The war on drugs has failed: doctors should lead calls for drug policy reform
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6067 (Published 14 November 2016) Cite this as: BMJ 2016;355:i6067
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The November 14th editorial and associated articles helpfully highlight the potential benefits of decriminalising the use of currently illegal drugs. I agree it is likely that benefits would accrue from decriminalisation of heroin use, as well as other drugs, and I believe that these benefits would be felt most by those currently most enmeshed in the consequences of illegality: the communities, at home and abroad, suffering from the consequential crime and distrust; and the individuals who use substances to palliate past trauma, abuse, loss and abandonment who are often stigmatised and imprisoned.
This response examines the problem from the wider lens of all addictive or psychoactive substances, and their production, marketing and distribution. As regularly exposed in this journal, tobacco contributes directly to more deaths than any other substance and mortality from alcohol is similar per head of population (14/100,000)1. In our work with homeless individuals, street acquired or prescribed pharmaceutical drugs such as Diazepam, and more recently Pregabalin, are the third group of psychoactive substances that figure in the search for relief from distress. Along with opiates and alcohol these substances dominate the lives of our patients and our consultations feel like being at the epicentre of contradictory policies and powerful marketing.
While promoting more liberal laws in relation to illegal drugs, we simultaneously support containment of tobacco and alcohol use through legislation and controls in relation to production, marketing and delivery. These apparently inconsistent stances can be rationalised as humanist liberal responses aiming to limit freedoms when there are consequent harms in order to optimise overall wellbeing; in effect limiting the freedom of producers, whether of pharmaceuticals, illegal drugs or alcohol and tobacco. It is time to campaign for an overarching and coherent evidence based policy towards all addictive or psychoactive substances. We would need to consider how much of a role the state in general, and medicine in particular, has in providing outlets for either the substances, or substitutes, craving blockers or alternative forms of palliation where they exist. At what point do we medicalise, and how should the state or private enterprise be involved?
For each group of legal and illegal substances we need to make decisions based on an objective view of the nature of harms, benefits and addiction, as well as the complex interaction of these properties with national and international contexts, and in particular the powerful interests of the manufacturers – be they illegal cartels, food and drink industries or pharmaceutical companies. These decisions, based on imperfect evidence, will be a compromise between the libertarian free market (still dominant with respect to alcohol) and paternalistic authoritarianism (still dominant with respect to heroin). Decisions will need to be made as to whether substances and related behaviours are in medical criminal or (legal) social domains. But as more people turn to substances as a result of emotional distress relating back to past trauma, marginalisation or economic hardship the imperative for a joined up approach to policy has never been stronger.
. 1http://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/c... (accessed 30/11/16)
Competing interests: No competing interests
Last century, reformists made the notion that social evils would be contained by the instrument of legal action. The legal sanction on substance abuse was one of them. The consumption of psychoactive substances has been disseminated throughout the world. The younger generation is greatly affected by this menace, and it has an inverse effect on their physical, mental and social health. As of today, our world society has been endangered by various factors like global terrorism, human made imbalance in ecosystem, drug misuse and growing communicable and non-communicable clinical disorders. The human community is greatly affected by drug abuse.
Adolescents are much more vulnerable in the consumption of psychoactive substances. There are multiple factors, and it varies from one part of the world to another. In India, we have observed that school going children at the onset of adolescence get involved in substance abuse. It is multifactorial but I think that misuse of newer technology and inappropiate parental and scholastic socialisation are important factors. The harm due to these malpractices is enormous at multiple levels: individual, family and society. Medical professionals should take the lead but at the same time the law should also make its meaningful contributions. We imagine a progressive society in this globalised world.
Competing interests: No competing interests
The war on drugs has failed and doctors should lead calls for drug policy reform say BMJ editor in chief, Fiona Godlee and features and debates editor, Richard Hurley .
However, despite overwhelming evidence most doctors’ professional organisations still have little to say about this needed reform . They say it’s not a medical problem even though drug-related deaths in the UK are the highest since records began . Most of these deaths were preventable but received little press coverage. In other areas of care this would be front-page news and answers would be sought at the highest level.
The evidence base for harm reduction interventions such as Opioid Substitution Treatment (“OST”) and Needle and Syringe Programmes (“NSP”), is extensive but access is very limited all over the world.
