A number of well-established and proven public health measures6,7 (generally referred to as harm reduction, an approach that includes syringe access and treatment using the proven medications methadone or buprenorphine) can minimize the risk of drug overdose deaths and the transmission of HIV and other blood-borne infections.8 However, governments often do not fully implement these interventions, concerned that by improving the health of people who use drugs, they are undermining a ‘tough on drugs’ message. This is illogical – sacrificing the health and welfare of one group of citizens when effective health protection measures are available is unacceptable, and increases the risks faced by the wider community.
IMPACT OF DRUG POLICIES ON RECENT HIV PREVALENCE AMONG PEOPLE WHO INJECT DRUGS9
Countries that implemented harm reduction and public health strategies early have experienced consistently low rates of HIV transmission among people who inject drugs. Similarly, countries that responded to increasing HIV prevalence among drug users by introducing harm reduction programs have been successful in containing and reversing the further spread of HIV. On the other hand, many countries that have relied on repression and deterrence as a response to increasing rates of drug-related HIV transmission are experiencing the highest rates of HIV among drug using populations.10,11,12
An indiscriminate approach to ‘drug trafficking’ is similarly problematic. Many people taking part in the drug market are themselves the victims of violence and intimidation, or are dependent on drugs. An example of this phenomenon are the drug ‘mules’ who take the most visible and risky roles in the supply and delivery chain. Unlike those in charge of drug trafficking organizations, these individuals do not usually have an extensive and violent criminal history, and some engage in the drug trade primarily to get money for their own drug dependence. We should not treat all those arrested for trafficking as equally culpable – many are coerced into their actions, or are driven to desperate measures through their own addiction or economic situation. It is not appropriate to punish such individuals in the same way as the members of violent organized crime groups who control the market.
Finally, many countries still react to people dependent on drugs with punishment and stigmatization. In reality, drug dependence is a complex health condition that has a mixture of causes – social, psychological and physical (including, for example, harsh living conditions, or a history of personal trauma or emotional problems). Trying to manage this complex condition through punishment is ineffective – much greater success can be achieved by providing a range of evidence-based drug treatment services. Countries that have treated citizens dependent on drugs as patients in need of treatment, instead of criminals deserving of punishment, have demonstrated extremely positive results in crime reduction, health improvement, and overcoming dependence.
PATIENTS NOT CRIMINALS: A MORE HUMANE AND EFFECTIVE APPROACH
Case Study One: Switzerland13
In response to severe and highly visible drug problems that developed across the country in the 1980s, Switzerland implemented a new set of policies and programs (including heroin substitution programs) based on public health instead of criminalization. The consistent implementation of this policy has led to an overall reduction in the number of people addicted to heroin as well as a range of other benefits. A key study14 concluded that:
“Heroin substitution targeted hard-core problematic users (heavy consumers) – assuming that 3,000 addicts represent 10 percent to 15 percent of Switzerland’s heroin users that may account for 30 percent to 60 percent of the demand for heroin on illegal markets. Heavily engaged in both drug dealing and other forms of crime, they also served as a link between wholesalers and users. As these hard-core users found a steady, legal means for their addiction, their illicit drug use was reduced as well as their need to deal in heroin and engage in other criminal activities.
The heroin substitution program had three effects on the drug market:
- It substantially reduced the consumption among the heaviest users, and this reduction in demand affected the viability of the market. (For example, the number of new addicts registered in Zurich in 1990 was 850. By 2005, the number had fallen to 150.)
- It reduced levels of other criminal activity associated with the market. (For example, there was a 90 percent reduction in property crimes committed by participants in the program.)
- By removing local addicts and dealers, Swiss casual users found it difficult to make contact with sellers.”
Case Study Two: United Kingdom15
Research carried out in the UK into the effects of their policy of diversion from custody into treatment programs clearly demonstrated a reduction in offending following treatment intervention. In addition to self-reports, the researchers in this case also referred to police criminal records data. The research shows that the numbers of charges brought against 1,476 drug users in the years before and after entering treatment reduced by 48 percent.
Case Study Three: The Netherlands16,17,18
Of all EU-15 countries, the percentage of people who inject heroin is the lowest in the Netherlands and there is no new influx of problematic users. Heroin has lost its appeal to the mainstream youth and is considered a ‘dead-end street drug’. The number of problematic heroin users has dropped significantly and the average age of users has risen considerably. Large-scale, low-threshold drug treatment and harm reduction services include syringe access and the prescription of methadone and heroin under strict conditions.
Medically prescribed heroin has been found in the Netherlands to reduce petty crime and public nuisance, and to have positive effects on the health of people struggling with addiction. In 2001, the estimated number of people in the Netherlands dependent on heroin was 28-30,000. By 2008, that number had fallen to 18,000. The Dutch population of opiate users is in the process of aging – the proportion of young opiate users (aged 15-29) receiving treatment for addiction has also declined.