Drug Policy and the Public Good: a summary of the book

INTRODUCTION: FRAMING THE ISSUES

The use of illegal psychoactive substances is commonplace in many parts of the world. If the last century's experience can serve as a guide, in the future many countries will face periodic drug ‘epidemics’ followed by aggressive campaigns to suppress them. In many other countries, continued ‘endemic’ (i.e. regular and widespread) drug use will generate a patchwork of policy responses that never quite keep up with the evolving problem. Contemporary drug policy constitutes three broad areas: programmes to prevent drug use, services that help heavy drug users change their behaviour and supply control programmes, including incarceration. The range of policy responses implies that there is no single approach to drug policy that will work for all times and for all countries. Criminal sanctions, drug interdiction, specialized drug treatment, school-based education, prescription management programmes and many other strategies and interventions are all part of the societal response to drug problems. Although each has its merits and drawbacks, it is the position of this book that public health concepts provide an important vehicle to organize societal responses to drug misuse, mainly because the health of populations affected by drug misuse requires the coordination of supply control and demand reduction measures to serve the public good more effectively. However, public health is not a complete approach because many things of great value to society—human rights, the successful rearing of children, among many others—are not health indicators per se. Drug policy is therefore a matter of the ‘public good’, rather than only being a question of public health. This paper provides a summary of Drug Policy and the Public Good[1], a book that reviews the scientific foundations of drug policies and the extent to which they serve the public good.

MATTERS OF SUBSTANCE

Psychoactive substances vary tremendously in their pharmacological properties, cultural symbolism and reinforcing effects [2]. Comparative risk assessments indicate that legal substances such as tobacco and alcohol are at least as dangerous as many illicit substances [3], taking into account health effects, degree of intoxication, general toxicity, social dangerousness, dependence potential and social stigma. The chemical substance itself, in its pure form, is simply one factor determining harm. Policies on substance use should reflect the social and pharmacological complexities of psychoactive substances as well as the relative differences among them. Figure 1 illustrates the complex relationships among use patterns, mediating variables and various health and social consequences.

THE INTERNATIONAL DIMENSIONS OF DRUG USE

The misuse of psychoactive substances is a global phenomenon. In 2008 the United Nations estimated that around the globe approximately 200 million people took illicit drugs at least once in the past year, of whom 165 million (80%) used marijuana and other forms of cannabis, 25 million amphetamine and 10 million ecstasy; 15 million people reported using opiates, of whom some 12 million were taking heroin; 15 million reported using cocaine [4].

The highest prevalence rates (predominantly of cannabis) are found in the high-income countries, although some low-income countries (e.g. Iran and Myanmar) have high rates of opiate abuse. Since 1990 there has been a dramatic growth of injecting drug use in newly independent states such as Russia and Ukraine [5]. Recently, there has been a significant increase in heroin use in areas of China close to the ‘Golden Triangle’[6]. Production and trafficking have also spread. For example, over the past decade Mexico has become involved increasingly in cocaine trafficking and methamphetamine production.

Adolescence is the period of greatest risk for the initiation of drug taking, especially in the high-income countries. Cannabis is the drug used most frequently by young people, but the use of inhalants is more prevalent in some countries, such as Brazil. Most of those who have tried illicit drugs do not go on to develop drug dependence or drug-related problems. Problem drug use tends to cluster in inner-city areas and in disadvantaged neighbourhoods [7]. Problem drug users are more often males and are likely to have a family history of substance dependence, delinquent behaviour and mental health problems. Problem drug use is most often interwoven in a complex network of other social problems, both at the individual and at the societal level.

HARMS ASSOCIATED WITH ILLICIT DRUG USE

Five types of morbidity and mortality as main expressions of health harm are associated with illicit drug use: (i) overdose; (ii) other injury; (iii) non-communicable physical disease; (iv) mental disorders; and (v) infectious disease. Burden of disease estimates combining years of life lost due to premature mortality and fractional years of life lost due to disability (see [8,9]) indicate that illicit drugs ranked eighth among causes of disease, death and disability in developed regions of the world. Two important policy implications can be derived from current scientific knowledge about the association between drug use and harm. First, both the drug class and the pattern of administration affect individual and societal outcomes. Opioids, cocaine and amphetamines entail greater risks, especially when they are injected. Other drugs, such as cannabis and ecstasy, involve less risk, even though their use is substantially more prevalent in most societies. In general, injection drug use constitutes a particular risk of mortality as well as other severe health outcomes. A second conclusion is that many harmful consequences are not completely intrinsic to the properties of the drug, but instead are associated with the physical and social environment in which drug use takes place.

