the lancet: public health and international drug policy (2016)

8/19/2019 The Lancet: Public health and international drug policy (2016)

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The Lancet Commissions

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Published online March 24, 2016 http://dx.doi.org/10.1016/S0140-6736(16)00619-X 1

Public health and international drug policy

Joanne Csete, Adeeba Kamarulzaman, Michel Kazatchkine, Frederick Altice, Marek Balicki, Julia Buxton, Javier Cepeda, Megan Comfort,

Eric Goosby, João Goulão, Carl Hart, Thomas Kerr, Alejandro Madrazo Lajous, Stephen Lewis, Natasha Martin, Daniel Mejía, Adriana Camacho,

David Mathieson, Isidore Obot, Adeolu Ogunrombi, Susan Sherman, Jack Stone, Nandini Vallath, Peter Vickerman, Tomáš Zábranský, Chris Beyrer

Executive summaryIn September, 2015, the member states of the UNendorsed Sustainable Development Goals (SDGs) for2030, which aspire to human-rights-centred approachesto ensuring the health and wellbeing of all people. TheSDGs embody both the UN Charter values of rights andjustice for all and the responsibility of states to rely onthe best scientific evidence as they seek to betterhumankind. In April, 2016, these same states will

consider control of illicit drugs, an area of social policythat has been fraught with controversy and thought of asinconsistent with human rights norms, and in whichscientific evidence and public health approaches havearguably had too limited a role.

The previous UN General Assembly Special Session(UNGASS) on drugs in 1998—convened under thetheme, “A drug-free world—we can do it!”—endorseddrug-control policies with the goal of prohibiting all use,possession, production, and trafficking of illicit drugs.This goal is enshrined in national laws in manycountries. In pronouncing drugs a “grave threat to thehealth and wellbeing of all mankind”, the 1998 UNGASS

echoed the foundational 1961 convention of theinternational drug-control regime, which justifiedeliminating the “evil” of drugs in the name of “the healthand welfare of mankind”. But neither of theseinternational agreements refers to the ways in whichpursuing drug prohibition might affect public health.The war on drugs and zero-tolerance policies that grewout of the prohibitionist consensus are now beingchallenged on multiple fronts, including their health,human rights, and development impact.

The Johns Hopkins–Lancet Commission on DrugPolicy and Health has sought to examine the emergingscientific evidence on public health issues arising fromdrug-control policy and to inform and encourage a

central focus on public health evidence and outcomesin drug-policy debates, such as the importantdeliberations of the 2016 UNGASS on drugs. TheCommission is concerned that drug policies are oftencoloured by ideas about drug use and dependence thatare not scientifically grounded. The 1998 UNGASSdeclaration, for example, like the UN drug conventionsand many national drug laws, does not distinguishbetween drug use and drug misuse. A 2015 report bythe UN High Commissioner for Human Rights, bycontrast, emphasised that drug use “is neither amedical condition, nor does it necessarily lead to drugdependence”. The idea that all drug use is dangerousand evil has led to enforcement-heavy policies and hasmade it difficult to see potentially dangerous drugs in

the same light as potentially dangerous foods, tobacco,and alcohol, for which the goal of social policy is toreduce potential harms.

Health impact of drug policy based on prohibitionThe pursuit of drug prohibition has generated a paralleleconomy run by criminal networks. Both these networks,which resort to violence to protect their markets, and thepolice and sometimes military or paramilitary forces that

pursue them contribute to violence and insecurity incommunities affected by drug transit and sales. InMexico, the striking increase in homicides since thegovernment decided to use military forces against drugtraffickers in 2006 has been so great that it reduced lifeexpectancy in the country.

Injection of drugs with contaminated equipment is awell known route of HIV exposure and viral hepatitistransmission. People who inject drugs are also at highrisk of tuberculosis. The continued spread of unsafeinjection-linked HIV contrasts with the progress thathas been made in reducing sexual and verticaltransmission of HIV in the past three decades. We found

that repressive drug policing greatly contributes to therisk of HIV linked to injection. Policing could be a directbarrier to services such as needle and syringeprogrammes (NSP) and use of non-injected opioids totreat dependence among those who inject opioids, whichis known as opioid substitution therapy (OST). Policeseeking to boost arrest totals have targeted facilities thatprovide these services to find, harass, and detain largenumbers of people who use drugs. Drug paraphernalialaws, which prohibit possession of injecting equipment,lead people who inject drugs to fear carrying syringesand force them to share equipment or dispose of itunsafely. Policing practices undertaken in the name ofthe public good have demonstrably worsened public

health outcomes.One of the greatest impacts of pursuit of drug

prohibition identified by the Commission with respect toinfectious disease is the excessive use of incarceration asa drug-control measure. Many national laws imposelengthy custodial sentences for minor, non-violent drugoffences, and people who use drugs are over-representedin prison and pretrial detention. Drug use and druginjection occur in prisons, although their occurrence isoften denied by officials. HIV and hepatitis C virus(HCV) transmission occurs among prisoners anddetainees, and is often complicated by co-infection withtuberculosis (in many places multidrug-resistanttuberculosis). Too few countries offer prevention ortreatment services despite international guidelines that

Published Online

March 24, 2016

http://dx.doi.org/10.1016/

S0140-6736(16)00619-X

Columbia University, New York

City, NY, USA (J Csete PhD,

Prof C Hart PhD); University of

Malaya, Kuala Lumpur,

Malaysia

(Prof A Kamarulzaman PhD); UN

Special Envoy, HIV in Eastern

Europe and Central Asia,Geneva, Switzerland

(Prof M Kazatchkine PhD); Yale

University, New Haven, CT,

USA (Prof F Altice MD);

Warsaw, Poland (M Balicki MD);

Central European University,

Budapest, Hungary

(Prof J Buxton PhD); Center for

Public Health and Human

Rights, Johns Hopkins

Bloomberg School of Public

Health, Baltimore, MD, USA

(J Cepeda PhD,

Prof S Sherman PhD,

Prof C Beyrer MD); RTI

International, Washington,

DC, USA (M Comfort PhD);University of California,

San Francisco, San Francisco,

CA, USA (Prof E Goosby MD);

Ministry of Health, Lisbon,

Portugal (J Goulão MD);

University of British Columbia,

Center of Excellence in HIV/

AIDS, Vancouver, BC, Canada

(Prof T Kerr PhD); Centro de

Investigación y Docencia

Económicas, Mexico City,

Mexico (Prof A M Lajous LLD);

AIDS-Free World, Toronto, ON,

Canada (Prof S Lewis);

University of California,

San Diego, San Diego, CA, USA

(N Martin DPhil); University ofthe Andes, Bogotá, Colombia

(Prof D Mejía PhD,

Prof A Camacho PhD); Human

Rights Watch, Yangon,

Myanmar (D Mathieson MA);

University of Uyo, Uyo, Nigeria

(Prof I Obot PhD); Youth Rise—

Nigeria, Lagos, Nigeria

(A Ogunrombi); University of

Bristol, Bristol, UK (J Stone MS,

P Vickerman PhD); Trivandrum

Institute of Palliative Sciences,

Trivandrum, India

(N Vallath MBBS); and Charles

University, Prague, Czech

Republic (Prof T Zábranský PhD)


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food insecurity and in some cases forces them to move

their cultivation to more marginal land. Geographicalisolation makes it difficult for state authorities to reachdrug-crop cultivators in public health and educationcampaigns and it cuts cultivators off from basic healthservices. Alternative development programmes meant tooffer other livelihood opportunities have poor records andhave rarely been conceived, implemented, or evaluatedwith respect to their impact on people’s health.

