Drug policy debate is needed
Cite this as: BMJ 2012;344:e2381
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Alcohol and tobacco cause at least as much much damage as heroin and cocaine. While it is legal and respectable to use alcohol and tobacco from the moral point of view of harm caused it is as wicked to use alcohol and tobacco as heroin and cocaine. As laws make crimes not wicked acts we must have profound concern if we criminalise some wicked acts but not others acts that are directly comparable.
A powerful way to attack any activity is to make that activity against the criminal code thus automatically making criminals of those who produce, transport, sell or use drugs. A major public dread is crime so criminalised suppliers and users of drugs become part of that dread and we will ferociously oppose any relaxation of prohibition of drugs even when face with the awful results of prohibition.
Attitudes to drugs can change as witness the changes legal status of termination of pregnancy and male/male sexual activities. While the courts are there to sentence according to the will of Parliament if those laws and sentences abitrarily distinguish between one set of drug use and users and another with draconian sentences we are looking at an unnecessary and vicous system of law and punishment. In other words drug producers, suppliers and users are a cruelly persecuted minority.
Competing interests: None declared
Self, 16, Walton Lane, Weybridge, Surrey. KT13 8NF
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This response is mainly directed towards the comments made by DR HC Raabe. The most useful aspect of his contribution is that it encapsulates the ubiquitous yet fundamental misunderstandings on this subject. To be blunt so much discussion on this subject is based upon a few simplistic arguments that are recited without any real thought or study ever having been applied to the problem. Sir Ian’s piece unfortunately set this up because whilst it is actually a very good summary of the arguments in favour of the need for reform; nevertheless falls into the trap of making some of the same errors as Dr Raabe makes. At least Sir Ian aspires to make a positive change, yet critics like Dr Raabe are actually arguing for an unconscionable state of affairs to continue or worsen. I sense more than a touch of piety overarching Dr Raabe’s views, I should make it clear that it is not ‘controlled drug’ use per se that is the legitimate concern of the law, but only the misuse of any drugs that gives rise to social harm. In fact, sensible peaceful use of drugs is arguably as much of a social benefit as any claim to class it as morally repugnant. The danger of imposing any religious or moral imperative into this subject is that this is a highly contentious matter as regards respecting difference, choices and personal autonomy. By denying access to certain drugs we actually control the mind states and modalities of thought that these substances facilitate – there is no absolute monopoly on truth in this arena; chemical moderation of consciousness is a legitimate area of interest for both scientific and subjective personal experience and study using drugs that are known to be relatively safe when used appropriately.
It’s easy to recognise when people are reciting propaganda and not really au fait with their subject because they use expressions such as ‘war on drugs’, ‘illicit drugs’, ‘legalising drugs’, ‘de-criminalising drugs’ etc – these concepts are completely meaningless. Has nobody stopped to think what this is about? It actually isn’t even about drugs, and let us be clear about one thing, drugs do not have legal agency and therefore they cannot be legal, illegal, criminal, decriminalised or anything else for that matter. Harmful drugs are supposed to be designated to be ‘controlled drugs’, but that does not mean that they are controlled. Not at all, whilst this first appears to be semantic, it’s actually a vital distinction to point out that it is persons who are controlled with respect to drugs, not the other way round. The whole reversal of subject and object and regulation that is pervasive amongst prohibitionist construct and sadly believed by most reformists is at the root of two evils. Firstly it should be painfully obvious to anyone with a real concern in this area that it is people, not substances that are being treated to inequality of treatment without any rational basis for it. An off-license who repeatedly sells alcohol to underage kids gets modest fines imposed, a cannabis user who self-medicates gets their doors kicked in and their lives ruined.
I am in touch with various persons who are suffering profound consequences as a result of their choice to use cannabis as medicine, even where those who were prescribed it by hospital consultants and yet the PCT refuses fund it. I am talking about being imprisoned without access to safe health care, having tenancies for entire families taken away at the behest of the police and local authorities, excellent workers being made unemployed/unemployable and even children being removed from families for frankly no good reason at all. My view is that this is happening because people want to profit from drugs, and I am not talking about these hapless cannabis users and small-time growers, but those who would try and get exclusive commercial monopolies to essentially sell the same drug at vastly inflated prices. We now have Professor Les Iversen, the chair of the Advisory Council on the Misuse of Drugs, supporting the absurd notion that herbal cannabis has no medical value, yet Sativex (which is very high strength cannabis in alcohol, produced by GW Pharmaceuticals) is deemed fine for specific medical uses.
