The British Medical Journal this week publishes a special edition on drug titled:
'Drug users and HIV: treat don't punish'. the cover feature includes a special commentary section on drugs, HIV/AIDS and harm reduction to coincide with the huge
AIDS 2010 conference in Vienna that kicks off this Sunday (see
this blog for details and Transform's involvement in the Global Village's Drug Policy Networking Zone).
The special edition of the BMJ features five commissioned commentaries, including;
'Alternatives to the war on drugs' by Transform's Steve Rolles, one of the first detailed explorations in a mainsteam medical journal of legal regulatory models as alternatives to existing unregulated criminal drug markets, specifically from a public health perspective. The full text (also available on the
BMJ site here, with
rapid responses here) is copied below as it appears online.
The issue also includes
Professor Tim Rhodes, Anya Sarang, Peter Vickerman, and Professor Matthew Hickman, on ‘Policy resistance to harm reduction for drug users and potential effect of change’;
Richard Hurley on ‘How Ukraine is tackling Europe’s worst HIV epidemic’ and
an editorial on ‘Evidence based policy for illicit drugs’ by Prof Evan Wood (who was on
BBC R4's Today program this Friday discussing these issues and talking about the
Vienna Declaration). These are all now available in full online.
In a significant endorsement, the editor of the BMJ Fiona Godlee, in an editorial titled
'Ideology in the ascendant' , concludes by noting that
:
"In a beautifully argued essay Stephen Rolles calls on us to envisage an alternative to the hopelessly failed war on drugs. He says, and I agree, that we must regulate drug use, not criminalise it."
Also of note is that two other leading journals, the Lancet and
Science, are running special editions on drugs and harm reduction this week. The
Lancet is due to lead with the publication of
the Vienna Declaration calling for science based drug policy and the decriminalisation of drug use. It is the declaration being adopted by the AIDS 2010 conference and supported by a growing list of
public figures from political and scientific establishments.
The BMJ has also produced this excellent short film (below) by Martin Freeth, titled 'HIV shoots up', to go with its special edition. It features Alex Stevens, Tim Rhodes, Gerry Stimson, Steve Rolles and Elzabeth Pisani.
Published 13 July 2010, doi:10.1136/bmj.c3360
Cite this as: BMJ 2010;341:c3360
Analysis
An alternative to the war on drugs
Stephen Rolles, senior policy analyst
1 Transform Drug Policy Foundation, Bristol BS5 0HE
Stephen Rolles argues that we need to end the criminalisation of drugs and instead set up regulatory models that will control drug markets and reduce the health and social harms caused by current policy
Consensus is growing within the drugs field and beyond that
the prohibition on production, supply, and use of certain drugs
has not only failed to deliver its intended goals but has been
counterproductive. Evidence is mounting that this policy has
not only exacerbated many public health problems, such as adulterated
drugs
1 and the spread of HIV and hepatitis B and C infection
among injecting drug users, but has created a much larger set
of secondary harms associated with the criminal market. These
now include vast networks of organised crime, endemic violence
related to the drug market,
2 corruption of law enforcement and
governments, militarised crop eradication programmes (environmental
damage, food insecurity, and human displacement), and funding
for terrorism and insurgency.
3 4
These conclusions have been reached by a succession of committees
and reports including, in the United Kingdom alone, the Police
Foundation,
5 the Home Affairs Select Committee,
6 The prime minister’s
Strategy Unit,
7 the Royal Society of Arts,
8 and the UK Drug
Policy Consortium.
9 The United Nations Office of Drugs and Crime
has also acknowledged the many "unintended negative consequences"
of drug enforcement,
10 increasingly shifting its public rhetoric
away from its former aspirational goals of a "drug free world,"
towards "containment" of the problem at current levels.
Problems of prohibition
Despite this emerging consensus on the nature of the problem,
the debate about how policy can evolve to respond to it remains
driven more by populist politics and tabloid headlines than
by rational analysis or public health principles.