Research about drugs and drug policy has suffered froma lack of a diversified funding base and assumptions aboutdrug use and drug pathologies on the part of the dominantfunder, the US Government. At a time when drug-policydiscussions are opening up around the world, there is anurgent need to bring the best of non-ideologically-driven

health science, social science, and policy analysis to thestudy of drugs and the potential for policy reform.

Policy alternatives in real lifeConcrete experiences from many countries that havemodified or rejected prohibitionist approaches in theirresponse to drugs can inform discussions of drug-policyreform. Countries such as Portugal and the Czech Republicdecriminalised minor drug offences years ago, withsignificant financial savings, less incarceration, significantpublic health benefits, and no significant increase in druguse. Decriminalisation of minor offences along withscaling up low-threshold HIV prevention services enabledPortugal to control an explosive, unsafe injection-linkedHIV epidemic, and probably prevented one fromhappening in the Czech Republic.

Where formal decriminalisation might not be animmediate possibility, scaling up of health services forpeople who use drugs can demonstrate the value to societyof responding with support rather than punishment topeople who commit minor drug infractions. A pioneeringOST programme in Tanzania is encouraging communitiesand officials to consider non-criminal responses to heroininjection. In Switzerland and Vancouver, Canada,substantial improvements in access to comprehensiveharm-reduction services, including supervised injectionsites and heroin-assisted therapy (ie, prescription of

heroin for therapeutic purposes under controlledconditions), have transformed the health picture forpeople who inject drugs. Vancouver’s experience alsoillustrates the importance of meaningful participation ofpeople who inject drugs in decision making on policiesand programmes affecting their communities.

Conclusions and recommendationsPolicies meant to prohibit or greatly suppress drugspresent a paradox. They are portrayed and defendedvigorously by many policy makers as necessary topreserve public health and safety, and yet the evidencesuggests that they have contributed directly and indirectlyto lethal violence, communicable-disease transmission,discrimination, forced displacement, unnecessary

physical pain, and the undermining of people’s right to

health. Some would argue that the threat of drugs tosociety might justify some level of abrogation of humanrights for protection of collective security, as is providedfor in human rights law in case of emergencies.International human rights standards dictate that, insuch cases, societies still should choose the least harmfulway to address the emergency and that emergencymeasures should be proportionate and designedspecifically to meet transparently defined and realisticgoals. The pursuit of drug prohibition meets none ofthese criteria.

Standard public health and scientific approaches thatshould be part of policy making on drugs have beenrejected in the pursuit of prohibition. The idea of

reducing the harm of many kinds of human behaviour iscentral to public policy in traffic safety, tobacco andalcohol regulation, food safety, safety in sports andrecreation, and many other areas of human life wherethe behaviour in question is not prohibited. But explicitlyseeking to reduce drug-related harms through policy andprogrammes and to balance prohibition with harmreduction is regularly resisted in drug control. Thepersistence of unsafe injection-linked transmission ofHIV and HCV that could be stopped with proven, cost-effective measures remains one of the great failures ofthe global responses to these diseases.

Drug policy that is dismissive of extensive evidence ofits own negative impact and of approaches that couldimprove health outcomes is bad for all concerned.Countries have failed to recognise and correct thehealth and human rights harms that pursuit ofprohibition and drug suppression have caused, and, indoing so, neglect their legal responsibilities. Theyreadily incarcerate people for minor offences but thenneglect their duty to provide health services in custodialsettings. They recognise uncontrolled illegal markets asthe consequence of their policies, but do little to protectpeople from toxic, adulterated drugs that are inevitablein illegal markets or the violence of organised criminals,which is often made worse by policing. They wastepublic resources on policies that do not demonstrably

impede the functioning of drug markets, and missopportunities to invest public resources wisely inproven health services for people often too frightenedto seek services.

To move towards the balanced policy that UN memberstates have called for, we offer the followingrecommendations:• Decriminalise minor, non-violent drug oences—

use, possession, and petty sale—and strengthenhealth and social-sector alternatives to criminalsanctions.

• Reduce the violence and other harms of drugpolicing, including phasing out the use of militaryforces in drug policing, better targeting of policingon the most violent armed criminals, allowing


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possession of syringes, not targeting harm-reduction

services to boost arrest totals, and eliminating racialand ethnic discrimination in policing.• Ensure easy access to harm-reduction services for all

who need them as a part of responding to drugs, indoing so recognising the effectiveness and cost-effectiveness of scaling up and sustaining theseservices. OST, NSP, supervised injection sites, andaccess to naloxone—brought to a scale adequate tomeet demand—should all figure in health servicesand should include meaningful participation ofpeople who use drugs in planning and imple-mentation. Harm-reduction services are crucial inprison and pretrial detention and should be scaled upin these settings. The 2016 UNGASS should do better

than the UN Commission on Narcotic Drugs (CND)in naming harm reduction explicitly and endorsingits centrality to drug policy.

• Prioritise people who use drugs in treatment for HIV,HCV infection, and tuberculosis, and ensure thatservices are adequate to enable access for all whoneed care. Ensure availability of humane andscientifically sound treatment for drug dependence,including scaled-up OST in the community and inprisons. Reject compulsory detention and abuse inthe name of treatment.

• Ensure access to controlled drugs, establishintersectoral national authorities to determine levelsof need, and give WHO the resources to assist theInternational Narcotics Control Board in using thebest science to determine the level of need forcontrolled drugs in all countries.

• Reduce the negative impact of drug policy and law onwomen and their families, especially by minimisingcustodial sentences for women who commit non-violent offences and developing appropriate healthand social support, including gender-appropriatetreatment of drug dependence, for those who need it.

• Eorts to address drug-crop production need to takehealth into account. Aerial spraying of toxicherbicides should be stopped, and alternativedevelopment programmes should be part of

integrated development strategies, developed andimplemented in meaningful consultation with thepeople affected.

• A more diverse donor base is needed to fund the bestnew science on drug-policy experiences in a non-ideological way that, among other things, interrogatesand moves beyond the excessive pathologising ofdrug use.

• UN governance of drug policy should be improved,which should including respecting WHO’s authorityto determine the dangerousness of drugs. Countriesshould be urged to include high-level health officialsin their delegations to CND. Improved representationof health officials in national delegations to CNDwould, in turn, be a likely result of giving health

authorities an important day-to-day role in

multisectoral national drug-policy-making bodies.• Health, development, and human rights indicatorsshould be included in metrics to judge success ofdrug policy, and WHO and the UNDP should help toformulate them. The UNDP has already suggestedthat indicators such as access to treatment, frequencyof overdose deaths, and access to social welfareprogrammes for people who use drugs would beuseful indicators. All drug policies should also bemonitored and assessed as to their impact on racialand ethnic minorities, women, children and youngpeople, and people living in poverty.

• Move gradually toward regulated drug markets andapply the scientific method to their assessment.

Although regulated legal drug markets are notpolitically possible in the short term in some places,the harms of criminal markets and other consequencesof prohibition catalogued in this Commission willprobably lead more countries (and more US states) tomove gradually in that direction—a direction weendorse. As those decisions are taken, we urgegovernments and researchers to apply the scientificmethod and ensure independent, multidisciplinary,and rigorous assessment of regulated markets to drawlessons and inform improvements in regulatorypractices, and to continue evaluating and improving.

