Should drugs be decriminalised? No

Califano's objections to the legal regulation and control of
currently illicit drug markets are based on a series of misunderstandings
and misrepresentations of the reform position, bolstered by a series of
either cherry picked, irrelevant, or simply incorrect facts. His piece is
very similar, some of it in fact identical, to a piece he produced for the
Financial Times in August (1) which was critiqued in the FT's online
Economist's forum (2) by a range of guest contributers including myself.

He has apparently refined his arguments and slightly toned down his
rhetoric following this experience but the same problems with his analysis
remain. Before considering some of his more speculative arguments, I would
like to address some of the some of the factual claims he makes:

"Switzerland's "needle park," touted as a way to restrict a few
hundred heroin users to a small area, turned into a grotesque tourist
attraction of 20 000 addicts and had to be closed before it infected the
entire city of Zurich"

Ignoring the rather unpleasant characterisation of addiction as a
contagion, "Needle Park" is of no relevance to this debate as it was
in no sense 'legalisation '; heroin was not legally supplied, and its
repeated referencing by prohibitions supporters is a familiar ploy to
misrepresent the reality of regulated drug supply. As an experimental
tolerance zone "Needle Park" did indeed prove a failure. However, in a
critical oversight, Califano fails to mention that the Swiss Government
responded to this failure with a pragmatic move to actual legalisation by
setting up a network of heroin prescribing clinics for long term relapsing
users, where they received pharmaceutical heroin (of known strength and
purity, unlike illicit supplies) consumed under medical supervision in a
clinical setting. This policy has been a great success on all public
health and criminal justice indicators; it has dramatically reduced
offending amongst users, public nuisance, street dealing and drug litter,
and has led many more long term users into rehab and abstinence than if
they had remained in the clutches of the illicit underground drug scene.
Given its success it has, unsurprisingly, been copied by many countries
including Canada, Australia and much of mainland Europe. The UK is
currently piloting a similar scheme.

"Italy, where personal possession of a few doses of drugs like
heroin has generally been exempt from criminal sanction,2 has one of the
highest rates of heroin addiction in Europe,3 with more than 60% of AIDS
cases there attributable to intravenous drug use"

This is, again, hopelessly misleading. The dubious honour of having
the highest level of heroin addiction in Europe belongs, sadly, to the UK,
where there is very much not a policy of tolerance, let alone Italian
style decriminalisation. The policies of Portugal, Germany, and the
Netherlands, which have also de-facto decriminalised (and/or prescribe)
heroin are unmentioned although , according to the European Monitoring
Centre for Drugs and Drug Addiction's annual reports, they have equal
or lower levels of heroin addiction than Italy. Looking beyond
Califano's cherry picking, there is in reality no demonstrable
correlation between the local level of criminality associated with
possession, and the corresponding level of use or misuse of heroin.

Regarding HIV transmission and AIDS it must be pointed out that the
60% of cases of HIV transmission in Italy that Califano mentions are
attributable, very specifically, to injection of illicit drugs, mostly
heroin. Significantly there is zero HIV transmission or AIDS caused by non
-injecting drug use, or indeed any form of legal drug use. The supervised
use of prescribed heroin with clean needles as discussed above (re: the
Swiss system) is not associated with any HIV transmission. None. So let us
be completely clear on this: Drug related HIV transmission and indeed most
other related risks amongst injecting drug users are very specifically
outcomes of prohibition and the high risk behaviours in high risk
environments that it fosters. Califano is therefore defending a policy
that has caused the very problem he identifies, a policy that has created
widespread misery and death, whilst attacking those who propose proven
approaches that entirely and unambiguously eliminate the problem.

"The Netherlands established "coffee shops," where customers could
select types of marijuana just as they might choose ice cream flavours.
Between 1984 and 1992, adolescent use nearly tripled. Responding to
international pressure and the outcry from its own citizens, the Dutch
government reduced the number of marijuana shops and the amount that could
be sold and raised the age for admission from 16 to 18."

