The Lancet CommissionsPublic health and international drug policy
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
References (430)
Cannabis policy reforms in the Americas: a comparative analysis of Colorado, Washington, and Uruguay
Int J Drug Policy
(2014)- et al.
Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed
Lancet
(2010) - et al.
What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010–2012? A review of the six highest burden countries
Int J Drug Policy
(2014) - et al.
Is the HCV–HIV co-infection prevalence amongst injecting drug users a marker for the level of sexual and injection related HIV transmission?
Drug Alcohol Depend
(2013) - et al.
Interventions to prevent HIV and hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness
Int J Drug Policy
(2014) - et al.
A review of medical and substance use co-morbidities in central Asian prisons: implications for HIV prevention and treatment
Drug Alcohol Depend
(2013) - et al.
Controlling HIV among people who inject drugs in eastern Europe and central Asia: Insights from modelling
Int J Drug Policy
(2014) - et al.
HIV and risk environment for injecting drug users: the past, present, and future
Lancet
(2010) Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union
Int J Drug Policy
(2007)- et al.
Patterns of heroin and cocaine injection and plasma HIV-1 RNA suppression among a long-term cohort of injection drug users
Drug Alcohol Depend
(2012)
Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward
Lancet
Integrating antiretroviral therapy in methadone maintenance therapy clinics: service provider perceptions
Int J Drug Policy
Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine
Drug Alcohol Depend
Illicit drugs in central Asia: what we know, what we don't know, and what we need to know
Int J Drug Policy
Human rights and access to hepatitis C treatment for people who inject drugs
Int J Drug Policy
Excluding people who use drugs or alcohol from access to hepatitis C treatments—is this fair, given the available data?
J Hepatology
Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study
Lancet HIV
Message on International Day Against Drug Trafficking and Abuse
Transforming our world: the 2030 agenda for sustainable development
Not just in transit: drugs, the state and society in West Africa
Study on the impact of the world drug problem on the enjoyment of human rights. Human Rights Council, 30th session
Political declaration of the UN General Assembly Special Session on the world drug problem
United Nations Single Convention on Narcotic Drugs. 1961 as amended by the 1972 protocol amending the Single Convention on Narcotic Drugs
World Drug Report
Reflections on a century of international drug control
The economics of new global strategy
Key statistics: illicit drug production, trafficking and consumption. Information sheet no. 2 for UN General Assembly Special Session on the World Drug Problem
World drug report
Joint ministerial statement of the 2014 high-level review by the Commission on Narcotic Drugs of the implementation by member states of the Political Declaration and Plan of Action on International Cooperation towards an integrated and balanced strategy to counter the world drug problem
Addressing the development dimensions of drug policy
Public health dimension of the world drug problem including in the context of the Special Session of the UN General Assembly on the World Drug Problem, to be held in 2016: report of the secretariat. 138th session, doc. EB 138/11, 2016
The drug problem in the Americas
War on drugs
Drugs and democracy: toward a paradigm shift
HIV and the law: risks, rights, and health
Drug-free ASEAN 2015: status and recommendations
‘Drug free’ ASEAN by 2015?
CDC vital aigns: today's heroin epidemic
Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review
Am J Public Health
Drug policy and overdose prevention and response
Presidential candidates are actually talking about America's heroin issue
Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century
Proc Natl Acad Sci USA
In heroin crisis, white families seek gentler war on drugs
Marijuana case filings plummet in Colorado following legalization. Denver Post
World report on violence and health
Global status report on violence prevention 2014
Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Lancet
The contagion of drug violence: spatiotemporal dynamics of the Mexican war on drugs
J Conflict Resolution
World crime trends and emerging issues and responses in the field of crime prevention and criminal justice. 23rd session, Commission on Crime Prevention and Criminal Justice
Transnational organized crime in Central America and the Caribbean: a threat assessment
Cited by (400)
Direct-acting antiviral therapies for hepatitis C infection: global registration, reimbursement, and restrictions
2024, The Lancet Gastroenterology and HepatologyPeople who use drugs’ prioritization of regulation amid decriminalization reforms in British Columbia, Canada: A qualitative study
2024, International Journal of Drug PolicyAvailability of substance use screening and treatment within HIV clinical sites across seven geographic regions within the IeDEA consortium
2024, International Journal of Drug PolicyCost-effectiveness of a police education program on HIV and overdose among people who inject drugs in Tijuana, Mexico
2024, Lancet Regional Health - Americas