We urge health professionals in all countries to informthemselves and join debates on drug policy at all levels.True to the stated goals of the international drug-controlregime, it is possible to have drug policy that contributesto the health and wellbeing of humankind, but notwithout bringing to bear the evidence of the healthsciences and the voices of health professionals.

Introduction

“We must consider alternatives to criminalization andincarceration of people who use drugs and focuscriminal justice efforts on those involved in supply. Weshould increase the focus on public health, prevention,treatment, and care, as well as on economic, social, andcultural strategies.”

Ban Ki-moon, UN Secretary-General, on International DayAgainst Drug Abuse and Illicit Trafficking, June 26, 2015 1

In 2015, member states of the UN, in the presence ofmore than 150 heads of state, endorsed a set ofSustainable Development Goals (SDGs) that wereformulated to embody the founding principles of theUN, including universal human rights and justice forall.2 The SDG resolution commits member states toaddressing climate change and other large issues inways that are informed by the best scientific research.The SDGs are also based on a notion of human securitythat is not confined to traditional public orderauthorities, but in which health and social sectors playan important part.2


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In April 2016, the same member states in a UN

General Assembly Special Session (UNGASS) will takeon a social policy challenge that affects millions oflives—what the UN has called the “world drugproblem”. As with the SDGs, addressing the use,production, and trafficking of drugs will challenge theUN to base its policies on the human rights norms thatare the bedrock of the UN Charter and the best scientificevidence available. This challenge is significant,because policy responses to drugs negatively affecthuman lives and human rights and contradict evidence-based public health approaches. As noted by formerUN Secretary-General Kofi Annan, “Drugs havedestroyed many people, but wrong policies havedestroyed many more”.3

A 2015 report4 from the UN High Commissioner forHuman Rights highlights some of the main ways inwhich drug-control policies cause violations of humanrights. The High Commissioner concluded that drugpolicies, law, and law enforcement have resulted inarbitrary arrest, detention, and ill treatment of peoplewho use drugs; unjust use of the death penalty for drugoffences; cruel and inhumane treatment of people whouse drugs in the guise of treatment; racial and ethnicdiscrimination in drug-law enforcement; denial of life-saving care and prevention interventions to people whouse drugs; excessive use of incarceration as a response tominor drug infractions; denial of the cultural rights ofindigenous peoples; and poor access to opioids and othercontrolled drugs for pain management and other clinicaluses, among other human rights violations.

The last UNGASS on drugs in 1998, which wasconvened under the theme “a drug-free world—we cando it!”, endorsed drug-control policies on the basis of theidea of elimination or prohibition of all use, possession,production, and trafficking of illicit drugs.5 This idea isembodied in national law in many countries. The 1998UNGASS declaration pronounced drugs a “grave threatto the health and well-being of all mankind”.5 In thispronouncement, it echoed the bedrock treaty of theglobal drug-control regime, the widely ratified 1961Single Convention on Narcotic Drugs, which states in its

preamble that drug control is motivated principally byconcern for “the health and welfare of mankind”.6 Neitherof these international agreements, however, refers to thenegative health consequences of pursuing drugprohibition. The time is long overdue for a review of thehealth impacts of these drug policies. The disconnectbetween drug-control policy and health outcomes is nolonger tenable or credible.

The Johns Hopkins–Lancet Commission on DrugPolicy and Health (panel 1) has sought to examine thescientific evidence for a broad range of public healthissues arising from drug-control policy to inform afocus on public health as a central consideration indrug-policy discussions, such as the importantdeliberations of the 2016 UNGASS. The Commission is

motivated partly by a concern that drug policies areoften founded on ideas about drug use and drugdependence that are not scientifically grounded. Likethe Single Convention, the declaration from the 1998UNGASS on drugs, for example, does not distinguishbetween drug use and drug misuse: all use is referred toas abuse.5 Suggesting some evolution of thinking in theUN, if not among member states, the UN HighCommissioner for Human Rights in his 2015 report, bycontrast, emphasises that “drug use is neither a medicalcondition nor does it necessarily lead to drugdependence” or loss of dignity.4 The authors of the UNOffice on Drugs and Crime (UNODC) 2015 annualreport concluded that, of an estimated 246 millionpeople who used an illicit drug in the past year,27 million (around 11%) experienced problem drug use,

which was defined as drug dependence or drug-usedisorders. 7 The idea that all drug use is dangerous andevil has made it difficult to see potentially dangerousdrugs in the same light as potentially dangerous foods,tobacco, alcohol, and other substances for which thegoal of social policy is to reduce harms. Harm reduction,an essential element of public health policy, has toooften been lost in drug policy making amid a dominantdiscourse on the overwhelming evil of drugs.

We hope that our review and analysis of evidence onthe health consequences of pursuing prohibition ofdrugs and drug use can inform rights-based policychange. Because language is important to drug policydiscussions, we include as an appendix to this report aglossary of some policy-relevant terms.

Panel : Introducing the Johns Hopkins–Lancet

Commission on Drug Policy and Health

The Johns Hopkins–Lancet Commission, cochaired by

Professor Adeeba Kamarulzaman of the University of

Malaya and Professor Michel Kazatchkine, the UN Special

Envoy for HIV/AIDS in Eastern Europe and Central Asia, is

composed of 22 experts from a wide range of disciplines

and professions in low-income, middle-income, and

high-income countries. We have reviewed the global

evidence base on the impacts of drug policy on health

outcomes and done novel analysis, including mathematical

modelling, to further enhance understanding of the

complex and manifold interactions of dug policy with

health, human rights, and wellbeing. The Center for Public

Health and Human Rights at the Johns Hopkins BloombergSchool of Public Health served as the secretariat for the

Commission, and scholars and fellows from the centre also

served as commissioners or analysts, or both. We produced

this report with the hope that it would enrich discussions at

the time of the UN General Assembly Special Session on the

world drug problem. We intend to continue our work after

the meeting, and especially to continue to advocate for

evidence-based and health-focused reform of drug policy.

See Online for appendix


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prohibition-oriented policies with respect to other drugs

in the USA, concrete experiences with large-scaleregulated cannabis markets provide an opportunity forrigourous assessments that will inform larger drug-policy debates.

Violence and enforcement of drug prohibitionSince it published its first report on violence and healthin 2002,29 WHO has highlighted numerous forms ofviolence as health issues.30 The Global Burden of DiseaseStudy of 2013 showed that interpersonal violence,including all types of violent assault, rose about 18·4% asa cause of mortality globally from 1990 to 2013. 31 Theregion most affected was Latin America, whereinterpersonal violence was among the top five causes of

death in 15 countries.31 The 2014 WHO report onpreventing violence discusses violence that is committedas a result of drug and alcohol use, but few investigators,including those at WHO, have investigated the violenceresulting from drug policies.30

A great deal of drug-related violence is associated withthe efforts of armed criminal groups to protect theirillicit markets, often against armed police or military orparamilitary forces. Some experts have suggested thatheavy crackdowns by drug police can lead to majorincreases in violence when disruption of a criminalnetwork leads rival groups to intensify their efforts tocapture the territory of the weakened group.32 Mexicoand Central and South America have borne an enormousburden of drug-related violence. In 2013, the OASasserted that the transit of illegal drugs through theAmericas leaves persistent violence in its wake,including “massacres, attacks by hired assassins, andcases of people being tortured to death”.15 As the OASnoted, drug trafficking is so entwined with othercriminal activity that to say that an extra-judicial killingis purely drug related is not always possible, butcriminal networks dealing in drugs are plainly behindmuch of this carnage.15 In its 2014 global analysis ofhomicides,33 the UNODC noted that the 30% ofhomicides accounted for by “organized criminal groupsand gangs” in the Americas, especially Central and

South America, dwarf the corresponding percentages inother regions (figure 1).