The success of Dutch drug policy has been frequently misrepresented
as failure in attempts to undermine calls for reform elsewhere around the
world. Since 1976 availability of cannabis in the Netherlands has been
tolerated and de-facto licensed and controlled (although not technically
legal). Recent local complaints focused on a small area of Amsterdam
frequented by rowdy tourists and stag parties, and some opportunistic
border sales. The system has recently been streamlined with some sensible
new restrictions imposed, but the pragmatic tolerance based approach
overall remains alive and well, enjoying broad (and increasing) support
from the public, parliamentarians, and law enforcement community, despite
a few vocal dissenters. It should also be noted that cannabis use has
risen across the Western world since 1976, but has risen slower in
Netherlands than many other countries. Young people's cannabis use in the
Netherlands is substantially lower than either the UK or the US. Califano
is again misleading readers by failing to provide any comparative context
for the statistics he quotes.

Califano's comments on treatment prevention education and social
support for problem users, whilst positive and welcome are irrelevant to
this debate. All sides in this agree these are important elements of any
rational drug policy and a pro or anti law reform position does not
preclude support of them. Such concepts are certainly not the exclusive
preserve of prohibitioists, indeed Transform have long argued for the
redirection of resources currently being squandered on demonstrably
futile and counterproductive drug enforcement into into such programmes
where they can be shown to be effective.

Califano's observations on UK drinking legislation are similarly
irrelevant as we are not discussing minor changes licensing and
regulations, we are discussing the far more stark choice of absolute
prohibition verses the option for a range of legal regulatory models for
production and supply. The key benefit of moving beyond the absolutist
prohibition position is that allows the Government to intervene on
precisely the sort of public health responses and regulatory structures
that Califano highlights. These can additionally include: age of
purchaser, place of purchase, public consumption, packaging and provision
of heath/safety information, information on strength and purity, and
advertising and marketing. The state is powerless to intervene on any of
these variables when control of the production and supply of any given
drug has been abdicated to organized crime networks and unregulated street
dealers.

Following on from this are Califano's comments about drug
availability, which he argues would increase dramatically post prohibition
and therefore lead to a jump in levels of use and misuse. The first
important observation is that under prohibition drugs are already, to a
large extent, freely available to anyone who wants them. Further more,
historical price data supported by questionnaires amongst users,
demonstrates that drugs have become increasingly available on a consistent
basis over the past 3 or 4 decades; they are cheaper and more available
today than at any point in recent history.

Legal regulation, crucially, allows a degree of controlled
availability and precisely the kind of Government interventions,
regulatory instruments and public health infrastructure that are
demonstrably impossible when markets are controlled by gangsters and
street dealers. These controls can be as strict as the state deems
appropriate, and will naturally vary according to the risks associated
with a given drugs. For high risk or addictive drugs a prescription /
supervised use model may be appropriate, for less risky drugs there are a
range of options for licensed sales, or licensed premises.

What is clear, however, is that once an illicit market is established
(and criminal profiteers will see to that), levels of use are
predominantly demand led. Whilst there is obviously some conventional
interaction between supply and demand (indeed illegal drugs present a near
perfect economic market, free as it is from all regulatory and external
constraints) availability generally follows demand rather than the other
way around. This is particularly the case with problematic use, as noted
by the Prime Minister's 2003 report produced by the Number 10 Strategy
Unit (3):

"Supply-side interventions have a limited role to play in reducing
harm
initiation into problematic drug use is not driven by changes in
availability or price:

risk factors -particularly relating to deprivation -are the prime
determinant of initiation into problematic drug use; price and
availability play a secondary role

there is no causal relationship between availability and incidence;
indeed, prices and incidence often fall or rise at the same time" (p.79)

I have briefly addressed the irrelevance of Sweden example in the
rapid response section for DR Chands pro-decriminalisation article (again
- it lacks the context of paired examples).

The information Califano presents on cannabis is irrelevant to this
debate. No one calling for legal regulation of drugs claims they are risk
free or harmless, only that if supplied legally and used in safer legal
environments that risk, and resultant harms, would be reduced. If anything
it is the illegal market that is fuelling the increasing potency of
cannabis, a pattern of intensification within illicit drugs that has been
similarly witnessed with opiates, and cocaine products (notably the
emergence of crack).