ILLEGAL MARKETS

Illegal drugs are commodities that are bought and sold mainly in markets. Figure 2 illustrates how the market distribution network for cocaine and heroin is shaped like two funnels, with the broad mouth at the top and bottom suggesting the relative proportions of individuals involved.

Many farmers are engaged in small amounts of drug-growing in the producing countries. Continuing towards the narrowed connection between the two funnels, there are comparatively small numbers of refiners, smugglers and top-level importers. Emerging into the second funnel, there are more wholesale sellers followed by very large numbers of retailers. Compared to most legal markets, there are many sellers relative to the number of buyers in drug markets. The number who distribute cannabis, for example, is particularly large because distribution often occurs within friendship networks, frequently not for profit [10]. One consequence of the network character of drug distribution is its resilience. Eliminating individual players or even entire organizations within a mature drug distribution network has little impact on the ability of the network as a whole to transport drugs from their source to the customers. This adaptability of mature drug distribution networks limits the ability of enforcement authorities to eradicate mass-market drugs.

A proper understanding of drug markets is critical to the development of effective drug policy because market characteristics affect directly the success of drug control efforts and because black markets can harm those engaged in the drug trafficking as well as the broader community. Most of the market-related harms, such as violence and corruption, stem from the money associated with the illegal drug trade, not the weight or quantity of drugs. Higher prices tend to suppress use, but may or may not reduce total spending, depending upon how responsive drug use is to price changes.

THE PHARMACEUTICAL INDUSTRY AND THE LEGAL MARKET

The growth of modern medicine, including psychiatry, is paralleled by substantial growth in psychopharmaceutical medications designed to treat psychiatric disorders, pain, cognitive dysfunction, mental distress and sleep disorders. These medications, many of which have high dependence potential, are distributed primarily through and controlled by a prescription system. Diversion of psychopharmaceuticals from this system for non-medical use constitutes a substantial part of the illicit drug market in a growing number of countries. While there is considerable criminal diversion, much of the leakage from one market to the other happens more informally, often at the consumer/patient end of the distribution chain. The use of psychopharmaceuticals, whether or not in accordance with a prescription, is greatest in the United States, Canada, the European Union, Japan and Australia, with relatively low levels of use in most low-income countries. Those differences are driven by a combination of relative affluence, cultural specificities and the social influence of pharmaceutical marketing. The global imbalance in the use of prescribed psychoactive substances parallels the imbalance in markets for illicitly produced drugs. Non-prescribed medications come onto the market via theft, unauthorized sales, prescription fraud or ‘double-doctoring’, counterfeit drugs and illicit internet sales. Societies with substantial use of psychoactive medications tend to have strong interests and ideologies that sustain ideas that psychoactive medications are useful in the relief of distress and the pursuit of wellbeing [11]. These societies seem to be particularly vulnerable to leakage from the legal to the illegal market, thereby blurring the distinction between the two.

STRATEGIES AND INTERVENTIONS TO REDUCE DRUG USE AND RELATED HARM

In recent years addiction science has matured as an aid to policy formation. The scientific evidence for policy options is derived from a variety of research methods and measurement techniques, ranging from randomized clinical trials of prevention programmes to ‘natural experiments’ that evaluate the impact of new policies on substance use. Table 1 lists the major programmatic approaches to drug policy according to their specific aims and broader goals. Drawing upon an extensive literature, both original research and integrative literature reviews, the remainder of this book evaluates critically the scientific evidence relevant to each of these areas.

PREVENTING ILLICIT DRUG USE BY YOUNG PEOPLE

Among the plethora of studies of school, education and community-based prevention programmes, there is evidence that some approaches can delay the initiation of drug and alcohol use [12]. A small number of high-quality studies find evidence of effectiveness for specific family-based or classroom management programmes in preventing drug or alcohol use. It is notable that these programmes do not focus exclusively or specifically on drug or alcohol use per se. Rather, their aim is to improve behaviour and social skills more generally within the family or classroom environment. These programmes also show evidence of wider effect beyond drugs or alcohol. In contrast, purely didactic prevention programmes and some of the most widely used ones, such as the Drug Abuse Resistance Education (DARE) programme, have no evidence of effectiveness, whether delivered through the mass media, in the community or in the classroom [13].

