution. The government's case against medical marijuana rests on an alleged lack of systematic studies of its safety and efficacy. Pot smoke contains carcinogens, says the PHS; it may harm the immune systems of AIDS patients; they may not like the "high". Besides, marijuana's main active ingredient, THC, is already sold in pill form, as Marinol. According to the Harvard study, however, 77% of those oncologists who had an opinion on the matter say smokeable marijuana is more effective than oral THC. Because puffs are easier for patients to measure than pills, it is also less likely to get them uncomfortably high. True, marijuana may be a carcinogen (though that has not been proved). But AZT, the most effective AIDS treatment, causes cancer in animals; and AIDS patients, in any case, are willing to risk anything. These concerns do not seem to bother the PHS and the DEA. They have other things on their minds. Last year a PHS spokesman admitted that for the government to say marijuana could ever be therapeutic would be an unwise signal to send during a "war on drugs". Recently James Mason, head of the PHS, said he feared that AIDS patients, crazed on marijuana, would be more likely to practise unsafe sex. Some sick people who would benefit from marijuana will be deterred by the ban; others, desperate, will smoke it anyway. So far, 35 states have endorsed medical marijuana. In San Francisco police have agreed to turn a blind eye to it. Unless the government does something similar, smoking marijuana to relieve intolerable discomfort will remain, incredibly, a crime. ============================================================================== Citation: JAMA, The Journal of the American Medical Association, Oct 16, 1991 v266 n15 p2061(2) Title: Current tobacco, alcohol, marijuana, cocaine use. (From the Centers for Disease Control) ============================================================================== Full Text COPYRIGHT American Medical Association 1991 PATTERNS of tobacco, alcohol, and other drug use usually are established during youth, often persist into adult-hood, contribute substantially to the leading causes of mortality and morbidity, [1] and are associated with lower educational achievement and school droupout. [2-5] This report presents selected data on current use of tobacco, alcohol, marijuana, and cocaine among 9th-12th grade students from two components of the Youth Risk Behavior Surveillance System [6]: 1) the 1990 national school-based Youth Risk Behavior Survey (YRBS) conducted during April-May 1990 and 2) similar surveys conducted by departments of education in 22 states and four cities. The national survey used a three-stage sample design to obtain a probability sample of 11631 students in grades 9-12 in the 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands. The 26 state and local sites used a variety of sampling schemes: 14 drew probability samples from well-defined sampling frames of schools and students, allowing computation of weighted results of known precision; nine drew probability samples of both schools and students, but either low overall response rates or unavailable documentation precluded weighting the data or making estimates of precision; and three used nonprobability samples of either schools or students. For the state and local surveys, school response rates ranged from 31% to 100%; student response rates ranged from 54% to 94%. Sample sizes ranged from 378 to 5675 students. Students in most samples were distributed evenly across grades and between genders. The racial/ethnic characteristics of the samples varied considerably. Among the state and local surveys, rates varied for current tobacco, alcohol, and drug use during the 30 days preceding the survey: 9%-37% of students (median: 31%) reported smoking at least one cigarette; 1%-20% (median: 11%) reported using smokeless tobacco; 28%-64% (median: 54%) reported having at least one drink of alcohol; 17%-47% (median: 35%) reported having five or more drinks on one occasion; 3%-17% (median: 12%) reported using marijuana at least once; and 1%-4% (median: 2%) reported using any form of cocaine, including powder, crack, or freebase. At most sites, more male than female students reported these behaviors. The median prevalence estimates from the state and local surveys were similar to the national prevalence estimates. Reported by: J Moore, Alabama State Dept of Education. D Sandau-Christopher, State of Colorado Dept of Education. J Sadler, District of Columbia Public Schools. G Davis, Georgia Dept of Education. J Grosko, Kansas State Dept of Education. I Mudd, Kentucky Dept of Education. T Dunn, Massachusetts Dept of Education. A Jordan, Mississippi State Dept Bur of School Improvement. J Owens-Nausler, Nebraska Dept of Education. B Grenert, New Hampshire State Dept of Education. B Blair, New Mexico State Dept of Education. A Sheffield, New York State Education Dept. P Hunt, North Carolina Dept of Public Instruction. J Reynolds, Oklahoma State Dept of Education. P Ruzicka, Oregon Dept of Education. M Sutter, Pennsylvania Dept of Education. J Fraser, South Carolina State Dept of Education. M Carr, South Dakota Dept of Education and Cultural Affairs. E Word, Tennessee State Dept of Education. L Lacy, Utah State Board of Education. L Zedosky, West Virginia Dept of Education. B Nehls-Lowe, Wisconsin Dept of Public Instruction. D Scalise, The School Board of Broward County; AN Gay, The School Board of Dade County, Florida. D Chioda, Jersey City Public School District, New Jersey. P Simpson, Dallas Independent School District, Texas. A Blanken, Div of Epidemiology and Prevention Research, National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration. Smoking and Health Office, Adolescent and School Health Div, National Center for Chronic Disease Prevention and Health Promotion, CDC. CDC Editorial Note: Because the quality of the samples varied among the state and local surveys, comparisons of data across sites should be made with caution. Nonetheless, these results can be useful in planning and evaluating broad national, state, and local interventions and monitoring progress toward achieving National Education Goals and health objectives. Goal 6 of the National Education Goals [7] aims to have every school in the United States free of drugs and violence and offer a disciplined environment conducive to learning by the year 2000. The results presented in this report will be incorporated in the first progress report on the status of the National Education Goals. Year 2000 national health objectives are to reduce the use of tobacco, alcohol, and other drugs among youth. [8] For example, objective 4.6 states that among youth aged 12-17 the prevalence of alcohol use during the previous 30 days should be no more than 12.6% that of marijuana use no more than 3.2%, and that of cocaine use no more than 0.6%. Prevalence rates from the national YRBS for 9th-12th grade