In conventional wars, sexual violence is both aconsequence of war and a weapon used to terrorise theenemy, and the war on drugs is no exception. TheUNODC asserts that the organised criminal networksthat dominate drug trafficking in Central Americaregularly use rape with impunity as they defend theirterritories and routes.34 Women and girls who might behired as low-level couriers or smugglers experiencesexual assault with no recourse.34 There are numerouswell documented accounts of rape of girls and youngwomen fleeing gang violence in Central America and thesevere injuries and post-traumatic stress suffered.35 Someobservers credit drug-related violence with increases in

femicide in Mexico and Central America, as brutal rapeand killing of women are used to terrorise communitiesand rival gangs.36,37

Intolerable levels of violence, insecurity, andcorruption have led to mass displacement in Mexicoand Central America, with displacement levels similarto those documented in war zones.38 Displacedindividuals, including children, are characterised byuncertain legal status and a dearth of services. By oneestimate, about 2% of the population of Mexico, around1·65 million people, were displaced because of violenceor the risk of violence between 2006 and 2011. 38 In aLondon School of Economics publication39 endorsed byfive Nobel-Prize-winning economists and other experts,Atuesta refutes the idea that this migration is largelyeconomic and not drug related, showing that mostpeople leaving violence-ravaged communities in Mexicogenerally move to lower salaries and sometimes noemployment opportunities at all.

Homicide in MexicoThe fateful decision of Felipe Calderón’s Government inMexico in 2006 to use its military in civilian areas to fightdrug traffickers ushered in an epidemic of violence inmany parts of the country that also spilled over intoCentral America.15 The increase in homicides in Mexicosince 2006 is virtually unprecedented in a country notformally at war. It was so great in some parts of thecountry that it contributed to a reduction in the country’sprojected life expectancy.40 Another analysis showed that,in the period 2008–10 in the state of Chihuahua—one ofthe states most heavily affected by drug violence—about5 years of life expectancy was lost for men. 41 In July, 2015,the Mexican Government reported that, from 2007 to2014, there were 164 345 homicides in the country, with a

Figure : Proportion of homicides involving gangs or organised criminal

groups by region, 2011 (or latest year)

Data for crime trends come from the UN Office on Drugs and Crime. Error bars

show the IQR.

Americas

(18 countries)

Asia and Oceania

(12 countries)

Europe

(19 countries)

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substantial increase after 2006. Figure 2 shows a join-point analysis43 done for this Commission withgovernment data.42 The increase in homicides after 2006is highly significant and notable, especially after a longdownward trend in homicides. No other country in LatinAmerica—and few elsewhere in the world—have hadsuch a rapid increase in mortality in so short a time.44

Not all of this increase in homicides can be attributedto drug-related violence, but much of it can be. Oneestimate suggested that drug-war-related deaths pushedthe national homicide rate up by 11 per 100 000, resultingin an overall rate of over 80 per 100 000 in heavily affected

locations.45 11 homicides per 100 000 is 2·5 times the total

homicide rate in the USA in 2014.

45

Other observerssuggest that the contribution of the drug war to overallmortality is readily quantifiable because drug-ganghomicides bear tangible signatures, such as the use ofidentifiable weapons, torture, beheading and otherdismemberment, group executions, and mass graves.44 Although homicides have fallen somewhat since 2012, bysome estimates homicides perpetuated by organisedcrime continued to increase to 2014.44

Drug-related violence in Mexico is not limited tokillings and other armed incidents on the street. TheCommission noted violence by state actors in thetreatment of people in Mexico incarcerated for drug-related crimes. We did analysis with a probability sample

of people who were in prison for drug crimes (n=479) inMexico during 2002–12—ie, before and after the militarycampaign against drugs—from eight federal prisons.46 About half the detainees (n=241) reported having beenbeaten or tortured at some time during theirimprisonment. Of these 241 detainees, experiencing anact of torture or abuse was 1·57 times more likely afterthe war on drugs than before (p=0·0001). Beinginterrogated by the military in prison was also morelikely after the military became involved in the war ondrugs (p


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Mexico is far from alone in registering high rates of

homicide linked to enforcement of drug prohibition.Colombia’s case is distinct from Mexico’s in that anti-drug efforts were superimposed on a lethal internal war,but homicides spiked when counter-narcotics activitieswere most intense.48 Mejía and Restrepo estimate thatabout 25% of the homicide rate in Colombia is explainedby the thriving cocaine markets and the war on drugs inthe country (figure 4). In other words, were it not for thelarge increase in the size of cocaine markets, Colombiawould have had a homicide rate in 2008 of about 27 per100 000 population instead of the observed 37 per100 000 population.51 Mejía and Restrepo characterisethese profound problems of homicide and other violence,corruption, and forced displacement as a package

outsourced from the major drug-consuming countries,mainly the USA, to producer and transit countries.48 Thatis, in return for some foreign assistance for counter-narcotics activities, the USA in particular keeps the worstof the heavy burden of violence, insecurity, anddisplacement outside its borders (panel 2). But, as theseauthors note, this exported pillar of the drug war isbeginning to be questioned in earnest by somegovernments in Latin America, as shown by statementscriticising the status quo in drug policy by the then-presidents of Mexico, Colombia, and Guatemala in theUN General Assembly in 2012, which led to the UNGASSon drugs being moved from 2019 to 2016.52

HIV, hepatitis C virus infection, and harmreduction: neglect of proven solutionsAt a time when gains in reduction of sexual transmissionof HIV are evident worldwide, HIV transmission linkedto injection of drugs with unsterile equipment continuesto drive incidence in many regions, including easternEurope and central Asia (EECA) and much of Asia,despite the availability of proven interventions to stopit.53,54 The prevalence of HIV infection among people whoinject drugs is many times higher than that in the generalpopulation in many countries (figure 5).55 Outside sub-Saharan Africa, an estimated 30% of HIV transmissionis linked to unsafe injection.55 Drug injection is a more

important determinant of HIV transmission in EECAthan in any other region.56 Although the incidence ofHIV infection declined by 35% globally from 2000 to2014, new infections increased by 30% during that periodin EECA, where unsafe drug injection accounts for over65% of cumulated cases.56

WHO estimates that about two-thirds of people whoinject drugs in the world are living with hepatitis C virus(HCV) infection, a much higher proportion than theestimated 13% living with HIV.57 WHO notes that EECA,sub-Saharan Africa and east Asia are particularly affected,57 although data are not regularly kept in some countries. Inhigh-income and upper-middle-income countriesgenerally, a high proportion of new HCV infections areamong people who inject drugs.57 A landmark US study

showed that over half of people who inject drugs wereinfected with HCV during their first year of injecting. 58 Anestimated 20–30% of people living with HIV are co-infected with HCV, but the frequency of co-infection

among people who inject drugs is estimated at 90%.59An extensive body of research has demonstrated that

effective tools are available for prevention of HIV andHCV infection among people who use drugs byinjection and other means. Rigorous reviews of thisresearch have informed strong recommendations byWHO, UNAIDS, and the UNODC for comprehensiveservices for people who use drugs,60 which include theseelements:• needle and syringe programmes (NSPs), including

other injection equipment• opioid substitution therapy (OST) and other drug-

dependence treatment• HIV testing and counselling• antiretroviral therapy (ART)

Figure : Homicide rate in Colombia, 1985–2012

Key periods of intensive counter-narcotics activities are highlighted. Reproduced from Mejía and Restrepo, 2014,

by permission of the London School of Economics IDEAS. 48 FARC=Revolutionary Armed Forces of Colombia.