The criminalisation of drugs has, historically, been presented
as an emergency response to an imminent threat rather than an
evidence based health or social policy intervention.
11 Prohibitionist
rhetoric frames drugs as menacing not just to health but also
to our children, national security, and the moral fabric of
society itself. The prohibition model is positioned as a response
to such threats,
12 13 and is often misappropriated into populist
political narratives such as "crackdowns" on crime, immigration,
and, more recently, the war on terror.
This conceptualisation has resulted in the punitive enforcement
of drug policy becoming largely immune from meaningful scrutiny.
14 A curiously self justifying logic now prevails in which the
harms of prohibition—such as drug related organised crime
and deaths from contaminated heroin—are conflated with
the harms of drug use. These policy related harms then bolster
the apparent menace of drugs and justify the continuation, or
intensification, of prohibition. This has helped create a high
level policy environment that routinely ignores or actively
suppresses critical scientific engagement and is uniquely divorced
from most public health and social policy norms, such as evaluation
of interventions using established indicators of health and
wellbeing.
Emerging change
Despite this hostile ideological environment, two distinct policy
trends have emerged in recent decades: harm reduction
15 and
decriminalisation of personal possession and use. Although both
are nominally permitted within existing international legal
frameworks, they pose serious practical and intellectual challenges
to the overarching status quo. Both have been driven by pragmatic
necessity: harm reduction emerging in the mid-1980s in response
to the epidemic of HIV among injecting drug users, and decriminalisation
in response to resource pressures on overburdened criminal justice
systems (and, to a lesser extent, concerns over the rights of
users). Both policies have proved their effectiveness. Harm
reduction is now used in policy or practice in 93 countries,
16 and several countries in mainland Europe,
17 18 and central
and Latin America have decriminalised all drugs, with others,
including states in Australia and the United States, decriminalising
cannabis.
19
Decriminalisation has shown that less punitive approaches do
not necessarily lead to increased use. In Portugal, for example,
use among school age young people has fallen since all drugs
were decriminalised in 2001.
20 More broadly, an extensive World
Health Organization study concluded:
"Globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones."21
Similarly US states that have decriminalised cannabis do not
have higher levels of use than those without. More importantly,
the Netherlands, where cannabis is available from licensed premises,
does not have significantly different levels of use from its
prohibitionist neighbours.
19
New approach
Although these emerging policy trends are important, they can
be seen primarily as symptomatic responses to mitigate the harms
created by the prohibitionist policy environment. Neither directly
tackles the public health or wider social harms created or exacerbated
by the illegal production and supply of drugs.
The logic of both, however, ultimately leads us to confront
the inevitable choice: non-medical drug markets can remain in
the hands of unregulated criminal profiteers or they can be
controlled and regulated by appropriate government authorities.
There is no third option under which drugs do not exist. The
choice needs to be based on an evaluation of which option will
deliver the best outcomes in terms of minimising the harms,
both domestic and international, associated with drug production,
supply, and use. This does not preclude reducing demand as a
legitimate long term policy goal, rather it accepts that policy
must also deal with the reality of current high levels of demand.
A historical stumbling block in this debate has been that the
eloquent and detailed critiques of the drug war have not been
matched by a vision for its replacement. Unless a credible public
health led model of drug market regulation is proposed, myths
and misrepresentations will inevitably fill the void. So what
would such a model look like?
Transform’s blueprint for regulation
22 attempts to answer
this question by offering different options for controls over
products (dose, preparation, price, and packaging), vendors
(licensing, vetting and training requirements, marketing and
promotions), outlets (location, outlet density, appearance),
who has access (age controls, licensed buyers, club membership
schemes), and where and when drugs can be consumed. It then
explores options for different drugs in different populations
and suggests the regulatory models that may deliver the best
outcomes (box). Lessons are drawn from successes and failings
with alcohol and tobacco regulation in the UK and beyond, as
well as controls over medicinal drugs and other risky products
and activities that are regulated by government.