students were four times higher for alcohol and marijuana use and three times higher for cocaine use than these objectives. Furthermore, most states and cities that conducted a YRBS have not reached these national objectives. To meet the National Education Goals and the national health objectives, efforts to help youth reduce current use of tobacco, alcohol, and other drugs will need to increase among federal, state, and local education, health, and drug-control agencies; families; media; legislators; relevant community organizations; and youth themselves. References [1] CDC. Results from the National Adolescent Student Health Survey. MMWR 1989;38:147-50. [2] Jessor R, Jessor S. Problem behavior and psychosocial development: a longitudinal study. New York: Academic Press, 1977. [3] Kolbe LJ, Green L, Foreyt J, et al. Appropriate functions of health education in schools: improving health and cognitive performance. In: Krasnegor NA, Arasteh JD, Cataldo MF, eds. Child health behavior: a behavioral pediatrics perspective. New York: Wiley and Sons, 1986. [4] Dryfoos J. Adolescents at risk: prevalence and prevention. N NY: Oxford University Press, 1990. [5] Mensch BS, Kandel DB. Dropping out of high school and drug involvement. Sociology of Education 1981;61:95-113. [6] Kolbe LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Education 1990;21:44-8. [7] National Education Goals Panel. Measuring progress toward the National Education Goals: potential indicators and measurement strategies--discussion document. Washington, DC: National Education Goals Panel, 1991. [8] Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (Public Health Service) 91-50212. ------------------------------------------------------------------------------ Citation: Scientific American, July 1991 v265 n1 p40(8) Authors: Musto, David F. ============================================================================== Full Text COPYRIGHT Scientific American Inc. 1991 Dramatic shifts in attitude have characterized America's relation to drugs. During the 19th century, certain mood-altering substances, such as opiates and cocaine, were often regarded as compounds helpful in everyday life. Gradually this perception of drugs changed. By the early 1900s, and until the 1940s, the country viewed these and some other psychoactive drugs as dangerous, addictive compounds that needed to be severely controlled. Today, after a resurgence of a tolerant attitude toward drugs during the 1960s and 1970s, we find ourselves, again, in a period of drug intolerance. America's recurrent enthusiasm for recreational drugs and subsequent campaigns for abstinence present a problem to policymakers and to the public. Since the peaks of these episodes are about a lifetime apart, citizens rarely have an accurate or even a vivid recollection of the last wave of cocaine or opiate use. Phases of intolerance have been fueled by such fear and anger that the record of times favorable toward drug taking has been either erased from public memory or so distorted that it becomes useless as a point of reference for policy formation. During each attack on drug taking, total denigration of the preceding, contrary mood has seemed necessary for public welfare. Although such vigorous rejection may have value in further reducing demand, the long-term effect is to destroy a realistic perception of the past and of the conflicting attitudes toward mood-altering substances that have characterized our national history. The absence of knowledge concerning our earlier and formative encounters with drugs unnecessarily impedes the already difficult task of establishing a workable and sustainable drug policy. An examination of the period of drug use that peaked around 1900 and the decline that followed it may enable us to approach the current drug problem with more confidence and reduce the likelihood that we will repeat past errors. Until the 19th century, drugs had been used for millennia in their natural form. Cocaine and morphine, for example, were available only in coca leaves or poppy plants that were chewed, dissolved in alcoholic beverages or taken in some way that diluted the impact of the active agent. The advent of organic chemistry in the 1800s changed the available forms of these drugs. Morphine was isolated in the first decade and cocaine by 1860; in 1874 diacetylmorphine was synthesized from morphine (although it became better known as hereoin when the Bayer Company introduced it in 1898). By mid-century the hypodermic syringe was perfected, and by 1870 it had become a familiar instrument to American physicians and patients [see "The Origins of Hypodermic Medication," by Norman Howard-Jones; SCIENTIFIC AMERICAN, January 1971]. At the same time, the astounding growth of the pharmaceutical industry intensified the ramifications of these accomplishments. As the century wore on, manufacturers grew increasingly adept at exploiting a marketable innovation and moving it into mass production, as well as advertising and distributing it throughout the world. During this time, because of a peculiarity of the U.S. Constitution, the powerful new forms of opium and cocaine were more readily available in America than in most nations. Under the Constitution, individual states assumed responsibility for health issues, such as regulation of medical practice and the availability of pharmacological products. In fact, America had as many laws regarding health professions as it had states. For much of the 19th century, many states chose to have no controls at all; their legislatures reacted to the claims of contradictory health care philosophies by allowing free enterprise for all practitioners. The federal government limited its concern to communicable diseases and the provision of health care to the merchant marine and to government dependents. Nations with a less restricted central government, such as Britain and Prussia, had a single, preeminent pharmacy law that controlled availability of dangerous drugs. In those countries, physicians had their right to practice similarly granted by a central authority. Therefore, when we consider consumption of opium, opiates, coca and cocaine in 19th-century America, we are looking at an era of wide availability and unrestrained advertising. The initial enthusiasm for the purified substances was only slightly affected by any substantial doubts or fear about safety, long-term health injuries or psychological dependence. History encouraged such attitudes. Crude opium, alone or dissolved in some liquid such as alcohol, was brought by European explorers and settlers to North America. Colonists regarded opium as a familiar resource for pain relief. Benjamin Franklin regularly took laudanum--opium in alcohol extract--to alleviate the pain of kidney stones during the last few years of his life. The poet Samuel Taylor Coleridge, while a student at Cambridge in 1791, began using laudanum for pain and developed a life-long