Health outcomes for people who inject drugs (“PWID”) are far worse in countries where punitive attitudes and actions are preferred to health focused interventions. In Russia where drug policy is punitive and OST is illegal, HIV infections among PWID have just passed one million but have been successfully prevented in many countries .
The Global State of Harm Reduction 2016, released only a few days ago (16.11.2016) shows “services to reduce drug-related harms are failing to keep up with growing need, despite pledges to combat AIDS among people who inject drugs and the drive to scale-up needle and syringe programmes and opioid substitution therapy for people who inject drugs has stalled” . The UN has pledged to end AIDS by 2030 but no new countries have established NSP since 2014. Only 90 out of the 158 countries where injecting drug use is reported provide NSP, leaving 68 without. OST is now available in 80 of these countries but only in three new countries (Monaco, Senegal and Kenya) since the last report two years ago. In some countries NSP and OST site provision has fallen since 2014. Report author Katie Stone said: “The 2011 UN target to halve HIV among people who inject drugs by 2015 was missed by 80% (6).
A study by Harm Reduction International found that over 40 states apply some type of judicial corporal punishment for drug and alcohol offences . Also 90% of people who inject drugs will be incarcerated at some point and HIV and hepatitis rates are much higher in prisons.
International Doctors for Healthier Drug Policies (“IDHDP”) is an international network of medical doctors challenging the ill-conceived drug policies that increase disease, reduce access to essential medicines and prevent people receiving treatment.
IDHDP wants to see policies based on the best possible evidence not on dogma nor political expedience. Good drug policy leads to improvement in the health and wellbeing of everybody. Like all good policies they should be subject to regular review and evaluation.
Switzerland is an example that has used the four pillar approach and the results speak for themselves :
• Between 1991 and 2004, drug related deaths declined by more than 50%
• Levels of new HIV infections divided by 8 within 10 years
• 90% reduction of property crime committed by drug users
• 70% of injectors are now in some kind of treatment
The BMJ editorial clearly identifies the huge role doctors must play if the health of the individual and society is to be at the centre of future drug policies. Increasing numbers of doctors from all over the world are questioning current policies that continue to allow an increase in drug related deaths, a huge increase in HIV and Hepatitis C infections and the continued mass incarceration of the most marginalised members of society.
At IDHDP we are seeing increasing numbers of obstetricians, paediatricians, cardiologists, surgeons and other specialists joining the more obvious candidates of HIV/AIDS and addiction specialists in calling for change.
Change is coming, and doctors need to be in there leading this change. Please join IDHDP now and be part of that change.
Dr Chris Ford Clinical Director and Sebastian Saville Executive Director IDHDP
Godlee F and Hurley R BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i6067 (Published 14 November 2016)
Hurley R Doctors, their leaders, and the drug policy debate
BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i6087 (Published 14 November 2016)
Cite this as: BMJ 2016;355:i6087
Office for National Statistics. Deaths related to drug poisoning in England and Wales: 2015 registrations. 2016. https://www.ons.gov.uk/releases/deathsrelatedtodrugpoisoninginenglandand...
Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and international drug policy[The Lancet-Johns Hopkins Commission]. Lancet2016;387:1427-80. doi:10.1016/S0140-6736(16)00619-X pmid:27021149.
http://www.independent.co.uk/news/world/europe/russian-hiv-cases-reach-r...
https://www.hri.global/files/2016/11/14/GSHR2016_14nov.pdf
Inflicting Harm: Judicial corporal punishment for drug and alcohol offences in selected countries. Harm Reduction International 2012
From the Mountaintops: What the world can learn from drug policy change in Switzerland October 2010 by Joanne Csete Global Drug Policy Program
Competing interests: No competing interests
The UK Psychoactive Substances Act 2016 criminalises importation, production, and sale but not use of these substances. Fair enough. Supervised consumption of opioid substitution therapy must continue until the prescriber is confident that the patient is compliant with the treatment.
On a different but relevant note, chemsex is associated with condomless sex (http://www.aidsmap.com/Very-high-levels-of-chemsex-and-slamsex-seen-in-H...) and increased demand for post-exposure prophylaxis (http://www.aidsmap.com/London-clinic-survey-shows-impact-of-chemsex-on-c...).
Any policy of decriminalisation must be guided by both science and ethics.
Amr Gohar FRCP Glasg UK
Royal College Clinical Educator
Competing interests: No competing interests
Dear John L B Carter
Thank you for your comment. The article was externally reviewed, as it states.
