![]() For cocaine, mandatory participation would pose thorny ethical, legal, and political questions, but the drug's illicit status makes such programs plausible (see National Research Council, 2001, Chapters 6 and 8 and Appendix E). 2 Voluntary relapse prevention for either drug seems most feasible and would face few ethical and legal obstacles. In addition to a drug's legal status, a related consideration is whether participation in a pharmacological program would be voluntary or mandatory. Prohibition increases the stigma associated with a drug, although stigma can have both desirable and undesirable consequences (see “ Social Norm Effects” this appendix). But of course the choice of users to target for a pharmacological intervention will also be determined by legal, ethical, economic, and political considerations not considered in this chapter. Relapse prevention I/DMs would disproportionately target right-tail users addiction protection I/DMs would presumably include individuals from the whole range of the use distribution (even including some who would never use anyway), depending on their recruitment process and our accuracy at predicting who is “at risk” for addiction. It will be more effective to target heavy users when the dose-response curve for various harms rises slowly at low doses and when the statistical distribution of consumption is heavily skewed. Everything else being equal, it will be more effective to target typical users when the dose-response curve for various harms rises very quickly with small doses and when typical users account for a large fraction of total consumption. The relative viability of targeting the median user versus hard-core users in the right tail of the distribution will probably vary as a function of several factors ( Edwards et al., 1994 MacCoun, 1998b Rose, 1992). As a result, the harmful consequences of substance use are not uniform but are disproportionately concentrated among the heaviest users. The distribution of consumption across users is strongly positively skewed for most drugs (see Everingham and Rydell, 1994 Skog, 1993)-though less dramatically so for tobacco than cocaine. ![]() In addition to these flows, it is important to consider the “stocks”-the distribution of individuals across these states. If effective, it should increase the flow of light users into nonuse and reduce the flow of nonusers into use. An addiction protection program would target some fraction of light users and perhaps (not shown) newly heavy users and (more controversially) those at high risk who have never used. If effective, it should increase the flow of heavy users into nonuse and reduce the flow of nonusers back into use. Presumably a relapse prevention program would target some fraction of heavy users. Thus, in the spirit of “devil's advocacy,” it has been chosen in this appendix to err on the side of caution, giving greater attention to arguments in support of various unintended consequences than to possible counterarguments (which are nevertheless noted).ĭrug use conceptualized in terms of flows among four distinct drug use states. 1 But the literature on technological risks also documents the dangers posed by excessive optimism on the part of enthusiastic program designers (e.g., Janis, 1983 MacCoun, 1998a Tenner, 1996 Vaughan, 1996). Economists and risk analysts have long noted the opportunity costs in foregone benefits that can result from extreme risk aversion (e.g., Viscusi, 1992 cf. Judgments about whether and how to implement I/DM programs should not necessarily be based solely on worst-case scenarios. “Plausible” is defined here as something more than simply possible but not necessarily “more likely than not.” ![]() This appendix identifies plausible mechanisms by which I/DMs might produce unintended consequences and reviews available evidence on the effects of these mechanisms in the research and clinical literatures on drug use and other risky behaviors. Nevertheless, it is desirable to design I/DM interventions that might minimize such risks. Given the novelty of such interventions and uncertainty about how they might be implemented, it is not possible to forecast either the likelihood or the magnitude of unintended behavioral responses. These actors are likely to change their behavior in both desirable and unintended ways. I/DMs may significantly alter the complex system of relationships among users, sellers, treatment providers, and social control agents. These interventions differ in important respects from other pharmacological treatments for drug addiction and, for that matter, from vaccines used to prevent viral diseases. Immunotherapy or depot medication (henceforth I/DM) programs that would prevent addiction or relapse to such drugs as tobacco or cocaine are largely unprecedented.
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