addiction to the drug. Opium use in those early decades constituted an "experiment in nature" that has been largely forgotten, even repressed, as a result of the extremely negative reaction that followed. Americans had recognized, however, the potential danger of continually using opium long before the availability of morphine and the hypodermic's popularity. The American Dispensatory of 1818 noted that the habitual use of opium could lead to "tremors, paralysis, stupidity and general emaciation." Balancing this danger, the text proclaimed the extraordinary value of opium in a multitude of ailments ranging from cholera to asthma. (Considering the treatments then in vogue--blistering, vomiting and bleeding--we can understand why opium was a cherished by patients as by their physicians.) Opium's rise and fall can be tracked through U.S. import-consumption statistics compiled while importation of the drug and its derivative, morphine, was unrestricted and carried moderate tariffs. The per capita consumption of crude opium rose gradually during the 1800s, reaching a peak in the last decade of the century. It then declined, but after 1915 the data no longer reflect trends in drug use, because that year new federal laws severely restricted legal imports. In contrast, per capita consumption of smoking opium rose until a 1909 act outlawed its importation. Americans had quickly associated smoking opium with Chinese immigrants who arrived after the Civil War to work on railroad construction. This association was one of the earliest examples of a powerful theme in the American perception of drugs: linkage between a drug and a feared or rejected group within society. Cocaine would be similarly linked with blacks and marijuana with Mexicans in the first third of the 20th century. The association of a drug with a racial group or a political cause, however, is not unique to America. In the 19th century, for instance, the Chinese came to regard opium as a tool and symbol of Western domination. That perception helped to fuel a vigorous antiopium campaign in China early in the 20th century. During the 1800s, increasing numbers of people fell under the influence of opiates--substances that demanded regular consumption or the penalty of withdrawal, a painful but rarely life-threatening experience. Whatever the cause--overprescribing by physicians, over-the-counter medicines, self-indulgence or "weak will"--opium addiction brought shame. As consumption increased, so did the frequency of addiction. At first, neither physicians nor their patients thought that the introduction of the hypodermic syringe or pure morphine contributed to the danger of addiction. On the contrary, because pain could be controlled with less morphine when injected, the presumption was made that the procedure was less likely to foster addiction. Late in the century some states and localities enacted laws limiting morphine to a physician's prescription, and some laws even forbade refilling these prescriptions. But the absence of any federal control over interstate commerce in habit-forming drugs, of uniformity among the state laws and of effective enforcement meant that the rising tide of legislation directed at opiates--and later cocaine--was more a reflection of changing public attitude toward these drugs than an effective reduction of supplies to users. Indeed, the decline noted after the mid-1890s was probably related mostly to the public's growing fear of addiction and of the casual social use of habit-forming substances rather than to any successful campaign to reduce supplies. At the same time, health professionals were developing more specific treatments for painful diseases, finding less dangerous analgesics (such as aspirin) and beginning to appreciate the addictive power of the hypodermic syringe. By now the public had learned to fear the careless, and possibly addicted, physician. In A Long Day's Journey into Night, Eugene O'Neill dramatized the painful and shameful impact of his mother's physician-induced addiction. In a spirit not unlike that of our times, Americans in the last decade of the 19th century grew increasingly concerned about the environment, adulterated foods, destruction of the forests and the widespread use of mood-altering drugs. The concern embraced alcohol as well. The Anti-Saloon League, founded in 1893, led a temperance movement toward prohibition, which later was achieved in 1919 and became law in January 1920. After overcoming years of resistance by over-the-counter, or patent, medicine manufacturers, the federal government enacted the Pure Food and Drug Act in 1906. This act did not prevent sales of addictive drugs like opiates and cocaine, but it did require accurate labeling of contents for all patent remedies sold in interstate commerce. Still, no national restriction existed on the availability of opiates or cocaine. The solution to this problem would emerge from growing concern, legal ingenuity and the unexpected involvement of the federal government with the international trade in narcotics. Responsibility for the Philippines in 1898 added an international dimension to the growing domestic alarm about drug abuse. It also revealed that Congress, if given the opportunity, would prohibit non-medicinal uses of opium among its new dependents. Civil Governor William Howard Taft proposed reinstituting an opium monopoly--through which the previous Spanish colonial government had obtained revenue from sales to opium merchants--and using those profits to help pay for a massive public education campaign. President Theodore Roosevelt vetoed this plan, and in 1905 Congress mandated an absolute prohibition of opium for any purpose other than medicinal use. To deal efficiently with the antidrug policy established for the Philippines, a committee from the Islands visited various territories in the area to see how others dealt with the opium problem. The benefit of controlling narcotics internationally became apparent. In early 1906 China had instituted a campaign against opium, especially smoking opium, in an attempt to modernize and to make the Empire better able to cope with continued Western encroachments on its sovereignty. At about the same time, Chinese anger at maltreatment of their nationals in the U.S. seethed into a voluntary boycott of American goods. Partly to appease the Chinese by aiding their antiopium efforts and partly to deal with uncontrollable smuggling within the Philippine Archipelago, the U.S. convened a meeting of regional powers. In this way, the U.S. launched a campaign for worldwide narcotics traffic control that would extend through the years in an unbroken diplomatic sequence from the League of Nations to the present efforts of the United Nations. The International Opium Commission, a gathering of 13 nations, met in Shanghai in February 1909. The Protestant Episcopal bishop of the Philippines, Charles Henry Brent, who had been instrumental in