Addiction is a health issue, not a moral failing, and physicians need to champion public policy changes that put treatment first and reverse the "absurd" focus on the war against drugs, which has never and will never work, say editors of the BMJ.
"All wars cause human rights violations and the war on drugs is no different," write Fiona Godlee, MD, editor-in-chief, and Richard Hurley, features and debates editor of the BMJ.
The editorial was published online November 14 in the BMJ.
Docs Can Make a Difference
Criminals who control the supply of drugs are responsible for "appalling violence" that has resulted in 65,000 to 80,000 murders in Mexico alone during the past 10 years.
In the United States, putting drug users in prison for even minor offenses has led to the highest incarceration rates in the world, and thousands have been killed in the Philippines since President Rodrigo Duterte called for brutal vigilantism against those who deal drugs.
They note that the war on drugs is costing society at least $100 billion annually, yet it has clearly failed to make a dent in either the supply or demand of illicit drugs or reduce addiction rates or harm.
"Health should be at the centre of this debate and so, therefore, should healthcare professionals," they write.
A number of physician organizations, including the British Medical Association, have called for a change in the way society treats drug users and to make treatment, rather than punishment, a priority.
Ruth Dreifuss, chair of the Global Commission on Drug Policy, Geneva, Switzerland, couldn't agree more. She told Medscape Medical News the European experience clearly shows that physicians are one of the main groups that can bring about a change in attitudes about drug use and possession.
"For people who are dependent on the substance they consume, punishing them makes no sense and is in contradiction with the ethics of medical care," she said.
She also noted that a wide range of therapies are available to treat drug-dependent patients.
Depending on the patient's goals – abstinence being only one – physicians are best positioned to determine how to proceed to meet those goals, opening up the possibility that patients will be able to bring their life back into better balance even if they still are receiving illicit substances as part of their treatment plan, she added.
More Humane Approach
BMJ editors and the Global Commission on Drug Policy are not alone in their call to humanize the treatment of drug addiction.
In a related analysis, Baroness Molly Meacher, chair, All Party Parliamentary Group for Drug Policy Reform, and Nick Clegg, a Liberal Democrat politician and a member of the Global Commission on Drug Policy, write that the United Nations (UN) has issued three drug conventions, the first in 1961, that ban the use of illicit drugs. The ban is based on the premise that it would lead to a steady reduction in the use of illicit drugs and the havoc their use creates.
"Yet never has any evidence suggested that such a hypothesis was valid," Meacher and Clegg write.
"Far from diminishing over time, drug use has grown substantially worldwide [and] in short, the simplistic prohibitionist interpretation of the UN conventions has failed to achieve their overarching objective," they add.
The UN recently reversed its thinking. In April 2016, the UN Office on Drugs and Crime stated that drug policies must be "evidence-based" and designed to improve public health, not undermine it.
Evidence supporting a more enlightened approach to the conundrum of drug addiction is fairly abundant.
Meacher and Clegg point out that a recent review of the medicinal use of cannabis indicates there is "good" evidence to support its use for the treatment of chronic pain, especially neuropathic pain — seizures, nausea, and anxiety.
There is also some evidence, although not as robust, supporting its use in disorders as diverse as posttraumatic stress disorder and fibromyalgia as well as some symptoms of Parkinson's disease.
The UK government's own Medicines and Heathcare Products Regulatory Agency recently announced that products containing either cannabidiol (CBD) or tetrahydrocannabinol (THC) — both key components of cannabis — have medicinal value.
Bizarrely, the plant itself is still scheduled as dangerous and as having no medicinal value at all, Meacher and Clegg note.
Freeing cannabis from its current highly restrictive status in the United Kingdom would address this discrepancy.
"If cannabis were rescheduled, doctors could prescribe it on a named patient basis, taking responsibility for patients' safety, until licensed cannabis medications became available," they write.
To date, 11 countries in Europe have recognized that cannabis has legitimate medicinal use, and Canada has endorsed legislation for licensed suppliers to grow and supply it to patients with prescriptions.
Evidence also supports a variety of enlightened drug programs that are in place in some European countries.
For example, in Switzerland, safe injection rooms and treatment for heroin addiction with either methadone or heroin itself are offered to individuals with heroin dependence.
Evaluations of the Swiss program confirm that this approach dramatically reduces drug use, crime, disease, and drug overdose and is cost-effective.
Meacher and Clegg also point to Portugal, where personal possession and use of all illicit drugs have not been criminally penalized since 2001.
"Production and supply remain illegal but users will not be subject to criminal sanctions or a criminal record for the possession or use of the drug," they write.
Dependent drug users in Portugal must enter a treatment program and pay a small fine if they do not complete it.
This switch to a civic-minded approach has allowed Portugal to transfer funds from policing drug users to treating them. It has reduced the number of drug users in the country as well as rates of HIV infections and drug-related overdoses.
Call for Decriminalization
Even stronger calls to reverse repressive drug strategies are emerging from the Global Commission on Drug Policy itself.
"We believe that decriminalization can and must go further," Dreifuss and Pavel Bem, a member of the same commission, write in a related article.
A soon-to-be-released report, Advancing Drug Policy Reform: A New Approach to Decriminalization, will offer ample detail of how the commission sees this decriminalization process taking place. The report is scheduled to be presented November 21, 2016, at the National Press Club in Washington, DC.
Dreifuss has made it clear that the commission welcomes the softening of attitudes toward drug use and the eventual decriminalization of all illicit drug use.
"From the Global Commission perspective, the steps that have been taken so far are just compromises between prohibition of drug use and real regulation of the drug market," Dreifuss said.
"We have to put into place a new principle that the state has no right to punish people for something that is not harming other people, or if it is harming the person who is using drugs, they need help, and this help has to be given," she added.
"Drug use is not a crime. It's not even a misdemeanor. It's a free choice, and the state has to respect this choice," Dreifuss said. "This is our position, and we think this step will offer great advantages from a public health point of view."
Commenting on the "war on drugs" for Medscape Medical News, John Renner, MD, vice-chair, Council on Addiction Psychiatry, American Psychiatric Association, agreed that current punitive approaches to drug use and addiction have not been successful.
"I also think the authors' suggestion that it's been more like a war on the people who use drugs rather than the drugs themselves is a point very well taken," Dr Renner said.
He noted that the price the United States has paid in terms of the cost both to individuals and to society for locking so many people up in jail for relatively minor drug offenses has been enormous, and there is no evidence it has been helpful.
On the other hand, marijuana, the real focus of the current debate, is not harmless, Dr Renner emphasized.
"If you look at people who get admitted to drug treatment programs, marijuana is almost at the top of the list after alcohol and opioids," he said. "So it's a very common reason for people seeking treatment."
Dr Renner also said that, although it seems reasonable to call on physicians to lead the charge to adopt more humane drug policies, he believes many physicians have already tried to help reshape drug policies, and it is not clear that anyone has listened so far.
"Not that I don't think we probably wouldn't be better off with some legalized form of marijuana," he noted, "but just opening the flood gates and pretending that there are no problems with marijuana is not the answer."
The authors or commentators have disclosed no relevant financial relationships.
BMJ. Published online November 14, 2016. Editorial, Analysis, Commentary
Medscape Medical News © 2016 WebMD, LLC
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Cite this: War on Drugs an Epic Fail, BMJ Editors Say - Medscape - Nov 17, 2016.