How changes to drug prohibition could be good for the UK—an essay by Molly Meacher and Nick CleggBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6006 (Published 14 November 2016) Cite this as: BMJ 2016;355:i6006
- Molly Meacher, chair of the All Party Parliamentary Group on Drug Policy Reform,
- Nick Clegg, member of parliament
- Correspondence to: M Meacher
Drug policy has been irrational for a long time—for 55 years to be precise. The United Nations drug conventions of 1961, 1971, and 1988 were rooted in the belief that banning a list of substances including heroin, cannabis, and cocaine would lead to a steady reduction in their use and the damage they cause. In turn, this would achieve the overarching objective of the conventions—to advance human health and welfare.1
Yet never has any evidence suggested that such a hypothesis was valid. Indeed, a growing body of evidence gathered since 1961 shows no correlation between the severity of the laws that prohibit drugs and the level of drug use.2 Far from diminishing over time, drug use has grown substantially worldwide.3 Many drugs are stronger and more dangerous now than they were before prohibition. “Skunk” has largely replaced lower potency cannabis; crack provides a more intense high than powder cocaine; and recently we have seen an explosion in use of potent new synthetic drugs. In short, the simplistic prohibitionist interpretation of the UN conventions has failed to achieve their overarching objective.
Finally, in April this year, the rhetoric changed fundamentally. After much discussion with reformers, the UN Office on Drugs and Crime, which helps member states meet their treaty obligations, made clear at a special session of the UN General Assembly that drug policies must be evidence based and aim to improve public health.
Development of an evidence base requires trying different approaches. These should be rigorously evaluated to identify policies or models that can best reduce addiction, minimise harm, cut violence, and reduce profits for organised crime. Whereas in the past the UN discouraged policy reform, we believe that now it will support member states that pursue evidence based public health policies.
What might this mean for the UK? We will focus on four policy areas: the scheduling of cannabis for medical purposes; heroin assisted treatment; decriminalisation of possession and use of all drugs; and the government's Psychoactive Substances Act 2016.
Cannabis for medical purposes
Cannabis was placed in schedule 1 of the Misuse of Drugs Regulations, the schedule for dangerous drugs with no medicinal value, in 1985.4 This explicitly forbids doctors from prescribing it and inhibits research. The classification is irrational: firstly, cannabis has low toxicity5 and is much safer than many established medicines, not to mention two legal recreational drugs, alcohol and tobacco.6 Secondly, people have used the cannabis plant for its medicinal properties for centuries, if not millenniums. Recent years have seen the discovery of the human endocannabinoid system7 and a growing literature on the medicinal value of cannabis for specific conditions.
On behalf of the All Party Parliamentary Group for Drug Policy Reform, Mike and Jennifer Barnes recently published a robust review of the global evidence on the medicinal properties of cannabis.7 They concluded that “good” evidence supports medicinal use of cannabis for chronic pain (particularly, neuropathic), seizures, nausea, and anxiety. For sleep disorders, appetite stimulation in the context of chemotherapy, fibromyalgia, post-traumatic stress disorder, and some symptoms of Parkinson’s disease, they found “moderate” evidence. In this light, the UK’s scheduling, denying any medicinal value for cannabis, looks ever more absurd.
Cannabidiol is a medicine
To promote the medicinal argument further, the government’s Medicines and Healthcare Products Regulatory Agency (MHRA) announced on 3 October 2016, “We have come to the opinion that products containing cannabidiol (CBD) are a medicine.”8 CBD and tetrahydrocannabinol (THC) are two of the most prevalent psychoactive ingredients in the cannabis plant. The MHRA continued, “Products for therapeutic use must have a medicines licence before they can be legally sold or supplied in the UK.” So we now have the bizarre situation where two key components of cannabis, THC and CBD, are recognised as having medicinal value but the plant itself is scheduled as dangerous and with no medicinal value.
Ministers urgently need to revisit the scheduling of cannabis and move the drug from schedule 1 to schedule 4—which includes benzodiazepines, for example—in recognition of the limited risks and the medicinal value of the plant and its constituent parts. This would facilitate research into the many conditions for which cannabis may be an inexpensive but effective treatment. But above all it would enable patients with a wide range of conditions to obtain cannabis medicines to alleviate their symptoms.
As well as the encouraging evidence from international clinical trials, we have heard striking testimonies from patients with epilepsy whose fits have reduced or ceased altogether; and others with chronic pain say that cannabis has “given them their life back” or “enabled them to sleep through the night for the first time for years.”9
If cannabis were rescheduled doctors could prescribe it on a named patient basis, taking responsibility for patients’ safety, until licensed cannabis medications became available. Different preparations are needed for different conditions, from quality controlled, chemically consistent herbal cannabis such as Bedrocan10 to pharmaceutical products with more conventional delivery mechanisms such as pills, creams, and inhalers. We would expect pharmacies to stock these preparations in the normal way. Encouragingly, the Royal Pharmaceutical Society voted in favour of rescheduling cannabis at its annual conference in 2015.
Eleven European countries and many others already formally recognise that cannabis has legitimate medicinal uses. Germany is in the process of passing a government backed bill to enable cannabis to be grown and supplied by licensed suppliers, prescribed, and made available through pharmacies. Canada has recently done the same. Surely it is time for the UK to follow suit?
Heroin assisted treatment
The UK government should also review other policies for which we already have reliable evidence. Switzerland offers people dependent on heroin a safer way back to a normal life. The model includes consumption rooms, treatment with the opioid substitute methadone, and treatment with heroin.