organizing the meeting, was chosen to preside. Resolutions noting problems with opium and opiates were adopted, but they did not constitute a treaty, and no decisions bound the nations attending the commission. In diplomatic parlance, what was needed now was a conference not a commission. The U.S. began to pursue this goal with determination. The antinarcotics campaign in America had several motivations. Appeasement of China was certainly one factor for officials of the State Department. The department's opium commissioner, Hamilton Wright, thought the whole matter could be "used as oil to smooth the troubled water of our aggressive commercial policy there." Another reason was the belief, strongly held by the federal government today, that controlling crops and traffic in producing countries could most efficiently stop U.S. nonmedical consumption of drugs. To restrict opium and coca production required worldwide agreement and, thus, an international conference. After intense diplomatic activity, one was convened in the Hague in December 1911. Brent again presided, and on January 23, 1912, the 12 nations represented signed a convention. Provision was made for the other countries to comply before the treaty was brought into force. After all, no producing or manufacturing nation wanted to leave the market open to nonratifying nations. The convention required each country to enact domestic legislation controlling narcotics trade. The goal was a world in which narcotics were restricted to medicinal use. Both the producing and consuming nations would have control over their boundaries. After his return from Shanghai, Wright labored to craft a comprehensive federal antinarcotics law. In his path loomed the problem of states' rights. The health professions were considered a major cause of patient addiction. Yet how could federal law interfere with the prescribing practices of physicians or require that pharmacists keep records? Wright settled on the federal government's power to tax; the result, after prolonged bargaining with pharmaceutical, import, export and medicinal interests, was the Harrison Act of December 1914. Representative Francis Burton Harrison's association with the act was an accidental one, the consequence of his introduction of the administration's bill. If the chief proponent and negotiator were to be given eponymic credit, it should have been called the Wright Act. It could even have been called a second Mann Act, after Representative James Mann, who saw the bill through to passage in the House of Representatives, for by that time Harrison had become governor-general of the Philippines. The act required a strict accounting of opium and coca and their derivatives from entry into the U.S. to dispensing to a patient. To accomplish this control, a small tax had to be paid at each transfer, and permits had to be obtained by applying to the Treasury Department. Only the patient paid no tax, needed no permit and, in fact, was not allowed to obtain one. Initially Wright and the Department of Justice argued that the Harrison Act forbade indefinite maintenance of addiction unless there was a specific medical reason such as cancer or tuberculosis. This interpretation was rejected in 1916 by the Supreme Court--even though the Justice Department argued that the Harrison Act was the domestic implementation of the Hague Opium Convention and therefore took precedence over states' rights. Maintenance was to be allowed. That decision was short-lived. In 1919 the Supreme Court, led by Oliver Wendell Holmes and Louis Brandeis, changed its mind by a 5-4 vote. The court declared that indefinite maintenance for "mere addiction" was outside legitimate medical practice and that, consequently, prohibiting it did not constitute interference with a state's right to regulate physicians. Second, because the person receiving the drugs for maintenance was not a bona fide patient but just a recipient of drugs, the transfer of narcotics defrauded the government of taxes required under the Harrison Act. During the 1920s and 1930s, the opiate problem, chiefly morphine and heroin, declined in the U.S., until much of the problem was confined to the periphery of society and the outcasts of urban areas. There were exceptions: some health professionals and a few others of middle class or higher status continued to take opiates. America's international efforts continued. After World War I, the British and U.S. governments proposed adding the Hague Convention to the Versailles Treaty. As a result, ratifying the peace treaty meant ratifying the Hague Convention and enacting a domestic law controlling narcotics. This incorporation led to the British Dangerous Drugs Act of 1920, an act often misattributed to a raging heroin epidemic in Britain. In the 1940s some Americans argued that the British system provided heroin to addicts and, by not relying on law enforcement, had almost eradicated the opiate problem. In fact, Britain had no problem to begin with. This argument serves as an interesting example of how the desperate need to solve the drug problem in the U.S. tends to create misperceptions of a foreign drug situation. The story of cocaine use in America is somewhat shorter than that of opium, but it follows a similar plot. In 1884 purified cocaine became commercially available in the U.S. At first the wholesale cost was very high--$5 to $10 a gram--but it soon fell to 25 cents a gram and remained there until the price inflation of World War I. Problems with cocaine were evident almost from the beginning, but popular opinion and the voices of leading medical experts depicted cocaine as a remarkable, harmless stimulant. William A. Hammond, one of America's most prominent neurologists, extolled cocaine in print and lectures. By 1887 Hammond was assuring audiences that cocaine was no more habit-forming than coffee or tea. He also told them of the "cocaine wine" he had perfected with the help of a New York druggist: two grains of cocaine to a pint of wine. Hammond claimed that this tonic was far more effective than the popular French coca wine, probably a reference to Vin Mariani, which he complained had only half a grain of cocaine to the pint. Coca-Cola was also introduced in 1886 as a drink offering the advantages of coca but lacking the danger of alcohol. It amounted to a temperance coca beverage. The cocaine was removed in 1900, a year before the city of Atlanta, Ga., passed an ordinance (and a state statute the following year) prohibiting provision of any cocaine to a consumer without a prescription. Cocaine is one of the most powerful of the central nervous system euphoriants. This fact underlay cocaine's quickly growing consumption and the ineffectiveness of the early warnings. How could anything that made users so confident and happy be bad? Within a year of cocaine's introduction, the Parke-Davis Company provided coca and cocaine in 15 forms, including coca cigarettes, cocaine