It is precisely because drugs are dangerous that they need to be
regulated and controlled; they are too dangerous to be left in the hands
of criminals. In this context the endlessly tedious cannabis how-bad-for-
you-is-it? debate becomes irrelevant and Califano's catchy final
flourish:

"Drugs are not dangerous because they are illegal; they are illegal
because they are dangerous."

makes no sense. Not only are many dangerous drug very much legal,
but the more dangerous a drug is, the more important that it is properly
controlled and regulated by the Government, within the law.

Appropriate legal regulation of different drugs is the rational
public health response to their continued use in society - in conjunction
with other public health interventions in the treatment, education and
prevention fields. Prohibition is an ideologically driven policy that has
failed on all meaningful public health and criminal justice measures,
requiring, as we have seen, ever more extravagant propaganda and rhetoric
to prop it up. It simply cannot survive sustained objective scientific
scrutiny.

1. http://www.ft.com/cms/s/0/6190a922-4b91-11dc-861a-
0000779fd2ac.html

2. http://blogs.ft.com/wolfforum/2007/08/how-to-starve-
t.html#comments

3.

http://www.cabinetoffice.gov.uk/upload/assets/www.cabinetoffice.gov.uk/s...

Competing interests:
I am Information Officer for Transform Drug Policy Foundation and provided some support with factual references for Dr Chand's companion article in favour of drug decriminalisation.

I thought the BMJ might have been able to do a better job of
encouraging a high-quality debate on what should be an important topic,
but this isn't it.

I'm not sure, for example, whether Ian Oliver intended to parody the
arguments for prohibition, but his summary achieves that goal. Every
single point is either completely irrelevant to the debate, disputable on
purely factual grounds or a tendentious restatement of the prohibitionist
position.

But the original article is not much better. Rather than reviewing
the totality of evidence and weighing it up, it merely advocates a
position (the article is sprinkled with references, but, on examination,
the majority are probably not independent analysis but partisan
prohibitionist advocacy). The article quotes isolated anecdotes (for
example about Sweden and Switzerland) as if they were the only stories to
tell: in both cases there is considerable debate, much of it more recent
and less partisan than the quoted sources. And how seriously can we take
evidence about the failure of UK alcohol liberalisation when one of the
sources is the Daily Mail?

The pro-decrimnalisation article was better, but still not a
particularly evidence-based statement of the position.

Any resolution of the debate should focus on clarity about the
balance of harm. But neither side has been particularly clear about
defining what evidence could or should be brought to bear on this. Here
are two critical areas where a clearer focus on evidence might move the
debate forward.

Clearly being addicted to a drug is bad for the individual, but the
important question is whether harm would be worse if the individual were
able to access constant strength, pure drugs. Do heroin addicts die from
the side effects of heroin or from the contaminants, the dirty needles,
the criminal activity and lifestyle? I don't know the answer, but I've
never seen the critical evidence about the mortality of long term users of
pure heroin, and liberalisers need to use this evidence to make a clear
case.

The possibility exists that, if drugs are decriminalised, the number
of users will increase. The balance of harm to society here depends on two
factors: the increase in harm to addicts and the reduction of crime
associated with addiction. Relevant facts are that a disturbing proportion
of all crime is drug related, so that could be a big reduction in harm.
Equally relevant are the experiments in countries such as switzerland
where medicalisation of the problem appears to have reduced the number of
new addicts (The Lancet 2006, vol 367, p1830-1834). Why did neither side
quote this experiment?

For a better debate I would expect to see the prohibitionists spell
out their assumptions and evidence about how much harm would be caused by
increased use (and explain why that would be worse than the current
situation where prisons and crime are dominated by the side effects of
prohibition). The liberalisers could also do a better job of explaining
just what sort of liberalisation is proposed and what the balance of harms
is (and admit that some things could get worse with some policy options).

Right now it seems that prohibitionists are so entrenched in their
belief that drug addiction is an absolute evil they are blind to the basic
failure of prohibition to prevent addiction and prepared to tolerate any
amount of social disruption to retain the status quo.

Competing interests:
tends towards a liberal view on prohibition