摘要：Objectives. We tested the hypothesis that higher rates of previous hard drug–related arrests predict lower rates of injection drug use. Methods. We analyzed drug-related arrest data from the Federal Bureau of Investigation's Uniform Crime Reporting Program for 93 large US metropolitan statistical areas in 1992 to 2002 to predict previously published annual estimates of the number of injection drug users (IDUs) per 10 000 population. Results. In linear mixed-effects regression, hard drug–related arrest rates were positively associated (parameter = +1.59; SE = 0.57) with the population rate of IDUs in 1992 and were not associated with change in the IDU rate over time (parameter = −0.15; SE = 0.39). Conclusions. Deterrence-based approaches to reducing drug use seem not to reduce IDU prevalence. Alternative approaches such as harm reduction, which prevents HIV transmission and increases referrals to treatment, may be a better foundation for policy. Injection drug use is a risk factor for HIV, hepatitis B and C, infectious endocarditis, and overdose mortality 1 – 3 and a serious public health and social problem. 4 Each year, more than 1.5 million people inject drugs in the United States, 5 and injection drug use is also widespread internationally 6 ; the effects of public policies on the extent of injection drug use are therefore important public health concerns. 7 , 8 Domestic drug policy in the United States and many other countries has largely been founded on the belief that arrests deter crime. Analysts such as Becker 9 and Tonry and Wilson 10 hold that punishment and stigmatization deter criminal behavior by making it costly for the perpetrator, an idea that has shaped policies to reduce drug use. For example, the International Narcotics Control Board stated, The deterrent effect of law enforcement efforts influences the demand for illicit drugs. The risk of penal sanctions may act as a deterrent to members of the general population who have never abused drugs. Though the risk of such sanctions does not, in all cases, deter addicts who require drugs regardless of the consequences, the impact of law enforcement efforts on supply may force addicts to take advantage of treatment and psychosocial intervention. 11 (p9) In the United States, these arguments have been accompanied by intensified street-level enforcement of drug laws and by increases in drug-related arrests and incarceration: the total number of jail and prison inmates increased from 1.2 million in 1990 to 2.2 million in 2006, 12 , 13 and arrests for unlawful possession, sale, use, or manufacture of illicit drugs rose from 1.0 million to 1.7 million in the same period. 14 Drug-related law enforcement strategies founded on deterrence theory are increasingly controversial because of their cost and, in the United States, their racially disparate effects. At this writing, an estimated 500 000 adults are serving time in a US prison or jail for a drug-related offense. 15 The drug-related incarceration rate for African Americans is 756 per 100 000 adults, more than 8 times that of Whites (90 per 100 000 adults). 16 The drug-related incarceration rate for Latinos falls between these 2 rates, at approximately 300 per 100 000 adults. 16 A recent estimate of the average annual expense per prisoner (i.e., the cost of inmate food, shelter, security, and medical care) is $23 876, 17 suggesting that the United States is now spending almost $12 billion annually to incarcerate 500 000 inmates for drug-related offenses (this figure excludes the cost of drug-related policing initiatives and presentencing expenditures). Considerable evidence suggests that high rates of arrest and incarceration may increase the spread of some infectious diseases, including HIV, sexually transmitted infections, and tuberculosis. 18 – 20 Arrest rates for heroin and cocaine possession or sale in US metropolitan areas in the mid-1990s were associated with higher HIV prevalence among injection drug users (IDUs) in 1998, 21 and arrests of individual drug users have been associated with higher rates of risk behaviors and with difficulty in using prevention programs. 22 – 24 The fear of arrest can induce drug users to become or remain drug injectors (to reduce the amount of drug purchased and thus the frequency with which they have to expose themselves by buying drugs, as well as through stigmatization effects on social integration and self-esteem) and may lead IDUs to inject less safely. 23 , 25 – 28 Furthermore, perhaps by intensifying shortages of men in some communities, high arrest and incarceration rates have been found to be associated with family disruption, excess rates of sexually transmitted infections, and other adverse health outcomes. 24 , 29 In Europe and central Asia, incarceration rates explain population increases in tuberculosis and in multidrug-resistant tuberculosis. 30 Arguably, however, arresting and incarcerating drug users might nevertheless reduce population-wide infectious disease rates by decreasing the pool of individuals at risk for injection-related health problems. This might occur through 2 mechanisms. First, incarcerating drug users removes them from the community. Second, if deterrence works as envisioned by Becker 9 and Wilson and Kelling, 10 arresting drug users would reduce infections in a locality by deterring people from initiating or continuing drug use. In the strictest sense, nonexperimental data cannot prove causality. However, if deterrence arguments are valid, then increasing the arrest rate for drug possession should be followed by decreases in drug use, and decreasing such arrests should be followed by increasing drug use. In others words, if increases in arrest rates cause decreases in drug use, we should at least observe an association, even if the association by itself is not sufficient to prove causality. Also, if there is separation in time between an observed increase in arrest rates and a decrease in drug use, that separation would help establish a causal direction, because it is more plausible that the variable measured earlier is a cause of the variable measured later. Time-lagged measures of arrest rates, along with models that calculate change in the prevalence of IDUs as a function of previous values of arrest rates, used in a regression-based analysis with appropriate controls, can assess deterrence effects. We tested whether changes in arrests for possession of heroin or cocaine in large US metropolitan areas from 1992 to 2002 were associated with later changes in the population prevalence of injection drug use.