for injection and cocaine for sniffing. Parke-Davis and at least one other company also offered consumers a handy cocaine kit. (The Parke-Davis kit contained a hypodermic syringe.) The firm proudly supplied a drug that, it announced, "can supply the place of food, make the coward brave, the silent eloquent and...render the sufferer insensitive to pain." Cocaine spread rapidly throughout the nation. In September 1886 a physician in Puyallup, Washington Territory, reported an adverse reaction to cocaine during an operation. Eventually reports of overdoses and idiosyncratic reactions shifted to accounts of the social and behavioral effects of and the increasing instances of cocaine being linked with violence and paranoia gradually took hold in popular and medical thought. In 1907 an attempt was made in New York State to shift the responsibility for cocaine's availability from the open market to medical control. Assemblyman Alfred E. Smith, later the governor of New York and in 1928 the Democratic party's presidential candidate, sponsored such a bill. The cost of cocaine on New York City streets, as revealed by newspaper and police accounts after the law's enactment, was typically 25 cents a packet, or "deck." Although 25 cents may seem cheap, it was actually slightly higher than the average industrial wage at that time, which was about 20 cents an hour. Packets, commonly glycine envelopes, usually contained one to two grains (65 to 130 milligrams), or about a tenth of a gram. The going rate was roughly 10 times that of the wholesale price, a ratio not unlike recent cocaine street prices, although in the past few years the street price has actually been lower in real value than what it was in 1910. Several similar reports from the years before the Harrison Act of 1914 suggest that both the profit margin and the street price of cocaine were unaffected by the legal availability of cocaine from a physician. Perhaps the formality of medical consultation and the growing antagonism among physicians and the public toward cocaine helped to sustain the illicit market. In 1910 William Howard Taft, then president of the U.S., sent to Congress a report that cocaine posed the most serious drug problem America had ever faced. Four years later President Woodrow Wilson signed into law the Harrison Act, which, in addition to its opiate provisions, permitted the sale of cocaine only through prescriptions. It also forbade any trace of cocaine in patent remedies, the most severe restriction on any habit-forming drug to that date. (Opiates, including heroin, could still be present in small amounts in nonprescription remedies, such as cough medicines.) Although the press continued to reveal Hollywood scandals and under-world cocaine practices during the 1920s, cocaine use gradually declined as a societal problem. The laws probably hastened the trend, and certainly the tremendous public fear reduced demand. By 1930 the New York City Mayor's Committee on Drug Addiction was reporting that "during the last 20 years cocaine as an addiction has ceased to be a problem." Unlike opiates and cocaine, marijuana was introduced during a period of drug intolerance. Consequently, it was not until the 1960s, 40 years after marijuana cigarettes had arrived in America, that it was widely used. The practice of smoking cannabis leaves came to the U.S. with Mexican immigrants, who had come North during the 1920s to work in agriculture, and it soon extended to white and black jazz musicians. As the Great Depression of the 1930s settled over America, the immigrants became an unwelcome minority linked with violence and with growing and smoking marijuana. Western states pressured the federal government to control marijuana use. The first official response was to urge adoption of a uniform state antinarcotics law. Then a new approach became feasible in 1937, when the Supreme Court upheld the National Firearms Act. This act prohibited the transfer of machine guns between private citizens without purchase of a transfer tax stamp--and the government would not issue the necessary stamp. Prohibition was implemented through the taxing power of the federal government. Within a month of the Supreme Court's decision, the Treasury Department testified before Congress for a bill to establish a marijuana transfer tax. The bill became law, and until the Comprehensive Drug Abuse Act of 1970, marijuana was legally controlled through a transfer tax for which no stamps or licenses were available to private citizens. Certainly some people were smoking marijuana in the 1930s, but not until the 1960s was its use widespread. Around the time of the Marihuana Tax Act of 1937, the federal government released dramatic and exaggerated portrayals of marijuana's effects. Scientific publications during the 1930s also fearfully described marijuana's dangers. Even Walter Bromberg, who thought that marijuana made only a small contribution to major crimes, nevertheless reported the drug was "a primary stimulus to the impulsive life with direct expression in the motor field." Marijuana's image shifted during the 1960s, when it was said that its use at the gigantic Woodstock gathering kept peace--as opposed to what might have happened if alcohol had been the drug of choice. In the shift to drug toleration in the late 1960s and early 1970s, investigators found it difficult to associate health problems with marijuana use. The 1930s and 1940s had marked the nadir of drug toleration in the U.S., and possibly the mood of both times affected professional perception of this controversial plant. After the Harrison Act, the severity of federal laws concerning the sale and possession of opiates and cocaine gradually rose. As drug use declined, penalties increased until 1956, when the death penalty was introduced as an option by the federal government for anyone older than 18 providing heroin to anyone younger than 18 (apparently no one was ever executed under this statute). At the same time, mandatory minimum prison sentences were extended to 10 years. After the youthful counterculture discovered marijuana in the 1960s, demand for the substance grew until about 1978, when the favorable attitude toward it reached a peak. In 1972 the Presidential Commission on Marihuana and Drug Abuse recommended "decriminalization" of marijuana, that is, legal possession of a small amount for personal use. In 1977 the Carter administration formally advocated legalizing marijuana in amounts up to an ounce. The Gallup Poll on relaxation of laws against marijuana is instructive. In 1980, 53 percent of Americans favored legalization of small amounts of marijuana; by 1986 only 27 percent supported that view. At the same time, those favoring penalties for marijuana use rose from 43 to 67 percent. This reversal parallels the changes in attitude among high school students revealed by the Institute of Social Research at the University of Michigan. The decline in