Economic analyses indicate that prevention programmes may be cost-effective even if they are only modestly effective because they are relatively inexpensive, and even small changes in use rates over the life-span of the user can be valuable [14]. Societies tend to make a small investment in prevention and, on average, they reap a small return. Poor choices of programmes can result in no benefit. However, even the wisest choices will not generate a large benefit.

HEALTH AND SOCIAL SERVICES FOR DRUG USERS

Health and social services attempt to reduce drug-related harm by promoting abstinence, by reducing the amount or frequency of drug use, by minimizing the direct damage of drug use and by changing behaviours that are harmful to drug users and society at large, such as human immunodeficiency virus (HIV) risk behaviour, drug overdose and criminal activity. Among the most carefully evaluated programmes are interventions focused primarily upon users of heroin and other opioids. Opioid substitution therapy (OST) has an impressive evidence base supporting its benefits, which include reduced overdose mortality, less HIV infection and lower crime rates [15,16]. Therapeutic Communities, contingency management, counselling for marijuana dependence and brief interventions for moderate-level drug use problems have the next strongest level of evidence [17–20]. For opiate dependence in particular, psychosocial interventions have relatively less evidence of effectiveness than OST, which offers psychosocial services in combination with pharmacotherapy. Psychosocial interventions for users of cocaine, methamphetamine, hallucinogens, benzodiazepines and club drugs also have evidence of effectiveness, but it is less compelling than that for opioids.

The advent of HIV epidemics has led to programmes designed to modify drug users' injecting behaviour to lower the risk for HIV infection and transmission. Studies have found higher rates of HIV infection among non-attenders versus needle and syringe exchange attenders [21], as well as better engagement with health and social services among attenders [22].

Peer-led mutual help organizations are voluntary associations of former heavy drug users who now help each other to abstain and improve their coping skills, prosocial behaviour and family life. They are operated typically by volunteers, charge no fees to participants and allow indefinite involvement. Length of NA (Narcotics Anonymous) membership is associated positively with higher self-esteem, lower anxiety and longer duration of abstinence from drugs [23,24].

In summary, the mantra ‘treatment works’ disguises a more nuanced situation: we have a great deal of evidence that treatment for opiate addiction is effective, encouraging evidence that counselling for dependent marijuana users and Therapeutic Communities for incarcerated drug users is effective, and modest evidence that stimulant dependence treatment is effective. Also, we have a great deal more evidence that services have a significant impact on people without other serious problems than we do for people with serious psychiatric comorbidities and grossly disordered lives.

Policies affecting the type, amount and organization of health and social services play an important role in the overall effectiveness of a service system [20]. Countries differ markedly in their service systems, which vary in terms of their availability, accessibility, coordination, cost-effectiveness and degree of coerciveness. Quality matters. Good treatment programmes achieve better results than poor programmes. Promoting better-quality services for drug users is a major challenge for systems managers, and some of the most widely employed methods (e.g. credentialling) have limited evidence of effectiveness. Process performance indicators seem the most promising approach, but will not realize their full potential until evaluation science specifies more clearly which proximal outcomes predict long-term changes in drug users' behaviour. Policy makers who think and act at a system level, and draw upon the emerging evidence base on the nature and impact of systems, have a much greater likelihood of making a significant contribution to ameliorating drug problems at both the individual and the population levels.

SUPPLY CONTROL

Supply control approaches to drug problems focus upon the production, distribution and sale of illicit psychoactive substances, and include alternative development programmes in producer nations, control of precursor chemicals used to produce certain drugs (e.g. methamphetamines) interdiction and the arrest and incarceration of drug dealers at all levels. Supply control interventions absorb the bulk of drug control spending in most nations, yet the evidence which would support these interventions is weak, in part because the existing evaluations fail to demonstrate effects on either the supply or the price of drugs in the market-place [25].