But why is there no differentiation between peaceful uses of drugs and anti-social ones? The law is supposed to target the latter, and indeed that is the point of the Misuse of Drugs Act. It is because the point I made about the reversal of the person with the drug in contemporary discourse and even in the application of the law, this point that so many dismiss as semantic actually lends credence to the fiction that the law is an instrument of prohibition, when it is not. There is no crime of using drugs, seriously there isn’t (except opium). The law is supposed to regulate property interests in ‘controlled drugs’ (and this category is supposed to include being ANY drug that causes social harm), to address harms caused by misuse, not simply to stop all use. It is the failure of policy to accurately reflect the law that is at the heart of almost all drug-misuse related harmful activities. The fiction that drugs can be legal or illegal allows two very nasty things to happen: firstly, the law is used as a blunt on/off tool that cannot be used to regulate sensibly people using drugs by differentiating between those that cause harm from those that do not (this despite the law itself having numerous regulatory powers under sections 7, 22 and 31 of the Misuse of Drugs Act), and secondly that vast majority of drug misuse is being claimed to be outside the jurisdiction of the very law there to protect against such misuse upon the spurious premise that this is misuse of ‘legal drugs’. It is this indivisibility of the lie that is ‘illicit drugs’ that reduces human agency to that of a slave or object, and this is why Dr Raabe’s contribution is actually offensive and nonsensical. Even if we ignore the misconstruction and cut to the content, it’s simply madness to imagine that policies constructed via a belief in an artificial divide can ever be rational, for one the whole ethos of having an outcome-based (ie evidential) policy has already been lost by declaring drugs to be a priori acceptable or unacceptable. The reality is that we have a drug dealing protection racket being official policy enforced by criminal law, thus creating insane monopolies for alcohol and tobacco dealing to thrive because the competition from better and safer drugs is denied. One simply cannot look at alcohol related harms and say well that’s what happens with a regulated market, its nonsense; alcohol is harming the nation to a huge extent because it is the only drug in town. If persons were regulated with respect to harmful drugs, starting from rescuing the essential threshold of proportionate interference into personal liberty, then the harms caused by any individual form of drug misuse would be less. Firstly there would be a rational and believable form of regulation and education, thus allowing people to mix and match drugs sensibly and not in ignorance as it is now. We would avoid all the paradoxes of consequences of prohibition policy and start to respect the autonomy of adults again – right now there is a wanton disregard for such respect, even to the point of arresting people who are peacefully engaged with spiritual and reflective practices using plants and drugs that have been used by various indigenous ancient societies for thousands of years for such purposes (eg peyote, ayahuasca, psilocybin fungi all declared to be class A drugs with no regulatory apparatus being applied to persons wanting to utilise these plants).
Competing interests: None declared
Drug Equality Alliance, 48 Ridgeway, Leeds, LS8 4DF
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While I have great respect for Sir Ian and am totally on his side regarding his endeavours to fight the alcohol problem in the UK, I respectfully disagree with his apparent call for decriminalisation of drugs, a suggestion which, as commissioned editorial, would also be in keeping with the usual editorial bias of the BMJ: enthusiastically and uncritically pro-legalisation of drugs, enthusiastically and uncritically pro-legalisation of euthanasia etc.
Sir Ian wrote: “What would drug reform look like? Most serious commentators call for decriminalisation…” and on several instances in the editorial refers to decriminalisation as a possible answer to the drug problem.
One notes in passing that the reference to “most serious commentators” appears to suggest that those who do not support decriminalisation cannot be taken serious, which I find quite an arrogant suggestion.
When I debated the issue of drug legalisation with him (and others) last year, he was debating for the legalisation of drugs while I took the opposite view. At the time, I challenged him to state clearly which drugs he would want to legalise. Sadly, Sir Ian refused to give a clear answer at that time. May I therefore respectfully invite Sir Ian to state
1. which drugs he would like to see decriminalised and why and
2. which drugs he would not like to see decriminalised.
This is, unless, of course, he has changed his views and no longer supports the decriminalisation of drugs?