favorable attitudes toward marijuana that began in the late 1970s continues. In the past few years we have seen penalties rise again against users and dealers. The recriminalization of marijuana possession by popular vote in Alaska in 1990 is one example of such a striking reversal. In addition to stricter penalties, two other strategies, silence and exaggeration, were implemented in the 1930s to keep drug use low and prevent a recurrence of the decades-long, frustrating and fearful antidrug battle of the late 19th and early 20th centuries. Primary and secondary schools instituted educational programs against drugs. Then policies shifted amid fears that talking about cocaine or heroin to young people, who now had less exposure to drugs, would arouse their curiosity. This concern led to a decline in drug-related information given during school instruction as well as to the censorship of motion pictures. The Motion Picture Association of America, under strong public and religious pressure, decided in 1934 to refuse a seal of approval for any film that showed narcotics. This prohibition was enforced with one exception--To the Ends of the Earth, a 1948 film that lauded the Federal Bureau of Narcotics--until Man with a Golden Arm was successfully exhibited in 1956 without a seal. Associated with a decline in drug information was a second, apparently paradoxical strategy: exaggerating the effects of drugs. The middle ground was abandoned. In 1924 Richmond P. Hobson, a nationally prominent campaigner against drugs, declared that one ounce of heroin could addict 2,000 persons. In 1936 an article in the American Journal of Nursing warned that a marijuana user "will suddenly turn with murderous violence upon whomever is nearest to him. He will run amuck with knife, axe, gun, or anything else that is close at hand, and will kill or maim without any reason." A goal of this well-meaning exaggeration was to describe drugs so repulsively that anyone reading or hearing of them would not be tempted to experiment with the substances. One contributing factor to such a publicity campaign, especially regarding marijuana, was that the Depression permitted little money for any other course of action. Severe penalties, silence and, if silence was not possible, exaggeration became the basic strategies against drugs after the decline of their first wave of use. But the effect of these tactics was to create ignorance and false images that would present no real obstacle to a renewed enthusiasm for drugs in the 1960s. At the time, enforcing draconian and mandatory penalties would have filled to overflowing all jails and prisons with the users of marijuana alone. Exaggeration fell in the face of the realities of drug use and led to a loss of credibility regarding any government pronouncement on drugs. The lack of information erased any awareness of the first epidemic, including the gradually obtained and hard-won public insight into the hazards of cocaine and opiates. Public memory, which would have provided some context for the antidrug laws, was a casualty of the antidrug strategies. The earlier and present waves of drug use have much in common, but there is at least one major difference. During the first wave of drug use, antidrug laws were not enacted until the public demanded them. In contrast, today's most severe antidrug laws were on the books from the outset; this gap between law and public opinion made the controls appear ridiculous and bizarre. Our current frustration over the laws' ineffectiveness has been greater and more lengthy than before because we have lived through many years in which antidrug laws lacked substantial public support. Those laws appeared powerless to curb the rise in drug use during the 1960s and 1970s. The first wave of drug use involved primarily opiates and cocaine. The nation's full experience with marijuana is now under way (marijuana's tax regulation in 1937 was not the result of any lengthy or broad experience with the plant). The popularity and growth in demand for opiates and cocaine in mainstream society derived from a simple factor: the effect on most people's physiology and emotions was enjoyable. Moreover, Americans have recurrently hoped that the technology of drugs would maximize their personal potential. That opiates could relax and cocaine energize seemed wonderful opportunities for fine-tuning such efforts. Two other factors allowed a long and substantial rise in consumption during the 1800s. First, casualties accumulate gradually; not everyone taking cocaine or opiates becomes hooked on the drug. In the case of opiates, some users have become addicted for a lifetime and have still been productive. Yet casualties have mounted as those who could not handle occasional use have succumbed to domination by drugs and by drug-seeking behavior. These addicts become not only miserable themselves but also frightening to their families and friends. Such cases are legion today in our larger cities, but the percentage of those who try a substance and acquire a dependence or get into serious legal trouble is not 100 percent. For cocaine, the estimate varies from 3 to 20 percent, or even higher, and so it is a matter of time before cocaine is recognized as a likely danger. Early in the cycle, when social tolerance prevails, the explanation for casualties is that those who succumb to addiction are seen as having a physiological idiosyncrasy or "foolish trait." Personal disaster is thus viewed as an exception to the rule. Another factor minimizing the sense of risk is our belief in our own invulnerability--that general warnings do not include us. Such faith reigns in the years of greatest exposure to drug use, ages 15 to 25. Resistance to a drug that makes a user feel confident and exuberant takes many years to permeate a society as large and complex as the U.S. The interesting question is not why people take drugs, but rather why they stop taking them. We perceive risk differently as we begin to reject drugs. One can perceive a hypothetical 3 percent risk from taking cocaine as an assurance of 97 percent safety, or one can react as if told that 3 percent of New York/Washington shuttle flights crash. Our exposure to drug problems at work, in our neighborhood and within our families shifts our perception, gradually shaking our sense of invulnerability. Cocaine has caused the most dramatic change in estimating risk. From a grand image as the ideal tonic, cocaine's reputation degenerated into that of the most dangerous of drugs, linked in our minds with stereotypes of mad, violent behavior. Opiates have never fallen so far in esteem, nor were they repressed to the extent cocaine had been between 1930 and 1970. Today we are experiencing the reverse of recent decades, when the technology of drug use promised an extension of our natural potential. Increasingly we see drug consumption as reducing what we could achieve on our own with healthy food and