US drug policy: A dynamic system of change in a multi-level environment

Issues: A prime example of how where one lives impacts health and health care access can be seen in drug policy: geographical location currently determines the difference between punitive deterrence, a public health approach with treatment access, or (for some substances), open adult use. An incomplete understanding of the variance in drug policy at local, state and national levels limits the effectiveness of advocacy efforts to reduce the costs and harmful consequences resulting from the use and/or abuse of alcohol, tobacco, and other drugs.

Description: This paper uses ecological systems theory and primary data to present how drug policy has been and continues to be developed and applied in the US.

Lessons Learned: Macro-level US drug policy should be understood as two connected yet separate policy levels: federal and state. The mezzo level includes systems and institutions such as public health, treatment and criminal justice. The micro level includes non-systems-level collective advocacy (organizing ballot initiatives and referendums), as well as individual attitudes and behaviors of abstainers, users, substance abuse treatment participants, etc. Each level exerts direct and reciprocal influences within and across other levels.

Recommendations: Recognition and understanding of the multi-level nature of drug policy in the US can strengthen efforts to bring levels of system balance to the very complex recursive US drug policy continuum. There are many potential levers of change that too often have been under-utilized, including recognition of the active role of systems/institutions—such as public health—in policy implementation.