Elsevier

The Lancet

Volume 387, Issue 10026, 2–8 April 2016, Pages 1427-1480
The Lancet

The Lancet Commissions
Public health and international drug policy

https://doi.org/10.1016/S0140-6736(16)00619-XGet rights and content

Section snippets

Executive summary

In September, 2015, the member states of the UN endorsed Sustainable Development Goals (SDGs) for 2030, which aspire to human-rights-centred approaches to ensuring the health and wellbeing of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April, 2016, these same states will consider control of illicit drugs, an area of social policy that has been

Setting the scene: an evolving international debate

The international drug-control system has its origins in decades-old legal instruments framed by politics more than science. From the time of the 1912 Hague Opium Convention, minimisation of the supply of some psychoactive drugs through policing has been the dominant strain in international drug law. 8 In the decades leading up to the 1961 Single Convention, international drug-control agreements largely sidestepped issues of demand and consumption. 9 The eventual solution in the 1961 Single

Violence and enforcement of drug prohibition

Since it published its first report on violence and health in 2002, 29 WHO has highlighted numerous forms of violence as health issues. 30 The Global Burden of Disease Study of 2013 showed that interpersonal violence, including all types of violent assault, rose about 18·4% as a cause of mortality globally from 1990 to 2013. 31 The region most affected was Latin America, where interpersonal violence was among the top five causes of death in 15 countries. 31 The 2014 WHO report on preventing

Homicide in Mexico

The fateful decision of Felipe Calderón's Government in Mexico in 2006 to use its military in civilian areas to fight drug traffickers ushered in an epidemic of violence in many parts of the country that also spilled over into Central America. 15 The increase in homicides in Mexico since 2006 is virtually unprecedented in a country not formally at war. It was so great in some parts of the country that it contributed to a reduction in the country's projected life expectancy. 40 Another

HIV, hepatitis C virus infection, and harm reduction: neglect of proven solutions

At a time when gains in reduction of sexual transmission of HIV are evident worldwide, HIV transmission linked to injection of drugs with unsterile equipment continues to drive incidence in many regions, including eastern Europe and central Asia (EECA) and much of Asia, despite the availability of proven interventions to stop it.53, 54 The prevalence of HIV infection among people who inject drugs is many times higher than that in the general population in many countries (figure 5 ). 55 Outside

The cost of neglecting harm-reduction and prevention measures

Preventable outbreaks of HIV in recent years have constituted graphic real-life demonstration of the value of ready access to harm-reduction services and the cost of impeding access to them. EECA bear a heavy burden from the neglect of harm-reduction measures. Harsh anti-drug policies and moral judgments against people who use drugs contribute to making health services for this population a low political priority. 87 In the first decade of its work, financial support from the Global Fund to

Law on the books

Evidence from a number of countries indicates that drug law, policy, and law-enforcement practices can be barriers to provision and use of harm-reduction and other HIV-prevention services. These barriers take many forms, some related to the letter of the law in force in a country—ie, the “law on the books”—but many more related to the way in which law is enforced in practice, or what Burris calls the “law on the street”. 124

In some cases, there are legal prohibitions against, or poor legal

Tuberculosis, drug use, and drug policy

According to WHO, tuberculosis is the most important cause of death among people living with HIV: it causes one in four deaths. 139 People living with HIV have a 30-times higher risk of tuberculosis infection than do HIV-negative people. 139 But WHO emphasises that people who use drugs are at very high risk of both infection with Mycobacterium tuberculosis and active tuberculosis even if they do not have HIV. The risk of tuberculosis was linked independently to drug injection—and even to

Use of incarceration in drug control

In 2014, the UNODC estimated that people convicted of drug crimes make up about 21% of incarcerated people worldwide. Possession of drugs for individual use was the most frequently reported crime globally (figure 11 ). 32 On the basis of data from 2011 annual country reports, the UNODC estimated that drug-possession offences constituted 83% of drug offences reported worldwide. 32 Although not all of the crimes reported by the police result in incarceration, mandatory prison sentences are

Infectious disease and drug-related incarceration

Prisons and pretrial detention facilities worldwide are high-risk environments for infectious disease transmission. UN agencies estimate that the prevalence of HIV infection, other sexually transmitted infections, HCV and hepatitis B virus infections, and tuberculosis is two to ten times higher in prisons than in the community. 55 Co-infection of these diseases is also likely in prison. In Argentina, for example, people living with tuberculosis who had a history of incarceration were six times