exercise. Our change of attitude about drugs is connected to our concern over air pollution, food adulteration and fears for the stability of the environment. Ours is an era not unlike that early in this century, when Americans made similar efforts at self-improvement accompanied by an assault on habit-forming drugs. Americans seem to be the least likely of any people to accept the inevitability of historical cycles. Yet if we do not appreciate our history, we may again become captive to the powerful emotions that led to draconian penalties, exaggeration or silence. FURTHER READING AMERICAN DIPLOMACY AND THE NARCOTICS TRAFFIC, 1900-1939. Arnold H. Taylor. Duke University Press, 1969. DRUGS IN AMERICA: A SOCIAL HISTORY, 1800-1980. H. Wayne Morgan. Syracuse University Press, 1981. DARK PARADISE: OPIATE ADDICTION IN AMERICA BEFORE 1940. David T. Courtwright. Harvard University Press, 1982. THE AMERICAN DISEASE: ORIGINS OF NARCOTIC CONTROL. Expanded Edition. David F. Musto. Oxford University Press, 1987. AMERICA'S FIRST COCAINE EPIDEMIC. David F. Musto in Wilson Quarterly, pages 59-65; Summer 1989. ILLICIT PRICE OF COCAINE IN TWO ERAS: 1908-14 AND 1982-89. David F. Musto in Connecticut Medicine, Vol. 54, No. 6, pages 321-326; June 1990. DAVID F. MUSTO is professor of psychiatry at the Child Study Center and professor of the history of medicine at Yale University. He earned his medical degree at the University of Washington and received his master's in the history of science and medicine from Yale. Musto began studying the history of drug and alcohol use in the U.S. when he worked at the National Institute of Mental Health in the 1960s. He has served as a consultant for several national organizations, including the Presidential Commission on the HIV epidemic. From 1981 until 1990, Musto was a member of the Smithsonian Institution's National Council. ============================================================================== Citation: U.S. News & World Report, Sept 11, 1989 v107 n10 p18(3) Title: Now, for the real drug war. (American military aid to Colombian narcotics interdiction campaign) ============================================================================== Full Text COPYRIGHT U.S. News and World Report Inc. 1989 As George Bush was putting the final touches on his national drug strategy last week, a bomb strapped to an ice-cream vendor's bicycle exploded in a paint factory nearly 5,000 miles away and, oddly enough, the two events were related. When Bush fills in the blanks on the new drug plan this week, in his first primetime address to the nation from the Oval Office, he will have much to say about the bombs of August in Colombia, and there is plenty of reason to think that America's war on drugs, stalled for so long by bureaucratic infighting and political myopia, may finally get itself into gear. Since 1981, the United States has spent $21.3 billion trying to keep drugs out of innercity schools, suburban living rooms and corporate boardrooms. And still the drugs came. Now, a few faraway bombs and murders, and one frail Colombian's stern words to American users, have pushed a President and a nation to try a new way to dam the river of drugs. "Go to the source," Bush's advisers told him. And that is what he intends to do, though there is no guarantee that it will work. Whether Bush likes it or not, the $65 million in helicopters and other hardware he authorized for Colombia is just the beginning. One drug baron, Pablo Escobar, fled to Panama (see box), a move that could encourage the U.S. to take harsher measures against his hostand Washington's nemesis-Gen. Manuel Noriega, himself an indicted drug dealer. Other nations, locked in combat with drug barons, will be watching carefully to judge the depth of the latest U.S. commitment to the drug war. Within the law-enforcement community and the military, and among Republicans and Democrats, there is general agreement that military aid to drug-producing countries has potential and ought to be tried. Across Latin America, there is a growing realization now that narcodollars are not enriching but destabilizing. The strategy could work on two levels. Besides trying to reduce the influx, Washington's new war on drugs is intended to help Latin democracies such as Colombia defend themselves against the cocaine cartels. "Drugs," says Lee Hamilton, a senior Democrat on the House Foreign Affairs Committee, "have become a top foreign-policy priority." In Latin America, cocaine has become for Bush what Communism was for Ronald Reagan. For the deep thinkers of American diplomacy, the drug issue, so long a poor cousin to grander strategic concerns, has finally hit the big time, Down-payment time. How much Bush has looked at the long-term implications of his new strategy is unclear, though he seems to have a good grasp of the cost. The $7.8 billion drug package he unveils this week provides for more than $300 million in aid to Colombia and its Andean neighbors, up from $162.6 million this year. The $300 million, officials say, is just the first installment on a five-year program that will cost $1.5 billion. Economic aid has not worked in the past to wean local coca-growing peasants from their crop, and Bush advisers are betting that a military campaign could be more productive. Bush's motives in elevating his commitment to the drug war are mixed. No doubt he was moved by the emotional address last week of Colombia's aging President, Virgilio Barco. "Those of you who depend on cocaine," Barco told a TV audience in halting English, "have created the largest, most vicious criminal enterprise the world has ever known." There is also political benefit to taking on cocaine crooks. Republican pollster Richard Wirthlin says drugs are hot, the rough equivalent of Americans' concern over inflation in 1981 and unemployment in 1983. "The risk of ignoring this issue," Wirthlin says, "is one hundred times worse than the risk of trying to do something in a credible way." That is hardly the most exalting thought to begin a long and dangerous war, but it probably means Bush must remain committed to the escalated drug war for the foreseeable future. Yet going to the source is a risky business, and there is no guarantee of success. In Colombia, for instance, Barco's crackdown has netted none of the most important cocaine traffickers. In time, the new U.S. helicopters, machine guns and sniper scopes will certainly help the military and police shut down more cocaine labs and seize more drug-financed planes, homes and businesses. But even that might not make much of a dent in the supply of cocaine reaching the United States. The cocaine barons have enormous resources. One plant raided last month by Colombian police and an Army unit had the production capacity of a mid-sized American manufacturing firm, The police seized a half-million gallons of chemicals and 1,200 kilograms of cocaine hydrochloride. Buried under a road were six 