Pubdate: Sat, 02 May 1998 Source: Economist, The (US) Contact: Website: http://www.economist.com GIVE THEM THEIR PILLS, THE FUDDLED MASSES America's addiction is not just to illegal drugs A GOOD general avoids wars he cannot win, which is doubtless one reason why General Barry McCaffrey has never followed political fashion by declaring "a war on drugs". Instead, President Clinton's drugs czar (more properly the director of the Office of National Drug Control Policy) argues that 'cancer is a more appropriate metaphor"~a long-term problem needing a variety of treatments to check its spread and improve its prognosis. Skirmishes, however, are a different matter, especially for a man who was the American army's most decorated combat officer. Last week he was denounced by black members of Congress; indeed, he was allegedly called "a skunk" by Eleanor Holmes Norton, the delegate to Congress from Washington, DC. His offence was to convince Mr Clinton not to allocate federal money to needle-exchange programmes, despite the recommendations of Donna Shalala, the health and human services secretary, and David Satcher, the new surgeon-general, and despite academically respectable studies showing that the provision of free, and so clean, syringes to drug addicts saves some 30 people a day from contracting DIV. General McCaffrey's argument, made all the more persuasive by the ap-proach of this year's congressional elections, was that aiding the programmes would send "the wrong message" about the administration's drugs policy. So what is the right message? This week the general defended himself with an address to the American Bar Association. The outcome of the needle-exchange quarrel is "a democratic solution of tremendous cunning" (others would call a solution that en-courages such programmes but refuses to finance them a fudge). A judicial system that holds 1.7m Americans in prison at any one time, half of them for drug-related offences, does indeed (said the general) bear disproportionately on blacks. It would certainly be better to make greater use of supervised drug-treatment programmes rather than long prison stretches. And it is wrong that a trafficker of just five grams ofcrack cocaine (usually caricatured as a black street hustler) should face a mandatory minimum prison sentence of five years while the threshold quantity of powder cocaine (the form preferred by rich whites) for such a sentence is 500 grams. As to the medical use of marijuana, "Come on!" is the general's first reaction, but he is prepared to change his mind if the drug that Mr. Clinton failed to inhale in his student days can eventually "pass medical and scientific scrutiny". The question is whether any message, right or wrong, is being heard. The general's goal, to be pursued with better education and better high-tech surveillance of America's borders, is to halve the use and avail-ability of narcotics in America by 2007. If he succeeds, illegal drugs will still be a problem for around 6.5m Americans--but that will be the fewest since records began. The peak was 25m, in 1979. Too good to be true? General McCaffrey, declaring himself "reasonably optimistic", points out that the use of illegal drugs has fallen by half over the past decade and that, for the first time in six years, the use by young people has stopped growing. Moreover, as the baby-boomers at last mature, there are some 61m Americans who have stopped using illegal drugs. But that still leaves about 3.6m with a cocaine habit and 810,000 chronic users of heroin. In addition, despite the "Just Say No" slogan that has been common currency since the late Reagan administration, a tenth of all Americans aged 12 and over now smoke marijuana or hashish (marijuana use by high-school students doubled between 1992 and 1995). Meanwhile, among America's 14-year-olds, some 10% use marijuana and some 4% methamphetamines and other stimulants. Whether these figures are encouraging or not is a matter of debate: is the glass half-full or half-empty? What punning pessimists will argue is that drugs meet an American need fora quick fix for any problem, however complex or deep-rooted. Their proof is not just the continuing, albeit "stabilising", demand for narcotics but the burgeoning sales of prescription and over-the-counter drugs for pretty well every ailment, from headaches to baldness. If it twinges, dose it The most recent example is viagra, a pill released a month ago to combat male impo-tence. With American men apparently afflicted by the millions, doctors are doling out viagra at the rate of more than 113,000 prescriptions a week-not quite on a par with the more than 436,000 dished out for the feel-good drug Prozac, but impressive nonetheless-and the share-price of Pfizer, viagra's manufacturer, is soaring. It will rise still higher if the doctors and chemists decide that viagra has a similar use for women (who are apparently as sexually dysfunctional as men). If Viagra and Prozac are extreme cases of pill-lervour, there are plenty of others that are impressive. Sales of anti-ulcerants such as Prilosec and Zantac rose by 9% last year, to $6.2 billion; and sales of anti-psychotics such as Zyprexa rose by 6i% to $1.6 billion. Turn to the morning newspaper or the television evening news and advertisement after advertisement recommends doctor-prescribed remedies for high cholesterol or high blood-pressure. Last year the sales of a single antihistamine, Claritin, rose by 40% to over $900m. Arguably, such sales reflect the general financial excess of the American health-care system: the United States spends more per head of population on pharmaceutical products than any western country apart from France; its spending on outpatient prescriptions has risen more than ten-fold since 1970; and its spending on health as a percentage of gross domestic product has doubled in less than 30 years. But that explanation is only part of the story. The truth is that demand for non-pre-scription drugs has grown every bit as fast. In 1970 the American market for drugs that could be bought over the counter was worth $2.7 billion; last year, it was worth $16.6 billion. The sales of one headache remedy, Tylenol, reached $664m; those of another, Advil, $302m; those of a third, Excedrin, $125m. Add in the various over-the-counter remedies for flatulence, con-stipation, diarrhoea, hayfever and the common cold, and the average American might seem to be a pill-popping hypochondriac. The industry denies this. It explains that many over-the-counter drugs were once available only on prescription, and that to buy them without a prescription saves around $20 billion in direct and indirect health-care costs. "Far from a 'pill-popping' culture", maintains the Nonprescription Drug Manufacturers Association, "Americans turn to over-the counter medicines only 38% of the time they experience a self-treatable condition." Maybe so, although "only" is an elastic word. The industry's surveys also show that Americans are likely to take a non-prescription pill for 75% of the headaches they get, and 73% of their bouts of indigestion. Moreover, mix the wrong legal drugs, or take the wrong dosage, and the result can be disastrous. Some surveys estimate that 140,000 people a year die from the side effects of prescribed drugs. That compares with some 14,000 who die each year from illegal drugs such as heroin-which at least, to quote General McCaffrey, offer "intense pleasure at the subrational level".