Prison services for infectious diseases and drug dependence

It is an international norm that people in prison and other custodial settings have a right to health services at the level of those offered in the community in their jurisdictions. 234 When it comes to HIV, HCV infection, and tuberculosis services, that norm is far from being respected. The UNODC and WHO recommend a comprehensive package of measures for HIV prevention, care, and support for incarcerated people, including NSPs and OST. 235 These measures are also important for HCV infection

Drug policy and death from overdose

Drug overdose should be an urgent priority in drug policy and harm-reduction efforts. Overdose can be immediately lethal and can also leave people with debilitating morbidity and injury, including from cerebral hypoxia. The authors of a 2013 systematic global review 258 concluded that overdose was a leading cause of mortality in people who inject drugs in all regions. 258 In 2014, WHO estimated that about 69 000 people worldwide died annually from opioid overdose, 259 but that estimate might

Compulsory detention

A small minority of people who use drugs develop dependence. But in many parts of the world, people who use drugs are assumed to be using problematically or to be criminals, and compelling them to undergo drug treatment is a widespread practice. In addition to the vast use of incarceration through criminal justice systems in the pursuit of drug prohibition, in some countries there is large-scale extra-judicial detention of drug offenders, allegedly in the name of treatment or rehabilitation. In

Drug-control policy: access to controlled drugs

The Single Convention on Narcotic Drugs of 1961 had the dual purpose of ensuring that controlled substances, including opioids, were available for medical and scientific purposes and preventing their misuse and diversion. However, after more than 50 years under this regime, around 75% of the world's population—roughly 5·5 billion people—do not have safe and adequate access to controlled drugs for the management of pain, including postoperative pain and the severe pain associated with cancer,

Assessing the public health risk and clinical value of controlled substances

The challenge of ensuring adequate access to controlled drugs is related closely to the way in which international and national authorities assess the degree of danger or potential harm associated with specific substances. For the international regime, article 3 of the Single Convention on Narcotic Drugs explicitly confers on WHO the responsibility to judge whether substances are dangerous and in need of strict control. 6 The 1971 Convention on Psychotropic Substances emphasises in article 2

Research challenges in drug policy

A large body of research has helped to advance many aspects of the drug-policy debate. OST, for example, has benefited from decades of clinical research in numerous settings to the point where good practices are well documented and can be adopted and adapted readily. The benefits and cost-effectiveness of NSPs and programmes to address opioid overdose are also supported by a strong research base that should inspire scaling up these programmes to reduce the needless morbidity and mortality of

Production flourishes despite risks

People become involved in drug markets for many reasons, but poverty and exclusion from mainstream economic opportunities are important factors in many cases. Nonetheless, drug policies are rarely assessed in terms of how they affect people living in poverty or human development more broadly. 13 In this report, we highlight the situation of people whose livelihood depends on growing crops used to make psychoactive drugs as an example of neglected health and human security issues at the

Rejection of criminalisation of minor offences and scaling up of health services

The public health harms of the pursuit of drug prohibition have led some cities and countries to rethink approaches to drug control. Their experiences with respect to many of the health problems described in previous sections are largely replicable and show the path to drug policies that support health and development and do not undermine human rights.

Portugal's transition from decades of isolating authoritarian rule to democratic governance in the mid-1970s brought enormous social change.

Sub-Saharan Africa

Even without fundamental change to drug laws and in the face of political and economic constraints, some countries have found ways to strengthen health-sector approaches that are a departure from policing-centred drug policy. An estimated 500 000 people use opioids in east Africa, and in Tanzania alone an estimated 30 000 people inject opioids. 304 Prevalence of HIV infection among people who inject drugs in Tanzania is estimated to be 42–50% and is plainly an important challenge for the

Conclusions and recommendations

Policies meant to prohibit or greatly suppress drugs present an apparent paradox. They are portrayed by policy makers to be necessary to preserve public health and safety, and yet they directly and indirectly contribute to lethal violence, disease, discrimination, forced displacement, injustice, and the undermining of people's right to health. The framers of international human rights law foresaw that there would be times, especially in the face of security threats, when some individual rights

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