22,000-gallon tanks of the type service stations use to store gasoline. In this case, the tanks held ether, a key agent in the production of cocaine. Enough plants of this size, and Bush and Barco may conclude there are simply too many sources to go to them all. And each is fraught with peril. The first shipments of military equipment to Colombia will be accompanied by American mechanics, pilots and as many as 100 advisers. Virtually everyone agrees that U.S. troops would never be sent overseas to fight the drug barons' armies. Indeed, there will likely be few armed confrontations with those in the employ of the big traffickers. Rather, the war will be more like the Irish troubles in Belfast: Bombings and assassinations but no pitched battles. That is not a situation in which U.S. troops would be of much use, in any event. American noncombatants would be ready targets, however, and the dilemma for Bush will eventually arise: How many killed or wounded Americans will it take before there are American cries that the price is too high? Operation Snowcap. Paramilitary missions will resume this week after a sevenmonth suspension following attacks on American personnel. The project, called Operation Snowcap, is being run jointly by the U.S. Drug Enforcement Administration and the State Department. Its intent is to provide armed DEA agents to assist police in Peru and Bolivia in search-and-destroy missions on cocaineprocessing facilities, Snowcap is directed at the world's two most productive cocagrowing areas, the Chapare region of Bolivia and the Upper Huallaga Valley in Peru. When Snowcap first got started, in early 1988, it was roundly criticized. DEA agents were poorly trained for paramilitary operations. Some did not even speak Spanish. No one anticipated the worst problem, however. Snowcap agents were regularly fired upon, a U.S. Embassy official on a helicopter run was shot and wounded and Peruvian police were ambushed and killed. Since then, training has been improved, and the DEA has built a fortified base camp in the Huallaga Valley town of Santa Lucia. The agency believes the operation is worth the risk. "We've got two places shooting cocaine at the U.S.," Charles Gutensohn, DEA's head of cocaine investigations, says, referring to Peru and Bolivia. "We can run along the border forever and try to catch loads as they come. Or we can go down to those two countries and try to stop the flow out." If it reduces the flow of cocaine to the U.S., the go-to-the-source strategy will be hailed a success. Even if it does not, it represents an important shift in thinking on an issue too long crippled by lack of vision. This week, Bush will present new proposals for treatment and education programs. On the supply side, the Pentagon, which has never been enthused about the drug war, has changed its tune, officials say. Though troops are out, covert operations against drug traffickers-kidnappings, disruption or sabotage of supplies and processing facilities-are not. The Pentagon will also probably be deeply involved in a multinational antinarcotics force, a kind of supranational SWAT team that has generated enthusiasm from Caribbean and Latin American leaders. Perhaps the greatest potential benefit of Bush's new commitment to Colombia is the signal it sends. Barco had long been opposed to the cocaine cartels, but to many of his countrymen they were symbols of great success in a land of great _poverty. When the cartels finally lost that support, having killed one Colombian too many, Barco stood up to them and the U.S. stood with him. "Why the $65 million?" asks Melvyn Levitsky, assistant secretary of state for international narcotics matters. "They were ready for it." There is still plenty of corruption in the Colombian police and military, and Barco may not prevail against the traffickers, but there is no gainsaying his will to fight. Other countries watching the Colombian experiment may take heart ftom it. And if the U.S. can encourage them, with guns, helicopters and other assistance, it could begin to turn the tide in its long war against drugs. After all, almost nothing else has worked. TIME TO SNATCH NORIEGA AND ESCOBAR? The gutsy Panama option Manuel Noriega just doesn't get it. While Colombia, Mexico and even Fidel Castro in Cuba have all declared war on the hemisphere's biggest drug dealers, the Panamanian dictator wants to be their friend and protector. U.S. intelligence officials say Pablo Escobar, an indicted leader of the Medellin cartel, sought refuge in Panama after the government crackdown on the drug dealers in Colombia began two weeks ago. They suspect some of Colombia's other big cocaine traffickers also have alighted in Panama, and that increases the chances of bolder U.S. action against Noriega or his guest. "Lot of macho." The Noriega-cartel alliance's profits are handsome. The U.S. estimates Noriega's personal profits from drug deals with the Medellin cocaine cartel somewhere between $200 million and $300 million. Besides the mansion in Panama City, the farm in France and the three Lear jets, Noriega's narcodollars have bought him three large yachts, the Macho 1, the Macho 11 and the Macho III. "That," Deputy Secretary of State Lawrence Eagleburger said last week, "is a lot of macho." Too much, in fact. Even as the Bush administration was turning up the heat on Noriega again last week, the pock-faced general was appointing a new President of Panama, an old buddy of his from high school named Francisco Rodriguez. Noriega annulled the results of elections in May, when his candidates lost. The new arrangement lets him continue as Panama's de-facto leader. Such political shenanigans were expected, but Noriega has now added insult to injury by allowing the drug kings safe haven and giving Washington new incentive to dislodge him. So far, Noriega has laughed off all U.S. attempts to topple him, and Washington has balked at using direct military force and confined its covert operations to supporting Panama's feeble political opposition. The dictator faces two indictments for drug dealing in tbe U.S., and he has refused to leave his country while the charges are pending. The latest occurrences, though, have created a rare constellation of events that could enable Bush to act. He broke off diplomatic relations with Panama last week and ordered new currency restrictions to deny cash to the puppet government. But he could do more. There are fewer qualms in the intelligence community and Congress about taking direct action against drug dealers. Bush needs no permission from the government of Panama to act there; the U.S. does not recognize its authority. Grabbing Escobar would deeply embarrass Noriega and send a powerful signal to Latin nations at war with the traffickers. Getting Escobar and Noriega would be best of all, however. For Bush, the temptation is probably growing. ==============================================================================