Decriminalisation of drugs has of course been tried in a number of countries and territories and usually has being reversed after some years because it has been associated with significant increase in drug use and/or because it fails to achieve the stated aims of the original policy. Everyone knows the Dutch example where The Netherlands introduced the “coffee shop” policy. One of the stated aims was to separate the markets for “soft” and “hard” drugs. However, this aim has not really been achieved. Unsurprisingly, there had been a significant increase in cannabis consumption and the large majority of Dutch coffee shops have now been closed down; a development that appears to have achieved much less publicity. Why repeat the mistakes that others have made?
All this his contrasts with the experience of countries like Sweden and Japan. Both have a very clear societal focus on drug prevention, both have very low rates of substance misuse and good health and societal outcomes; Sweden has among the lowest rates of drug use in Europe (probably even lower than the Portugal so beloved by some) and Japan has among the lowest rates of drug use worldwide, lower than Western European countries.
In my view the “secret” of the low rates of drug misuse in Sweden and Japan has to do with a clear engagement of civic society with the drugs problem. Both Sweden and Japan have for many years realised that decriminalisation is not the answer, but drug prevention/demand reduction on the basis of a societal consensus that aims to have drug misuse as only a marginal phenomenon in society is perhaps the single most important factor.
It would be nice to see if those calling for “reform” and “evidence” and “decriminalisation” were also prepared to take into consideration evidence for example from Sweden and Japan even if it does not suit their apparent agenda.
I tried this with the LibDems mentioned in Sir Ian’s editorial. The individual LibDem politician responsible for the motion calling for the legalisation of drugs did not even acknowledge the substantial evidence challenging his views that I had sent him. It probably didn’t suit his agenda, one would speculate…
If one really wants to make an inroad into the drug problem, one needs a societal consensus that would want to see drug misuse as only a marginal phenomenon in society or – as Sweden has done – to even aim for a drug-free society.
Decriminalising /legalising drugs will undermine such a consensus and simply lead to normalisation of drug use - see the examples of alcohol and tobacco with all the adverse public health consequences that Sir Ian is so very aware of.
Is this what we as society want – to normalise the use of drugs?
Is normalising the use of currently illicit drugs the answer to the health and social problems associated with drug use?
This has not been the case for tobacco and alcohol as Sir Ian knows very well and it will not be the case for currently illicit drugs either.
Competing interests: None declared
Partington Central Surgery, Central Road, Partington M31 4FY
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All those working in the field of substance misuse will welcome Prof Ian Gilmore’s call (BMJ 2012;344:e2381) for doctors to encourage rational debate about how best to minimise harm to the health of the population through advocating evidence-based policies.
However they may query his suggestion in support of this argument that use of the most problematic drugs has risen in recent years, particularly among younger adults.
The latest estimates from independent Glasgow University research into the number of heroin and crack users in England shows a fall to 306,150 from a peak of about 332,000. This drop was particularly significant among the 15-24 and 25-34 age-groups.(1)
These findings echo data from the National Drug Treatment Monitoring System (NDTMS) showing fewer adults are starting treatment for heroin and crack addiction. In particular, the number of heroin and crack users entering treatment aged 18-24 has halved in the last six years, and the 25-29s have come close to matching this.(2)
The trend is also evident in NDTMS data for under-18s, where the number of young people treated for heroin and crack problems has slumped from just over 1,000 to about 350 in the last five years.(3)
Indeed, Dr Clare Gerada, chair of the Royal College of GPs, recently told the Commons home affairs committee: “When I first started as a GP – I have been a GP for 35 years - every day a young drug user (sometimes as young as 16 or 17) would come in wanting help for heroin use. I cannot think of the last time a new heroin user came to see me.”(4)
Since waiting times to enter drug treatment remain at their lowest-ever level – five days on average – we are confident that the declining numbers genuinely reflect demand. What this means is that the challenge for treatment services is increasingly focussed on helping older, more entrenched users to recover.
The over-40s are now the largest age-group amongst those starting treatment. These people may have been using steadily for many years, but are now finding their health is failing as they get older. They are finally seeking help to overcome their dependency, yet may find it harder to make progress because of the social, economic and health problems associated with prolonged heroin use.
Drug use continues to present major challenges to society which, as Prof Gilmore says, we will only overcome if we base policy on evidence. However this continuing challenge should not blind us to those areas where things are improving.
The evidence that fewer younger people are using drugs in general is now difficult to refute. It is becoming increasingly apparent that this is now also true of the more dangerous drugs, heroin and crack cocaine.
Competing interests: None declared
National Treatment Agency for Substance Misuse, Skipton House, 80 London Road, London SE1 6LH
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