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Panel : Exporting drug-related violence—a thought experiment

To illustrate the exportation of violence from the situation in Mexico and Central

America, consider the following scenario. Suppose that cocaine consumption in the USA

disappears and is displaced to Canada, but cocaine continues to pass through the USA.

Because of its international treaty obligations, the USA is obliged to do everything in its

power to keep cocaine from passing through its borders to Canadian cities. Canada shares

some of the cost of this effort, but the result of fighting the cocaine cartels is that the

homicide rate in Seattle spikes from its current level of about five homicides per

100 000 population to over 100 per 100 000 population to keep cocaine from reaching

Vancouver. Similar violence seizes other border cities, and a massive wave of internal

displacement in the northern USA challenges social services and stability of governance.

Even if the Canadian Government shared the costs to the tune of billions of dollars per

year, how long would such a situation be tolerated?

Source: Mejía and Restrepo, 2014.48


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• prevention and treatment of sexually transmittedinfections

• condom programmes for people who use drugs andtheir sexual partners

• targeted information, education, and communicationfor people who use drugs and their sexual partners

• vaccination, diagnosis, and treatment of viral hepatitis• prevention, diagnosis, and treatment of tuberculosis.

NSPsProgrammes that provide sterile injection equipmentto people who inject drugs—often in the form ofexchange programmes in which used equipment istraded for sterile equipment—are a crucial part ofprevention services and decreasing circulation time ofcontaminated syringes. WHO found that NSPs,particularly low-threshold (easy-access) exchangeprogrammes, effectively reduced HIV transmissionand were not associated with increased injection

frequency or initiation of new injection in people notalready injecting drugs.61 A meta-analysis62 suggestedthat NSPs were associated with a reduction in HIVtransmission of about 58%, although there were caveatsabout the quality of some studies and the difficulty ofdisentangling the effects of NSPs from those of otherservices.62

As the high prevalence of HCV infection among peoplewho inject drugs indicates, HCV is transmitted moreefficiently than is HIV through unsafe injection. Evidencefrom controlled trials for the effectiveness of NSPs inHCV prevention is more equivocal than that for HIV.63 Part of the challenge is that some people new to druginjection will be infected with HCV even before theybegin to take advantage of NSP services. NSPs are most

effective at preventing HCV infection when coverage isvery high and they can reach people from a time close towhen they first inject.64

OSTThroughout the Commission, we repeatedly refer to theopioid agonists methadone and buprenorphine, whichare the oral drugs most commonly used in drug-assistedtreatment of opioid dependence, which is referred to asOST. OST has a dual role as treatment for opioiddependence, in which it can help to stabilise lives with allof the attendant benefits, and as prevention of HIV andHCV infection because, when effective, it eliminatesinjection. Arguably, no form of treatment of any drugdependence has as vast a scientific evidence base or aslong a successful clinical experience as does OST. 65 Inboth its treatment and harm-reduction roles, OST facesdrug-policy impediments because the drugs used areheavily regulated in most countries. Countries do not

always allocate adequate quantities of these oral opioiddrugs for OST, and doctors in some countries arereluctant to prescribe them for fear of prosecution ifthere is diversion of these drugs to non-medical use.

A 2012 meta-analysis65 of studies from Europe, NorthAmerica, and Asia concluded that oral OST, andmethadone maintenance in particular, reduces risk ofHIV transmission among people who inject opioids byabout 54%. The authors of a 2014 review of reviewsconcluded that the evidence is strong for the impact ofOST on HIV prevention, particularly when doses ofopioid agonists are adequate.63 Observational studiesfrom the USA, the UK, Canada, and Australia showedthat OST use was associated with substantially reducedrisk of acquisition of HCV among people who inject

Figure : Prevalence of HIV infection among people who inject drugs and in the general population

Countries with more than 30 000 people who inject drugs are shown. Data for people who inject drugs are from 2009–14, those for the general population are from

2014. Source: UNAIDS Gap Report, 2014.55

I n d o n

e s i a

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t a n

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drugs,64,66–68 with data from the Netherlands and the UK

also showing that combined OST with NSPs furtherreduces the risk of acquisition of HCV.64,69,70 A modelanalysis based on data from the UK illustrates that ifenough people can get access to OST and to sufficientsterile injection equipment for virtually every injection,transmission of HCV infection could declinesubstantially (figure 6).71

Despite the very large body of evidence for theeffectiveness and cost-effectiveness of opioid agonisttherapy, some countries insist that generating newresearch in their settings is necessary before scaling upOST. For these and other reasons, OST has remained inperpetual pilot mode in several countries.72

Access to OST in western Europe is a positive contrast

to most other regions: several western Europeancountries have almost eliminated HIV transmissionfrom unsafe injection as a public health concern byscaling up NSPs and OST in addition to treatment forHIV.73 Unlike their counterparts in western Europe,EECA countries generally have inadequate coverage,quality, and accessibility of NSP and limited or no accessto OST.74,75

Gains have been made in harm-reduction policy andpractice in some Asian countries with large populationsof people who use drugs. In China, Malaysia, andVietnam, zero tolerance of harm reduction has given wayto government-supported OST and sometimes NSPs.54 China was estimated in 2015 to have been serving about200 000 OST patients,56 but this figure still representsonly a small proportion of people who might benefit, andthe problems of high dropout rates and low dosagesremain challenging.54 According to a 2015 estimate,Vietnam was reaching 32 000 OST patients in 44 provinces(the country has an estimated 130 000 people who injectdrugs).76 Although coverage might be relatively low, theexistence and continued growth of these programmesare important achievements.

Although it is advantageous with respect to HIVprevention that coverage levels for these measures beas high as possible, an important body of researchdemonstrates that if OST, NSPs, and HIV treatment are

all present then their synergistic effects can compensatefor partial coverage. Figure 7 illustrates this point withdata from Dushanbe, Tajikistan. In that case, if needleexchange and ART alone are available, for a50% decrease in incidence of HIV infection over10 years, coverage of both programmes needs to beabout 30%.77 But if ART, NSPs, and OST are all available,a 50% decline in incidence over the same period can beachieved with 20% coverage of these interventions.77 Similar results have been reported in other settings.53,78

Therefore partial coverage of OST, NSPs, and ART canprovide effective prevention if it is not possible to attainvery high ART coverage, which might be especiallychallenging where people who use drugs arecriminalised.

