The Global Commission on Drug Policy’s latest report, published ahead of World AIDS Day on Dec 1, describes decriminalisation of drug use as an essential precursor to ending HIV and viral hepatitis as public health threats. Since its formation in 2011 by political, economic, and cultural leaders, the Commission has advocated for decriminalisation as part of a rights-based approach to drug policy, rooted in scientific evidence and principles of public health, to minimise the harms arising from drug use. The UN recognises criminalisation of drugs as “proven to have negative health outcomes” and to “counter established public health evidence”; yet a disconnection between discourse and policy action persists. National drug policies largely remain punitive; they are polarised, simplified, and based more on ideology than evidence. According to the Global State of Harm Reduction 2022 report, 115 of 128 included countries still criminalise drug use, and only 105 countries support harm reduction as an official policy.

Decriminalisation alone is, of course, not sufficient. In its report, the Commission emphasises the need to expand harm-reduction approaches alongside decriminalisation of personal drug possession and use. Portugal garnered international attention when, in the early 2000s, it decriminalised drugs as part of its progressive response to the growing use of injectable drugs and transmission of HIV and viral hepatitis in the country. The number of people using heroin fell from an estimated 100 000, in 2001, to 25 000, in 2017; fatal overdoses decreased by more than 85%, and new HIV diagnoses by more than 90%. When the use of illicit drugs in the country began to rise in recent years, critics leapt on the reversal as evidence of the policy’s failure. But the increase in drug use coincided with a fall in funding for Portugal’s drug treatment programme—an essential part of the policy. Portugal’s approach was not to simply decriminalise; it redefined addiction as an illness and provided extensive treatment and recovery support, moving people who use drugs away from the judicial system and towards professional care. Comprehensive medical, psychological, and social support need to accompany decriminalisation to address factors such as homelessness and unstable housing, ill mental health, poverty, racial inequities, and inadequate access to health care, all of which might drive people into drug use.

What has long been clear is that punitive approaches are both ineffective and harmful. Decades of criminalisation have not only spectacularly failed to disincentivise drug use but also propelled the global epidemics of HIV and hepatitis by hindering efforts to prevent transmission and provide care for people in need. The Johns Hopkins–Lancet Commission on drug policy and health found no evidence that the threat of imprisonment is an effective deterrent against drug use. Incarceration often reduces access to care, introduces adverse outcomes (eg, homelessness) following release, and facilitates negative exposures during time spent in prison, where the lack of safe injecting equipment and other harm-reduction services heighten the risk of viral hepatitis and HIV transmission—which is already approximately 35 times higher for adults who inject drugs than among those who do not. Stigma and discrimination only make it less likely that people who use drugs will get the help they need.

Meanwhile, evidence supporting the approaches advocated for by the Global Commission on Drug Policy grows stronger. Harm reduction strategies such as opioid-agonist treatments, sterile injecting equipment, safe injection centres, and psychosocial interventions do not, contrary to belief, promote drug use. For example, 2 years of monitoring showed no substantial increases in crime, disorder, or health emergency calls after the first two government-sanctioned safe consumption sites opened in New York, NY, USA. A 2019 report of global opioid use found that only two interventions resulted in increases in opioid use: compulsory drug treatment and criminalisation of drug use.

Mitigating harm is not easy: drug use patterns are shifting (as illustrated by the rise of synthetic opioids) and vary widely between urban and rural settings and among marginalised populations. Decriminalisation works, but not in isolation; and although it does not mean removing law enforcement from the complex environment of drug use, it does require health professionals, and not the criminal justice system, to be the first responders to this public health crisis. Evidence to show that criminalisation has failed is overwhelming. Bold and comprehensive reforms are needed to pursue health-oriented, rights-based drug decriminalisation policies. What more will it take for policy makers to listen?

Source : The Lancet

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