It is a fact that Portugal decriminalised minor personal drug possession 15 years ago.
Here is the text of the legislation in English, on the website of the Portuguese drug agency of its Ministry of Health
http://www.sicad.pt/BK/Publicacoes/Lists/SICAD_PUBLICACOES/Attachments/9...
Or see this BBC news story http://news.bbc.co.uk/1/hi/world/europe/823257.stm
Richard
Competing interests: No competing interests
I am this week involved in a hospital survey team in Portugal. My clinical colleagues are astonished to read in The BMJ that there has been a policy of decriminalisation here for 15 years and that this argument is being used to substantiate a case for changes in U.K. legislation. I note the article was not externally reviewed and ask where the validity of the claim can be confirmed.
Competing interests: No competing interests
Addictive drug abuse is a growing problem in all countries among children, adolescents, adults and elders. In developing countries, particularly India, over the counter sales of these drugs are the main cause of this problem. In India, cough syrups, antipsychiatric drugs, antihistamines and nargotic analgesics are the most commonly abused drugs. These drugs are used alone or with alcoholic beverages. Thus awareness and strict law enforcement to regulate over the counter sales of these drugs are important in preventing drug abuse.
Competing interests: No competing interests
Prohibition has failed, criminalizing many who have done no harm to anyone but themselves Criminals will take advantage of them. The law, being virtually impossible to enforce, is brought into disrepute. . The curious adolescent will have his way and it may be healthy curiosity. Those who become addicted are often mentally distressed in some way and need help, preferably before addiction takes hold .
Principals
1. You must pay for your pleasures
2. Children must be protected.
3. It is impossible to police what adults imbibe..
Conclusions:
1. There should be no law that prevents an adult imbibing what he wishes. However, the cost of the item should include the estimated cost of the medical attention his action is likely to incur at some time in the future.
2. Children, ( upto aged 18,) must be protected because of the increased likelihood of addiction and damage to the developing brain. Children that are vulnerable in some way should be treated in a timely fashion before becoming victims.There must be appropriate sanctions for selling potentially dangerous items to children.
3. Formal education early about dangerous substances and upto date information on packaging must be available.
Competing interests: No competing interests
The War on Illegal Drugs has failed abysmally.
In my work as a psychiatrist and as a Forensic Medical Examiner , working with the Police, I see and experience the consequences of that failure day in and day out.
I see the economic costs: daily (millions and millions of pounds spent locally on wasted professional time) and,
I see the human costs: family lives, personal lives being torn to shreds. People living with the consequences of having criminal convictions for behaviour that would be better managed as a crisis in Public Health.
I see the irrationality and perversity of drug legislation. Criminal gangs being able to exploit the demand for drugs.
Other countries have tried , some more successfully than other, a more rational approach:
decriminalisation of substance addiction and mis-use makes rational sense.
Licencing certain professionals to provide daily heroin to addicts, for instance, cuts out the 'middle man', the dealer or the large scale criminal operative.
Rohibition of alcohol in the USA in the 1930s didn't work. Prohibition of illicit drugs does not work in the 21st century, for the same reason.
I humbly request that policy makers and decision makers now give serious thought to finally abondoning an approach that has clearly failed and that they take to courageous steps to do what is right.
Competing interests: No competing interests
Early Day Motion 743
The Editorial prompted an early day motion in parliament:
Early day motion 743
THE WAR ON DRUGS
Session: 2016-17
Date tabled: 29.11.2016
Primary sponsor: Cowan, Ronnie
Sponsors: Wilson, Corri Black, Mhairi Docherty, Martin Blackman, Kirsty Chapman, Douglas
That this House welcomes the report from the British Medical Journal, entitled the war on drugs has failed: doctors should lead calls for drug policy reform; notes that the report argues that all wars cause human rights violations, and the war on drugs is no different. Criminally controlled drug supply markets lead to appalling violence; further notes that the report also states that this year a thorough review of the international evidence concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible; acknowledges the actions of organisations such as Law Enforcement Against Prohibition who continue to argue for control and regulation of drugs; and believes that when the people who have been most affected and the people that have been enforcing the current system are saying it is not working, we must respect their opinions and take time to listen and learn.
https://www.parliament.uk/edm/2016-17/743
Competing interests: No competing interests