HIV and HCV infection treatmentHIV testing with a link to treatment is important for allpeople. For people who use drugs as for other populations,ART can suppress viraemia and lower transmission risks.ART coverage for people who use drugs is high in westernEurope, North America, and Australasia, but it was notalways so. In the early years of ART availability, peopleliving with HIV who used drugs had to battle scientificallyunfounded ideas that excluded them from treatmentprogrammes. One such idea was that the lives of peoplewho use drugs are too chaotic to allow them to adhere todaily multi-pill treatment regimens,79 although researchhad shown that people who use drugs can adhere to ARTand achieve viral suppression.80 It took more research inseveral settings and the experience of successfullyexpanded treatment programmes for people who usedrugs to dispel these ideas.81

Studies from various settings have shown that agonisttreatment for opioid dependence improves adherence to

ART adherence among people who use drugs.81 InVancouver, Canada, several longitudinal studies showednot only that OST continuation improved ART adherenceover time,82 but also the converse—ie, thatOST discontinuation significantly increased the risk ofART non-adherence83—and that OST patients with higheropioid agonist doses had the strongest adherence to ART.84 In China, the understanding of the importance of theOST–ART link led to an effort to integrate ART services inmethadone clinics.85 Although practical challenges wereencountered, the effort showed an appreciation for thevalue of integrating these areas of care. In Ukraine,patients with access to integrated and colocated ART andOST services had greater access to ART than did thosereceiving OST in non-integrated facilities.86

Figure : Impact on prevalence of HCV infection over time of scaling up OST

and high-coverage (100%) NSPs from 0% to 20%, 40%, or 60% coverage for

three epidemic scenarios with a baseline chronic prevalence of HCV infection

of 20%, 40%, or 60%

Over time, prevalence of HCV infection (20%, 40%, or 60% at time zero)

decreases when OST and 100% NSPs (defined as obtaining one or more sterile

syringes from an NSP for each injection reported per month) are scaled up, with

greater impact achieved for greater coverage of OST and 100% NSP and for

greater prevalence of HCV infection at baseline. Reproduced from Vickerman

et al, 2012,71 by permission of John Wiley & Sons. HCV=hepatitis C virus.

OST=opioid substitution therapy. NSPs=needle and syringe programmes.

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studies disprove this assertion.91,92 None of these claims

should stand in the way of comprehensive preventionand treatment of HCV infection for people who injectdrugs. WHO, along with many professional liver andinfectious disease associations, urges screening for, andtreatment of, HCV infection in people who use drugs, asa public health priority.91,92 Modelling analyses haveindicated that treatment of HCV infection in people whoinject drugs could be an effective and cost-effectivemeans of HCV prevention,93,94 and that combinationprevention strategies incorporating OST, NSPs, andinfection treatment could greatly reduce incidence andprevalence among people who inject drugs in a rangeof settings.95

Condom programmes, supervised injection, andpre-exposure prophylaxisUnsafe injection-linked transmission of HIVsometimes overshadows sexual transmission inprogramme priorities for people who use drugs, butboth are essential. UN reports and research in manysettings have for years highlighted the importance ofcondom programmes for all men who have sex withmen (MSM), and particularly those who use drugseither to enhance sexual pleasure, lower sexualinhibitions, escape or cope with situations ofdiscrimination, persecution, or uncertainty aboutsexuality, or for other reasons.96,97 Many studies havedemonstrated a link between drug use at the time ofsexual activity (so-called sexualised drug use) and lowercondom use, resulting in a high prevalence of HIV andother sexually transmitted infections and lowerincidence of condom use.97–99 But more work is neededin many settings to understand the complex motivationsfor sexual decision making that would inform effectivecondom-promotion programmes.100

The UN recommendations do not include severalinterventions that have evidence to justify theircontributions to an HIV or HCV infection response.Supervised injection sites are an example. In severalEuropean countries, Australia, and Canada, there arelegally sanctioned indoor locations where people can

inject (and sometimes smoke and inhale) illicit drugsunder medical supervision, obtain clean equipment, bereferred to OST, and receive HIV and overdose-prevention education. The harm-reduction intent ofthese facilities is not only to reduce HIV transmissionbut also to prevent mortality and other adverse outcomesof overdose and reduce unsafe disposal of syringes.73 Ameta-analysis showed a 69% reduction in syringe sharingresulting from use of supervised injection sites.101 In thecase of Insite, the supervised injection facility inVancouver, Canada, a conservative estimate indicatesthat, on the sole grounds of HIV cases averted, Insitemore than pays for itself, and savings are even greaterwhen behavioural change leading to use of sterilesyringes outside Insite is taken into account.102

As noted by Coffin and colleagues,103 research aboutpre-exposure prophylaxis with tenofovir, an importantnew HIV prevention measure, has often excluded peoplewho use drugs. Nonetheless, an important Bangkok-basedtrial104 among people who use drugs demonstrated anHIV prevention effect for both men and women whoinject drugs.

The cost of neglecting harm-reduction andprevention measuresPreventable outbreaks of HIV in recent years haveconstituted graphic real-life demonstration of the valueof ready access to harm-reduction services and the cost ofimpeding access to them. EECA bear a heavy burdenfrom the neglect of harm-reduction measures. Harshanti-drug policies and moral judgments against peoplewho use drugs contribute to making health services for

this population a low political priority.87 In the first decadeof its work, financial support from the Global Fund toFight AIDS, Tuberculosis and Malaria helped toovercome these difficult political environments andsupported the expansion of harm-reduction services,especially NSPs and OST, in several EECA countries andin east and southeast Asia.105 However, with changes inGlobal Fund policy that have eliminated or reducedfunding for middle-income countries, some of theseservices have been cut (panel 3).106

In 2010–12, of the 27 EU member states (plus Norway,Iceland, and Turkey), Romania and Greece wereestimated to account for a third of all the incidence ofHIV infection among people who inject drugs, the twocountries together having seen a 20-times increase in

Figure : Barriers to treatment for hepatitis C virus infection for people who inject drugs

Reproduced from Wolfe et al, 2015,90 by permission of Elsevier.

Cost

• Prohibitive cost of new medicines• Antidiversion requirements (viral load tests,

empty pill bottles)

Criminalisation

• Detention in the name of rehabilitation• Imprisonment for drug use or possession

Health regulations

•Treatment protocols excluding people whoinject drugs or who are co-infected with HIV

• Addition of names of people who inject

drugs to government registries

Clinic

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new diagnoses linked to drug injection.111 In Romania,the reduction in external support for harm-reductionservices coincided with the availability of relativelyinexpensive amphetamine-type legal highs—newpsychoactive substances (NPS) not yet under legalcontrol. Some people who previously injected heroinshifted their consumption to these new stimulants. Butheroin is injected two or three times a day, whereas

these stimulants are injected six to ten times daily.111 NPS use was found to be more associated with syringesharing and high-risk sexual practices than was heroinuse. The number of people injecting drugs is estimatedto have risen from about 17 000 in 2008, to about20 000 in 2011 (with riskier and more frequentinjection112), and harm-reduction services were largelycurtailed in 2010. Non-governmental organisations raneffective NSPs and OST services that kept the frequencyof HIV infections low until then, but funding from theGlobal Fund was lost when Romania joined the EU. 106 The striking rise in HIV cases is shown in figure 10,which represents cases at a major hospital in Bucharestthat practitioners think mirrors the national situation.Among the newly infected people who inject drugs,

about 20% were estimated to be injecting heroin,20% NPS, and 20% a combination of the two (Oprea C,Victor Babes Hospital, personal communication). AsUNAIDS has noted, HIV outbreaks among people whoinject drugs tend to grow extremely quickly.54

