Intended for healthcare professionals


An alternative to the war on drugs

BMJ 2010; 341 doi: (Published 13 July 2010) Cite this as: BMJ 2010;341:c3360

Re:Are we in danger of losing the plot on drugs

Nigel - with apologies for the delay in responding to your points
(partly due to other ongoing correspondence in the BMJ that I have been
waiting to play out and will also endeavor to respond to):

You criticise me because I 'failed to consider data from the United
States as part of [my] analysis but instead chosen to concentrate on much
smaller countries, such as Portugal and Switzerland'.

In fact I to refer to the US (albeit regarding cannabis) once,
Portugal once, and do not mention Switzerland at all.

Regards the fall in cocaine use in the US:

Focussing on a fall in the use of one drug (in one country, over one
period of time) whilst ignoring other trends can dramatically distort the
overall picture of drug use and related harms more broadly.

Simultaneous to the US fall in cocaine powder use since its peak
around 1979 (a fact acknowledged in Transforms 'After the War on Drugs;
Blueprint for Regulation', (p.42) - which I authored which is clearly
referenced as the source text and linked in the BMJ paper) has been the
emergence (and subsequent partial retreat) of a devastating epidemic of
inner city crack cocaine use. Likewise, the use of ecstasy, and more
destructively, methamphetamine, has risen over the same period. The non-
medical (mis)use prescription stimulants has also risen dramatically as
cocaine use has declined.

Why has cocaine use fallen, whist ecstasy and meth use has risen -
when they are all subject to the same punitive prohibitions (all are
shedule 1)? It is evidently not due to supply side cocaine enforcement
success; the price of cocaine has fallen by around 80% during the same
period so cocaine is, by inference, actually more available than
previously. In the UK, by ontrast, ecstasy use has been level or falling
for some years, whilst cociane use has risen sharply (the price of both
has been falling).

so from the US (and UK) experience some general conclusions:

- Overall levels of use often appear to rise and fall independently
of price changes.

- Use of different drugs seems to rise and fall under the same legal
regime, often moving in opposite directions simultaneously.

This suggests that enforcement is a marginal factor in determining
levels of use; which are primarily determined by a complex interplay of
cultural, economic and social variables. The comparative analysis studies
mentioned/referenced in the paper (re cannabis decriminalisation states in
the US and Australia, the Portugal paper in the British Journal of
Criminology, and the international WHO study), are supporting evidence for
this general position.

Whilst levels of use seem to be only marginally related to intensity
of encforcement or punitiveness of sanctions I argue there is more direct
impact of enforcement on harms associated with use; encouraging use of
riskier products, and riskier behaviours in riskier environments - a point
made in the BMJ paper, and in more detail in 'Blueprint for
Regulation'(the emergence of crack and methampahetamine use are given as
examples). I also argue that prohibition is directly associated with the
well documented social harms of the illegal market, domestically and in
producer/transit countries.

It is is these harms that a legal regulation apporach seeks to
reduce, supported via diversion of some drug enforcement resources into
proven public health interventions (including educating people about drug

regard the crack 'ommission':

This is misplaced and unfair criticism as there is a detailed section
on crack in the stimulants chapter of the full text of 'After the War on
Drugs; Blueprint for Regulation'. The 2000 words in the BMJ obviously did
not allow the detail of a 50,000 word book. I do however refer to:

"Medical prescription model or supervised venues--For highest risk
drugs (injected drugs including heroin and more potent stimulants such as
methamphetamine) and problematic users".

Perhaps if I had said crack instead of methamphetamine you would have
hauled me up for not mentioning methamphetamine? In fact 'Blueprint'
covers both in some detail as part of a wider discussion of stimulant use
and regulation. I would welcome comments on that content once you have had
a chance to read it (the full text of Blueprint is available as a free

Finally, the criticism based on my 'suggestion that heroin addicts
must necessarily turn to crime in order to fund their habit' is a little
baffling as no such link is made anywhere in the BMJ piece.

Competing interests: I am author of the original BMJ paper

05 January 2011
Stephen Rolles
senior policy analyst
Transform Drug Policy Foundation