The consumption facility allows people to take their street drugs in a safe and clean space without fear of arrest. A doctor and social worker offer healthcare and help with housing and money problems. The professionals aim to persuade people into appropriate treatment, generally successfully. For most this will be opioid substitution treatment, but for people having difficulty with methadone, heroin assisted treatment (HAT) is an option.
HAT is not a soft option. Patients must be alcohol-free when they attend, and in the early stages they must hand over most of their benefits to staff, who ensure their rent and utility bills are paid. In return, patients receive medical grade diamorphine, free of charge and administered at the clinic. The service also seeks to tackle the complex and often deep seated problems of patients dependent on heroin.
The results of HAT in Switzerland and elsewhere are impressive.11 Every published evaluation has shown positive outcomes: reductions in the use of controlled drugs, crime, disease, and drug overdoses and improvements in health, wellbeing, and rehabilitation. Within one cohort of around 300 heroin users in Switzerland, 81% of people were using heroin illicitly on a daily basis to begin with compared with 6% reporting almost daily illicit heroin use at six months. People reporting an income from illicit sources reduced from 69% to 10%.12
The HAT element of the Swiss model has been trialled for several years at three clinics in the UK by John Strang, consultant psychiatrist at King’s College London. Funding was recently withdrawn because the Department of Health deemed that the precise model was effective but not cost effective. Evaluations of similar models in Switzerland, the Netherlands, and Germany, however, found evidence of cost effectiveness.13
Decriminalise drug possession and use
A third policy deserving immediate attention is well established in Portugal, where since 2001 the personal possession and use of all drugs have not been subject to criminal penalties. Decriminalisation is a widely misunderstood term and often wrongly seen as synonymous with legalisation. If a drug is decriminalised, production and supply remain illegal but users will not be subject to criminal sanctions or a criminal record for the possession or use of the drug. They may be subject to administrative sanctions if they fail to comply with a “treatment contract,” as in Portugal. Legalisation refers to a system of regulation where a drug may be produced, sold, possessed, and used in accordance with regulations. This is a much more radical reform than decriminalisation.
The Portuguese system is far from soft: police apprehending someone in possession of a small amount of a drug (calculated as up to 10 days’ supply) refer the person to a multiagency “dissuasion panel.” The panel interviews the person and determines whether he or she is drug dependent. If drug dependent, the person will be referred for treatment and encouraged to complete it with the goal of recovery. If treatment is not completed, the dissuasion panel will impose a civil rather than criminal sanction for breach of contract. The majority of non-dependent users attending a panel for the first time receive no sanction. A subsequent appearance may result in a fine of €30-€40 (£27-£36; $33-$44).14
The policy transfers resources from criminal justice to drug treatment, and although the trafficking and supply of drugs remain in the hands of organised crime and subject to criminal penalties, the police, courts, and prisons have been freed to focus on drug supply and conventional crime.
The Portuguese model has been evaluated by Alex Stevens, professor in criminal justice at the University of Kent, and others, with encouraging findings.15 Between 2000 and 2005, the number of problematic drug users fell from 7.6 to 6.8 per 1000 population. Most particularly there is evidence of a decrease in drug use among 14-19 year olds under the policy.16 There have also been reductions in HIV infections from more than 1000 new diagnoses in 2001 to fewer than 100 in 2013. Drug related deaths have reduced from over 70 in 2001 to fewer than 20 in 2012.17 Despite initial scepticism, all Portuguese political parties now support the policy.
Drug related deaths in England and Wales—that is, those with an underlying cause of drug misuse, dependence, or poisoning—are running at a record 3674 a year, with 2479 related to illegal drug use alone.18 British politicians should seriously consider introducing a version of the Portuguese model in the UK, allowing a substantial transfer of resources from criminal justice to treatment services.
It’s already begun
The government took tentative steps towards decriminalisation this year with the Psychoactive Substances Act 2016. This excluded the possibility of criminal penalties for personal possession or use of “new psychoactive substances,” such as Spice (a synthetic cannabinoid). If such a policy is right for potentially dangerous synthetic drugs it surely is right for drugs derived from natural plants like cannabis and coca leaf.
Indeed, more sensible policies for other drugs might reduce the temptation for people to experiment with unknown synthetic substances, whose acute side effects and long term harms are much less well understood. The government hopes its ban on the sale of such substances will reduce use. The experience of Ireland, which introduced similar legislation in 2010, suggests otherwise. There, the prevalence of use of “legal highs” among 15 to 24 year olds has increased from 16% of those studied in 2011 to 22% in 2014,19 and deaths related to these drugs increased from 6 in 2010 to 28 in 2013.20
The radical shift in UN opinion in April this year, and its call for evidence based policy, make this the right time for the UK government to reschedule medical cannabis without delay and to establish a review of drug policy more widely.
Nick Clegg is a Liberal Democrat politician who served as deputy prime minister in the coalition government from 2010 to 2015 and as leader of the Liberal Democrats from 2007 to 2015. He is a member of parliament for Sheffield Hallam, where he was first elected in 2005. He has a long standing interest in drug policy reform and is a member of the Global Commission on Drug Policy.
Baroness Molly Meacher worked in mental health on the front line and as a board member and NHS trust chair for several decades. She became a crossbench peer in 2006 and has for the past decade chaired the All Party Parliamentary Group for Drug Policy Reform. She also chaired a European Drugs Initiative and worked with Mexico, Colombia, and others to reform global UN drug policy. In April the UN high command endorsed the need for evidence based public health policies promoted by her and other reformers.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.