There are several reasons why supply control approaches fail to have a major impact. First, there is no evidence that promoting alternative development as part of a global drug control strategy has a noticeable effect upon use in the principal consuming countries. Secondly, the occasional success of interventions far up the distribution chain (crop eradication, interdiction, precursor controls) cannot be replicated consistently because the literature offers only educated guesses for when such interventions might achieve noticeable market disruptions. Thirdly, when it comes to punishing high-level dealers, what little evidence exists suggests that there may be diminishing returns to drug policy goals from extended periods of incarceration. Finally, local or street-level enforcement is probably not a viable strategy for reducing drug use, simply because the number of retail sellers is so large as to overwhelm the capacity of the criminal justice system to deliver punishment. Rather, its primary effects may be controlling harms associated with drug markets, encouraging dependent users to make contact with service providers and expressing the moral outrage of many people who live in those communities.

CRIMINALIZATION AND DECRIMINALIZATION OF DRUG USE

There has long been interest in the possible benefits of reducing or eliminating criminal penalties for possession of small amounts of drugs for personal use, on grounds both of proportionality and effectiveness-orientated policy. An increasing number of jurisdictions, national and subnational, have made such changes for cannabis. A few nations have removed criminal penalties for possession of small amounts of all prohibited drugs. Most decriminalization or depenalization programmes involve the substitution of civil penalties for criminal penalties for possession offences, while retaining full formal prohibition. This might increase demand by reducing the deterrent effect of the law.

Evaluations of such changes [26] suggest that decriminalization makes little difference to prevalence of cannabis use. The Dutch coffee shop system, in which cannabis is de facto legally available to adults, is difficult to evaluate systematically, but cannabis use rates for the Netherlands are not significantly different from other western European countries. Those rates did, however, rise sharply among youth after the coffee shop system became more commercially sophisticated with better advertising during a period in which use rates for cannabis did not rise in most other western countries. For decriminalization or recriminalization affecting other drugs there are descriptive evaluations from the Czech Republic [27] and Portugal [28]. Generally, drug use did not fall in the Czech Republic when possession was recriminalized, and drug use and problems decreased rather than rose in Portugal after decriminalization.

What conclusions can be drawn from this literature is much debated (including within the Drug Policy and Public Good authorial group). The balance of the available evidence is that removing or reducing criminal penalties on possession does not lead to substantial increases in use. For cannabis, in particular, there are a number of cases where no change was measured in consumption from such a policy change. However, the research is limited in four senses: (1) it almost all comes from developed countries; (2) most of the evidence concerns only cannabis; (3) there is only limited evidence about the effects of changes in the opposite direction, namely recriminalization or intensified enforcement against users; and (4) the studies are generally not methodologically strong.

PRESCRIPTION REGIMES

There is extraordinary variation in the availability of prescription psychoactive drugs, with most prescription drug use being concentrated in developed countries. A variety of measures aim to prevent abuses, such as ‘doctor-shopping’ and diversion of psychopharmaceuticals from the medical and pharmacy systems. The available evidence suggests that prescription regimes affect the behaviour of physicians, although often resulting in medication substitution. There are some instances of beneficial net effects on adverse consequences from prescription regime tightening. Price can be used to channel demand between two drugs that are substitutes for each other, moving demand from a drug with more adverse consequences to a less risky alternative. The evidence on effects of package size and place-of-sale restrictions on over-the-counter sales is mixed. Nor is there much evidence on the effects of restricting over-the-counter (OTC) sales to ‘behind-the-counter’ sales or sales by a pharmacist. Advice to physicians on prescribing, in the absence of regulatory enforcement, seems to have limited effect unless the advice concerns a new and serious side effect and alternative medicines can be prescribed. Shifting a prescribed drug onto a special prescription register, in conjunction with guidelines that limit prescriptions, usually reduces prescriptions of that drug. In summary, the development of a strong pharmacy system can limit illicit diversion of prescription medications, but in countries with a very high demand for psychopharmaceuticals such systems have not been able to prevent periodic epidemics of prescription drug misuse.

