The U.S. War on Drugs, initiated in the 1970s, has led to significant societal costs, criminalization, and limited success in addressing substance use disorders (SUD). This paper examines the early history of U.S. drug policies, the economic burden of the War on Drugs, and explores successful international models that focus on rehabilitation rather than punishment. Ultimately, it argues for a reevaluation of the U.S. approach to substance abuse.
Early History and the Impact of Alcohol Prohibition
The failure of alcohol prohibition in the early 20th century is a powerful historical analogy for the current War on Drugs. Just as prohibition did not eradicate alcohol use but drove it underground, modern drug prohibition has not eliminated drug use. Instead, it has fueled black markets and associated crime, worsened public health outcomes, and resulted in unregulated and dangerous varieties of alcohol sold occultly.
Moreover, the repeal of prohibition—being almost exclusively focused on decriminalizing alcohol and alcohol users–exemplifies the failure of policies focused solely on drug use regulation without accompanying rehabilitation efforts. After the repeal of alcohol prohibition in 1933, there was a notable decline in organized crime, law enforcement, and judicial costs, along with improvements in public health due to access to safer alcohol.1 The government also gained $20 billion annually in tax revenue. However, alcohol use disorder (AUD) rates increased after the repeal, now exacting a staggering toll: (1) 30 million people in the U.S. have an AUD, (2) about 178,000 people die from excessive alcohol use annually,2 and (3) AUD costs the U.S. an estimated $300 billion annually, according to the CDC.3
Repealing prohibition was not accompanied by significant efforts to prevent, treat, or research AUD. In fact, the first federal funding targeted for AUD came 40 years later in 1971, when $6.5 million was allocated to the newly formed NIAAA (National Institute on Alcohol Abuse and Alcoholism).4 Today, while the annual budget for addressing AUD has grown to about $500 million, it represents only 1% of the War on Drugs (WoD) budget.
Historical Evolution of the War on Drugs
In 1971, President Nixon declared drug abuse as “public enemy number one” in the U.S. and stated “(T)o,” which took the form of the establishment of the DEA and mandatory sentencing for drug crimes.5 This marked the beginning of the War on Drugs.
Under the Reagan and Clinton administrations, the War on Drugs escalated further, with mandatory arrests for drug crimes skyrocketing from 300,000 in 1971 to 1.16 million in 2022.6 Criminalizing drug possession and users created significant stigma toward individuals with substance use disorders (SUD). Imagine if obesity were treated similarly, with laws criminalizing the possession of fattening food and punishing those who consume it. This harsh treatment fosters mistrust and secrecy among those struggling with addiction.
Economics of the War on Drugs
The U.S. spends $50 billion annually on the WoD: $30 billion for enforcement, $10 billion for incarceration, and only $10 billion for prevention and treatment.7 To put this into perspective, the WoD budget is 25 times the NIH addiction research budget ($2 billion), 7 times the NIH cancer research budget ($7.3 billion), and 6 times the CDC’s public health budget ($8.4 billion). Meanwhile, drug users spend $150 billion per year on illicit drugs, with approximately $90 billion (60%) flowing to drug cartels, $37.5 billion (25%) toward weapons, and $22.5 billion (15%) to corruption and bribes.8
Outcomes of the War on Drugs (1970s–2022)
Despite decades of effort, the WoD has failed to decrease overall drug use. Marijuana use increased by 1.4 times (from 13% to 19%), heroin use tripled (from 0.1% to 0.3%), and while cocaine use decreased slightly (from 1.5% to 0.9%), overall illicit drug use has remained steady at around 13.5%.
Incarceration rates have surged, with drug-related incarcerations increasing ninefold to account for 25% of the total incarcerated population—resulting in 2 million people being imprisoned annually for drug-related charges. Notably, Black men are incarcerated at a rate 5.5 times higher than white men, with 1 in 3 Black men born in the 1980s being incarcerated, compared to 1 in 17 white men.9 This disproportionate incarceration is a clear violation of the 14th Amendment’s Equal Protection Clause, which guarantees that laws must be applied equally without discrimination.
Healthcare outcomes have also worsened. Each year, there are over 1.3 million drug-related emergency room visits and more than 1 million drug-related hospitalizations.10 Overdose deaths have risen dramatically, increasing 16-fold from 6,100 to over 100,000 per year.11
Global Alternatives and Policy Experiments
Portugal’s decriminalization of all drug use (but not sale) in 2001, paired with improved treatment, provides a successful model of drug regulation coupled with drug user rehabilitation. As a result of these changes drug-related deaths decreased by 94%, HIV rates among drug users dropped by 75%, and heroin use declined by 50%. Portugal saved $225 million annually from reduced criminal justice and healthcare costs, illustrating that regulation combined with rehabilitation is effective.12-14 Such results stand in contrast to the outcomes of U.S. policies, highlighting the importance of a shift from punishment to regulation with rehabilitation.
Switzerland’s Heroin-Assisted Treatment (HAT) program also shows promising results from their regulation and rehabilitation approach. Property crimes committed by participants have decreased by 60%, new HIV cases have dropped by 50%, and 70–80% of participants stopped using illicit heroin after one year. Long-term, 20–40% transitioned off heroin entirely. The program generates net savings of $37.5 million per year, with a 2–3 times return on investment.15
These are just two of many examples illustrating how changing drug policies, paired with increased treatment efforts, can effectively combat addiction, reduce harm, and save resources. These examples suggest that the U.S. could achieve similar results by shifting its approach, focusing on rehabilitation rather than criminalization.
Cost-Benefit Analysis of Shifting Spending
A comprehensive analysis of 12 economic studies conducted between 2003 and 2021 found that on average every $1 invested in treatment yields a $4 return in societal savings.16 If the entire $50 billion WoD budget were redirected toward treatment, it could cover 3 million patients annually and generate $250 billion in savings. This includes $80 billion from reduced criminal activity, $75 billion in criminal justice savings, and $95 billion from increased productivity and social services, resulting in a total net savings of $200 billion.
The War on Drugs has failed, causing more harm than good. High incarceration rates, particularly for Black men, and the criminalization of drug users have worsened our present collective situation. By shifting focus from enforcement to rehabilitation, the U.S. could make significant progress in the fight against addiction. It’s time to rethink the national strategy, redirect resources toward evidence-based approaches, and prioritize public health and human dignity. The fallout from the War on Drugs is crippling a generation suffering from addiction, and it is imperative that we act now to make meaningful changes.
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15. Liebrenz M, Gamma A, Buadze A, et al. Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study. Harm Reduct J. Oct 13 2020;17(1):67. doi:10.1186/s12954-020-00412-0
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Blog post written by:
Adam Kaplin, M.D, Ph.D.
MyMD Pharmaceuticals
President Mira1a Pharmaceutical and Adjunct Faculty Johns Hopkins Medicine