In Greece, even before the severe economic recessionof 2008–09, harm-reduction services for people whouse drugs were provided at a low level of coverage. 113 The recession was associated with impoverishment andlarge increases in homelessness among people whoinject drugs, which separated some people even morefrom existing services, and funding to existing NSPswas cut substantially.114 After years of fewer than 20 newcases of HIV transmission among people who injectdrugs in the country, in 2011 the number of new casesof HIV linked to injection was 260, and in 2012 itjumped to 522.113 With assistance from the EU, Greecescaled up low-threshold harm-reduction services,including in cities that had not had them previously,and existing services got support to distribute low-dead-space syringes (ie, syringes that are designed so thatafter injection not much of the injected liquid remainsin the syringe; they are thus important to prevent

disease transmission because the motivation to reusethe syringe is reduced), which reduce the risk of HIVtransmission.115

For most of the period since HIV emerged as a publichealth problem, the US Government banned the use offederal funds for NSPs, although some states andmunicipalities supported them.116 In January, 2016, theUS Congress lifted that ban for all NSP costs other thanneedles and syringes—a move seen by many as aresponse to an increasingly visible opioid injectionproblem even outside major urban areas. 117 In 2015, arural county in Indiana experienced a substantialincrease in HCV infection followed by a linked outbreakof HIV cases linked to injection of oxymorphone, asynthetic opioid.118 135 people were infected with HIV

Figure : Proportion of people who i nject drugs in Romania who are

infected with HIV, 2007–13

Source: Oprea C, Victor Babes Hospital, personal communication.

2007 2008 2009 2010 2011 20120

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Injection drug usersPanel : Funding crisis for HIV-related harm reduction

In pure fiscal terms, preventing HIV through harm-reduction measures should be an

easy sell. Cost-effectiveness is high, and start-up costs for these services are low. But

harm reduction continues to be resisted as a funding priority in too many countries.

Support from the Global Fund to Fight AIDS, Tuberculosis and Malaria in its first

decade, however, inspired some countries that had not previously scaled up needle and

syringe programmes and opioid substitution programmes to do so, particularly in

eastern Europe and central Asia.105 The Global Fund encouraged the inclusion of HIV

prevention services for people who inject drugs and other so-called key populations in

country proposals.106

In the first ten funding rounds of the Global Fund, plus a special transitional funding

period, US$620 million in grant support went to programmes for people who inject

drugs in 55 countries, an unprecedented wave of life-saving support for a politically

unpopular population.106

When the official country proposal to the Global Fund inThailand, for example, excluded programmes for people who use drugs despite a high

prevalence of HIV infection in that population, the Global Fund made a special grant

to non-governmental organisations that were able to bring services directly to

the community.107

In 2013, the Global Fund unveiled a new funding model that, unlike its previous

processes, assigned ceiling amounts to countries and substantially limited funding to

most middle-income countries, even those with severe injection-linked epidemics where

it was unlikely that governments would pick up the costs of the newly scaled-up

programmes that had previously been funded by the Global Fund. 108 Romania lost

funding at a key moment (see main text), Serbia’s harm-reduction programmes are

operating on a shoestring,109 programmes in Ukraine—a country with over

350 000 possessions with the intent to deliver—are gravely threatened,108 and Vietnam

might have a similar fate.106

Thailand is no longer eligible for support. Civil societyorganisations continue to advocate for governments to provide the funding no longer

available from the Global Fund,110 but it is clear that, when it comes to politics, drug-

related harm reduction will remain a hard sell in many places.


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in a short time in a district that previously had reported

very few cases. Almost half the new infections wereamong women, and they spanned a wide age rangebecause injection took place in multigenerationalgroups.118 Indiana did not permit NSPs before theoutbreak: non-medical use of syringes was a felonypunishable by up to 3 years in prison.116 The Governor ofIndiana changed the state’s policy to allow NSPs for ayear on the basis of a public health emergency.116 Similaroutbreaks of HCV infection among people who injectdrugs have been reported across this region, includingin Kentucky and West Virginia—all states with few orno NSPs and poor access to OST.116

For policy makers interested in hard data for the value ofcomprehensive HIV and HCV prevention, the cost

savings associated with these services are considerable.The Australian Government, for example, which hasinvested substantially in harm reduction from the earlyyears of HIV, estimated that for every dollar spent onNSPs, more than $4 was gained in short-term savings onhealth-care costs. For every dollar spent on NSPs, about$12 was gained in 10 year savings on health-care costs, andabout $27 was gained if productivity increases as a resultof averted disease are included.119 A World Bank study inMalaysia, where about two-thirds of HIV transmission isrelated to unsafe injection, showed that, in the long term,NSPs, even at a low rate of coverage, would give a morethan threefold return on investment.120 Other studies haveshown that NSPs can also help to refer people to treatmentfor HIV and drug dependence and other services.121,122 A2015 review121 suggests that the low cost of theseprogrammes and the high cost of the HIV suffering andtreatment that can be averted means that NSPs are “one ofthe most cost-effective interventions ever funded”.

WHO, the UNODC, and UNAIDS have asserted boththe effectiveness and cost-effectiveness of OST withrespect to HIV, noting that for every dollar spent on it, areturn of $4–7 could be expected from crime reductionalone, and a return of about $12 if health-care savings areincluded.123 Although OST is more expensive per personthan are NSPs, Wilson and colleagues assert in theirreview121 that OST is highly cost effective, not only in HIV

prevention terms but also because of health savingslinked to less relapse, reduced incarceration, and a widerange of quality-of-life improvements.

Impact of law enforcement on services for HIVand HCV infectionLaw on the booksEvidence from a number of countries indicates that druglaw, policy, and law-enforcement practices can be barriersto 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 theway in which law is enforced in practice, or what Burriscalls the “law on the street”.124

In some cases, there are legal prohibitions against, or

poor legal grounding for, harm-reduction services forpeople who inject drugs. The case of Russia is extreme:OST is prohibited by law even though opioid injection iswidespread, and NSPs have been allowed only sporadicallyand are generally not supported by the state.125 In manyjurisdictions, NSPs are banned by law or effectivelyblocked by policy, including zoning restrictions.74 Theofficial estimate of Russians living with HIV rose to907 000 by the end of 2014, up almost 7% from 2013figures, and up from 500 000 in 2010.126 More than 57% ofnew cases were attributed to unsafe drug injection.

