1. Drug policies must be based on solid empirical and scientific evidence. The primary measure of success should be the reduction of harm to the health, security and welfare of individuals and society.

In the 50 years since the United Nations initiated a truly global drug prohibition system, we have learned much about the nature and patterns of drug production, distribution, use and dependence, and the effectiveness of our attempts to reduce these problems. It might have been understandable that the architects of the system would place faith in the concept of eradicating drug production and use (in the light of the limited evidence available at the time). There is no excuse, however, for ignoring the evidence and experience accumulated since then. Drug policies and strategies at all levels too often continue to be driven by ideological perspectives, or political convenience, and pay too little attention to the complexities of the drug market, drug use and drug addiction.

Effective policymaking requires a clear articulation of the policy’s objectives. The 1961 UN Single Convention on Narcotic Drugs made it clear that the ultimate objective of the system was the improvement of the ‘health and welfare of mankind’.

This reminds us that drug policies were initially developed and implemented in the hope of achieving outcomes in terms of a reduction in harms to individuals and society – less crime, better health, and more economic and social development. However, we have primarily been measuring our success in the war on drugs by entirely different measures – those that report on processes, such as the number of arrests, the amounts seized, or the harshness of punishments. These indicators may tell us how tough we are being, but they do not tell us how successful we are in improving the ‘health and welfare of mankind’.

2. Drug policies must be based on human rights and public health principles. We should end the stigmatization and marginalization of people who use certain drugs and those involved in the lower levels of cultivation, production and distribution, and treat people dependent on drugs as patients, not criminals.

Certain fundamental principles underpin all aspects of national and international policy. These are enshrined in the Universal Declaration of Human Rights and many international treaties that have followed. Of particular relevance to drug policy are the rights to life, to health, to due process and a fair trial, to be free from torture or cruel, inhuman or degrading treatment, from slavery, and from discrimination. These rights are inalienable, and commitment to them takes precedence over other international agreements, including the drug control conventions. As the UN High Commissioner for Human Rights, Navanethem Pillay, has stated, “Individuals who use drugs do not forfeit their human rights. Too often, drug users suffer discrimination, are forced to accept treatment, marginalized and often harmed by approaches which over-emphasize criminalization and punishment while under-emphasizing harm reduction and respect for human rights.”5

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.

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.

3. The development and implementation of drug policies should be a global shared responsibility, but also needs to take into consideration diverse political, social and cultural realities. Policies should respect the rights and needs of people affected by production, trafficking and consumption, as explicitly acknowledged in the 1988 Convention on Drug Trafficking.

The UN drug control system is built on the idea that all governments should work together to tackle drug markets and related problems. This is a reasonable starting point, and there is certainly a responsibility to be shared between producing, transit and consuming countries (although the distinction is increasingly blurred, as many countries now experience elements of all three).

However, the idea of shared responsibility has too often become a straitjacket that inhibits policy development and experimentation. The UN (through the International Narcotics Control Board), and in particular the US (notably through its ‘certification’ process), have worked strenuously over the last 50 years to ensure that all countries adopt the same rigid approach to drug policy – the same laws, and the same tough approach to their enforcement. As national governments have become more aware of the complexities of the problems, and options for policy responses in their own territories, many have opted to use the flexibilities within the Conventions to try new strategies and programs, such as decriminalization initiatives or harm reduction programs. When these involve a more tolerant approach to drug use, governments have faced international diplomatic pressure to ‘protect the integrity of the Conventions’, even when the policy is legal, successful and supported in the country.

A current example of this process (what may be described as ‘drug control imperialism’), can be observed with the proposal by the Bolivian government to remove the practice of coca leaf chewing from the sections of the 1961 Convention that prohibit all non-medical uses.
Despite the fact that successive studies have shown19 that the indigenous practice of coca leaf chewing is associated with none of the harms of international cocaine markets, and that a clear majority of the Bolivian population (and neighboring countries) support this change, many of the rich ‘cocaine consumer’ countries (led by the US) have formally objected to the amendment.20

The idea that the international drug control system is immutable, and that any amendment – however reasonable or slight – is a threat to the integrity of the entire system, is short-sighted. As with all multilateral agreements, the drug conventions need to be subject to constant review and modernization in light of changing and variable circumstances. Specifically, national governments must be enabled to exercise the freedom to experiment with responses more suited to their circumstances. This analysis and exchange of experiences is a crucial element of the process of learning about the relative effectiveness of different approaches, but the belief that we all need to have exactly the same laws, restrictions and programs has been an unhelpful restriction.

ariable circumstances. Specifically, national governments must be enabled to exercise the freedom to experiment with responses more suited to their circumstances. This analysis and exchange of experiences is a crucial element of the process of learning about the relative effectiveness of different approaches, but the belief that we all need to have exactly the same laws, restrictions and programs has been an unhelpful restriction.

UNINTENDED CONSEQUENCES

The implementation of the war on drugs has generated widespread negative consequences for societies in producer, transit and consumer countries. These negative consequences were well summarized by the former Executive Director of the United Nations Office on Drugs and Crime, Antonio Maria Costa, as falling into five broad categories:

1. The growth of a ‘huge criminal black market’, financed by the risk-escalated profits of supplying international demand for illicit drugs.

2. Extensive policy displacement, the result of using scarce resources to fund a vast law enforcement effort intended to address this criminal market.

3. Geographical displacement, often known as ‘the balloon effect’, whereby drug production shifts location to avoid the attentions of law enforcement.

4. Substance displacement, or the movement of consumers to new substances when their previous drug of choice becomes difficult to obtain, for instance through law enforcement pressure.

5. The perception and treatment of drug users, who are stigmatized, marginalized and excluded.21

4. Drug policies must be pursued in a comprehensive manner, involving families, schools, public health specialists, development practitioners and civil society leaders, in partnership with law enforcement agencies and other relevant governmental bodies.

With their strong focus on law enforcement and punishment, it is not surprising that the leading institutions in the implementation of the drug control system have been the police, border control and military authorities directed by Ministries of Justice, Security or Interior. At the multilateral level, regional or United Nations structures are also dominated by these interests.

Although governments have increasingly recognized that law enforcement strategies for drug control need to be integrated into a broader approach with social and public health programs, the structures for policymaking, budget allocation, and implementation have not modernized at the same pace.

These institutional dynamics obstruct objective and evidence-based policymaking. This is more than a theoretical problem – repeated studies22,23 have demonstrated that governments achieve much greater financial and social benefit for their communities by investing in health and social programs, rather than investing in supply reduction and law enforcement activities. However, in most countries, the vast majority of available resources are spent on the enforcement of drug laws and the punishment of people who use drugs.24

The lack of coherence is even more marked at the United Nations. The development of the global drug control regime involved the creation of three bodies to oversee the implementation of the conventions – the UN Office on Drugs and Crime (UNODC), the International Narcotics Control Board (INCB), and the Commission on Narcotic Drugs (CND). This structure is premised on the notion that international drug control is primarily a fight against crime and criminals. Unsurprisingly, there is a built-in vested interest in maintaining the law enforcement focus and the senior decisionmakers in these bodies have traditionally been most familiar with this framework.

Now that the nature of the drug policy challenge has changed, the institutions must follow. Global drug policy should be created from the shared strategies of all interested multilateral agencies – UNODC of course, but also UNAIDS, WHO, UNDP, UNICEF, UN Women, the World Bank, and the Office of the High Commissioner on Human Rights. The marginalization of the World Health Organization is particularly worrisome given the fact that it has been given a specific mandate under the drug control treaties.