DRUG POLICY AND CONTROL AT THE INTERNATIONAL LEVEL

International drug control efforts are designed to coordinate domestic laws with international activities that regulate or limit the supply of psychoactive substances. These efforts are currently organized around three main drug control treaties: the 1961 Single Convention on Narcotic Drugs, the 1971 Convention on Psychotropic Substances and the 1988 Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances. Almost all countries have ratified and are bound by the three treaties. The first two treaties codify internationally applicable control measures in order to ensure the availability of narcotic drugs and psychotropic substances for medical and scientific purposes, and to prevent their diversion into illicit channels. They also include general provisions on illicit trafficking and drug abuse. The third treaty, represents a further redefinition of the system in terms of controlling crime, stressing the danger of drug traffic to national security, the links between the drug trade and corruption and the role of the drug traffic in undermining economic development.

Three specialized international bodies are responsible for implementation of the treaties: the Commission on Narcotic Drugs (CND), a political body with states elected as members by the UN; the United Nations Office on Drugs and Crime (UNODC), the administrative body for the UN's programmes in both the drug area and the crime area; and the International Narcotics Control Board (INCB), which monitors compliance with the treaties [29].

The effects of the system have been evaluated mainly in terms of the ability of limited drug control efforts to eliminate illicit markets and supply. In this context, very little attention is paid to the other aim of the system: making psychoactive medications available for medical and scientific use. For high-income countries, the INCB in its role as custodian of the world market appears to have made adequate provisions in a timely manner for supplies of such medication. In much of the developing world, however, the picture is very different. The gross imbalance in world consumption of legal opiates is a pointer to the limited availability of effective pain medications in many low-income countries, with 80% of the world's population having either no or inadequate access to treatment for moderate or severe pain [30].

THE VARIETY OF NATIONAL DRUG POLICIES

For some nations the drug problem is defined primarily in terms of domestic drug use, while for others trafficking to other nations is the principal way in which illicit drugs damage domestic public health and safety. For example, since 2006 Mexico has experienced a huge rise in the number of killings related to drug trafficking, and its drug problem is often defined in terms of this epidemic of violent deaths. On the other hand, the United Kingdom is concerned primarily with high rates of dependent use of heroin and cocaine. It is hardly surprising, then, that drug policies differ among nations in both appearance and substance. Some nations treat drugs primarily as a problem for law enforcement or the military and give great prominence to efforts to suppress trafficking; others focus their efforts primarily upon prevention and education, upon helping dependent drug users and upon reducing the adverse consequences of drug use. For example, Nigeria places drug policy primarily in the domain of foreign policy, while for Sweden it is an aspect of social policy. This variation across nations reflects differences in attitudes towards drug use itself, individual rights and the role of government. It also reflects the nature and history of national drug problems, the broader political structure of a country and the different ways in which drugs affect a nation. Policy advice that ignores these differences across nations and assumes that there is a single ‘best policy’ for all nations is itself likely to be ineffective.

SUMMARY AND CONCLUSIONS

The main message of this book is that scientific research is available to inform the development and implementation of effective drug policy; yet current drug policy in most societies takes little or limited account of this research. Among the 43 options presented in this book, 17 show some evidence of effectiveness in at least one country. Unfortunately, policies that have shown little or no evidence of effectiveness continue to be the preferred options of many countries and international organizations. Even when a policy works, it cannot totally eliminate drug problems, but it can often reduce their prevalence or their negative impact.

We now present some implications of these findings for achieving various policy goals. In so doing, we recognize that policy making cannot and should not be solely a technocratic endeavour entrusted to scientists. Scientists are experts in measuring the nature of the problem and in assessing the outcomes of policy, but their expertise cannot be used to decide the specific outcomes a society should care about the most. What follows, therefore, is not a prescription for what any society or policy maker should do, but rather an analysis of the probable consequences of exercising particular options. This information becomes meaningful only in light of whatever goals a policy maker or society has chosen to pursue.

In conclusion, the scientific evidence reviewed in this book is not sufficient to stem the rising tide of global drug problems. However, many countries are not utilizing existing resources to best effect. The evidence in this book could be a powerful ally of leaders and policy makers with the courage, creativity and conviction to create more effective drug policy.

NOTE

The Drugs and Public Policy Group consists of the following authors, listed in alphabetical order: Thomas Babor, Jonathan Caulkins, Griffith Edwards, Benedikt Fischer, David Foxcroft, Keith Humphreys, Isidore Obot, Jürgen Rehm, Peter Reuter, Robin Room, Ingeborg Rossow and John Strang.