Five basic models for regulating drug availability22
- Medical prescription model or supervised venues—For highest risk drugs (injected drugs including heroin and more potent stimulants such as methamphetamine) and problematic users
- Specialist pharmacist retail model—combined with named/licensed user access and rationing of volume of sales for moderate risk drugs such as amphetamine, powder cocaine, and methylenedioxymethamphetamine (ecstasy)
- Licensed retailing—including tiers of regulation appropriate to product risk and local needs. Used for lower risk drugs and preparations such as lower strength stimulant based drinks
- Licensed premises for sale and consumption—similar to licensed alcohol venues and Dutch cannabis "coffee shops," potentially also for smoking opium or poppy tea
- Unlicensed sales—minimal regulation for the least risky products, such as caffeine drinks and coca tea.
|
|
Such a risk guided regulatory approach is the norm for almost
all other arenas of public policy, and in this respect it is
prohibition, not regulation, that can be viewed as the anomalous
and radical policy option.
Moves towards legal regulation of drug markets depend on negotiating
the substantial institutional and political obstacles presented
by the international drug control system (the UN drug conventions).
They would also need to be phased in cautiously over several
years, with close evaluation and monitoring of effects and any
unintended negative consequences.
Rather than a universal model, a flexible range of regulatory
tools would be available with the more restrictive controls
used for more risky products and less restrictive controls for
lower risk products. Such differential application of regulatory
controls could additionally help create a risk-availability
gradient. This holds the potential to not only reduce harms
associated with illicit supply and current patterns of consumption
but, in the longer term, to progressively encourage use of safer
products, behaviours, and environments. Understanding of such
processes is emerging from "route transition" interventions
aimed at encouraging injecting users to move to lower risk non-injecting
modes of administration by, for example, providing foil for
smoking.
23 This process is the opposite of what has happened
under prohibition, where a profit driven dynamic has tended
to tilt the market towards ever more potent (but profitable)
drugs and drug preparations, as well as encouraging riskier
behaviours in high risk environments.
The oversight and enforcement of new regulations would largely
fall within the remit of existing public health, regulatory,
and enforcement agencies. Activities that take place outside
the regulatory framework would naturally remain prohibited and
subject to civil or criminal sanctions.
Regulation is no silver bullet. In the short term it can only
seek to reduce the problems that stem from prohibition and the
illicit trade it has created. It cannot tackle the underlying
drivers of problematic drug use such as inequality and social
deprivation. But by promoting a more pragmatic public health
model and freeing up resources for evidence based social policy
and public health based interventions it would create a more
conducive environment for doing so. The costs of developing
and implementing a new regulatory infrastructure would represent
only a fraction of the ever increasing resources currently directed
into efforts to control supply. There would also be potential
for translating a proportion of existing criminal profits into
legitimate tax revenue.
Different social environments will require different approaches
in response to the specific challenges they face. Transform’s
blueprint does not seek to provide all the answers but to move
the debate beyond whether we should end the war on drugs to
what the world could look like after the war on drugs. It is
a debate that the medical and public health sectors have failed
to engage with for far too long.
Cite this as: BMJ 2010;341:c3360
Contributors and sources: SR is the author of
After the War on Drugs: Blueprint for Regulation. The book is published by
Transform Drug Policy Foundation, which actively campaigns for
drug policy and law reform, and is available free online (
www.tdpf.org.uk/Transform_Drugs_Blueprint.pdf).
Competing interests: The author has completed the unified competing
interest form at
www.icmje.org/coi_disclosure.pdf (available
on request from him) and declares (1) the writing and production
of SR’s book, including a contribution to his salary,
were funded by the J Paul Getty Jr Charitable Trust and the
Glass House Trust; (2) no financial relationships with commercial
entities that might have an interest in the submitted work;
(3) no spouses, partners, or children with relationships with
commercial entities that might have an interest in the submitted
work; and (4) no non-financial interests that may be relevant
to the submitted work.
Provenance and peer review: Commissioned; externally peer reviewed.
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(Accepted 3 June 2010)