Although OST might not be banned outright orexplicitly, in some countries methadone andbuprenorphine, the medicines used most often in OST,

might not be registered or authorised for this indication.74 This problem persists despite the inclusion of methadoneand buprenorphine on the WHO Model List of EssentialMedicines and strong support from WHO for OST.There are many other ways in which drug-control laws orregulations limit the use or usefulness of OST, includingarbitrary restrictions on numbers of patients, arbitrarylimitation of dosages and duration of treatment,prohibition of take-home doses, requirements for periodsof drug or alcohol abstinence or trying other types oftreatment as a prerequisite to starting OST, restrictionson the neighbourhoods or geographical zones whereOST services can be offered, lack of integration withaccessible community health services so that people haveto make special trips for OST, and lack of access to OSTin prison and pretrial detention.74,127 In several countriesthere is good access to OST in the community, but nonein prison or other detention.74

As with OST, NSPs even when not banned outrightcan be undermined by various laws and policies.According to a 2014 estimate by Harm ReductionInternational, significant drug injection is reported in158 countries, but only 90 have functioning NSPs, mostof which have very low coverage.74 Laws, policies, orlocal ordinances can limit NSPs to remote or unpleasantneighbourhoods, the hours of operation or permittedgeographical coverage, the number of needles or

syringes that can be exchanged (or require one-to-oneexchange in every transaction—ie, the patient needs toreturn one used syringe for every clean syringe theywant), the age of NSP participants, and the provision ofclean injection equipment in prison and pretrialdetention (which can also be banned outright).74 In theUSA, the 50 states have a dizzying array of laws andregulations about needle exchange. In somejurisdictions, local health authorities have to declareemergencies periodically to continue to justify NSPs;some states simply ban these services.74

In many countries, drug paraphernalia lawsundermine NSPs and often prohibit the possession ofsyringes. In the Global-Fund-supported project knownas CHAMPION (2008–13), which was meant to help to

For the Model List of Essential

Medicines visit http://www.who.

int/medicines/publications/

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address the high prevalence of HIV infection among

people who inject drugs in Thailand, evaluatorsreported that an important impediment to scaling upNSPs was that people who inject drugs feared carryingsyringes,128 because being caught with syringes couldlead to arrest, detention, forced drug treatment, andobligatory urine testing. In some countries healthworkers are required or strongly encouraged to registerpeople who use drugs, and registries are turned over tothe police (appendix).

“Law on the street”In some places, there is no legal prohibition of possessionof drug paraphernalia, but police nonetheless usepossession of injection equipment as grounds for stop-

and-search, arrest, and detention. For example, amongnearly 600 Russians living with HIV surveyed in 2014,over 50% reported having been arrested for possessing asyringe (or having a syringe planted on them by thepolice), although possession of a syringe is not againstthe law in Russia.125 Those reporting such arrests weremore likely to have shared needles with others and tohave overdosed than were those not arrested. 125 Thisquantitative study corroborates qualitative accountssuggesting that repressive policing in Russia in manyways raises the risk of HIV and discourages seeking outand using the few HIV prevention services that exist. 129 In other countries where syringe possession is legal,police routinely seize injection equipment that they find,further undermining protection of health.73 Policepresence was associated with unsafe rushed injectionamong people who inject drugs in Bangkok, Thailand, ina multivariate analysis,130 and a small sample of peoplewho inject drugs in Hai Phong, Vietnam, reportedgreater likelihood of needle sharing and other riskypractices when police were present or their presence wasfeared.131

The performance of drug police in many countries isjudged by the number of arrests that they make, andpeople who use drugs are likely to be easier to find thanmajor drug traffickers, so they can help to bolster arresttotals. It is perhaps for this reason that police target

facilities providing health and harm-reduction servicesto people who use drugs.132 A 2015 study of more than500 methadone patients by non-governmental serviceproviders in New York showed that 38% of the patientsreported being stopped and searched by police outsidethe clinics where they received methadone, and 70%reported witnessing someone else being searched inthese locations.133 In some countries, extortion of bribesfrom people who use drugs might be an importantsource of income for poorly paid police.134

Crackdowns and other intensive policing, oftentargeting low-income people, minorities, ormarginalised people, can undermine harm reductionand add to drug-related risk. During a crackdown ondrug use known as Operation 24/7 in Vancouver in

2003, researchers noted a significant decline in access to

sterile injection equipment as police actions drovepeople who inject drugs away from the only NSP openat night.135 During police crackdowns in Australia,people who used drugs reportedly switched frominhalation or smoking of substances to injection, whichis much riskier, partly because during crackdownsdrugs became scarcer and injection could beaccomplished with lower quantities of drugs, morequickly, and less visibly than smoking.136 Other studieshave shown that crackdowns lead to rushed injections,more vascular accidents, and the likelihood that stepssuch as disinfecting the injection site will be skipped.137 In Malaysia, rushing an injection because of policepresence was linked to risk of overdose.138

Tuberculosis, drug use, and drug policyAccording to WHO, tuberculosis is the most importantcause of death among people living with HIV: it causesone in four deaths.139 People living with HIV have a30-times higher risk of tuberculosis infection than doHIV-negative people.139 But WHO emphasises thatpeople who use drugs are at very high risk of bothinfection with Mycobacterium tuberculosis and activetuberculosis even if they do not have HIV. The risk oftuberculosis was linked independently to druginjection—and even to non-injection drug use—wellbefore HIV was in the picture.140

WHO estimates that people who both live with HIVand inject drugs are two to six times more likely tocontract tuberculosis than people who live with HIV whodo not inject drugs.141 But the role of drug use in theepidemiology of tuberculosis is complex and, as noted byDeiss and colleagues,142 the existing research does notalways distinguish drug injection from other drug use.Many elements of the risk environment of at least somepeople who use drugs—homelessness or sub-standardhousing, heavy alcohol and tobacco use, andincarceration, for example—are risk factors fortuberculosis. Some studies suggest that people who usedrugs present later than do other people to seek testingor care for tuberculosis.142 Deiss and colleagues142 also

raise the possibility that use of opioids could inhibit thecough reflex and thus mask symptoms of tuberculosisthat might otherwise lead to seeking care.

Multidrug-resistant (MDR) tuberculosis has threatenedto undermine progress in tuberculosis control in manyparts of the world.143 The region with the highestdocumented proportion of MDR tuberculosis amongtuberculosis cases is EECA, which is also home to majorunsafe-injection-linked HIV and HCV infectionepidemics.139 Remarkably, although HIV and HCVco-infection is high in the region, HIV–tuberculosis co-infection is reportedly low, but experts warn that thecombination of sparse harm-reduction services, low ARTcoverage among people who use drugs, high rates ofincarceration of people who use drugs, non-integrated


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vertical health services, and substandard housing and

social support means that a perfect storm of HIV andMDR tuberculosis co-infection could be brewing.144

WHO recommends that people who use drugs beincluded systematically in anti-tuberculosis efforts andespecially that HIV, HCV infection, and tuberculosisservices be integrated and low threshold for people whouse drugs.141 The reality, however, is that recommendedservices remain out of reach for many people who usedrugs worldwide. Identification of acid-fast tuberculousbacilli by microscopy and molecular DNA detectionusing GeneXpert systems are recommended fordiagnosis of tuberculosis,141 but in central Asia, forexample, diagnosis is still mostly based on chestradiography,144 even though radiographic results are

compromised by the presence of HIV.141WHO has compiled detailed guidance for integrated

treatment of tuberculosis and HIV and tuberculosis andHCV infection, including ensuring sustained access toART for all who need it.145 The exclusion of people whouse drugs from ART, which persists in many parts ofthe world, undermines the effectiveness of tuberculosisand HCV infection treatment. The importance ofintegrated and sustained care cannot be overstated.Deiss and colleagues142 report cases in which tuberculosistreatment was integrated with treatment for drugdependence but was discontinued after people left drugtreatment. The non-governmental organisation Partnersin Health addressed the challenge of keeping peoplewho use drugs in sustained care for MDR tuberculosisin a programme called Sputnik in Tomsk, Russia,through a strategy of intensive accompaniment ofpatients.146 Trained teams of nurses, drivers, and othersworked with patients to ensure delivery of treatment inplaces and circumstances that the patient couldmaintain to minimise missed appointments. Family,friends, and neighbours were helped to understand theimportance of treatment and to provide support topatients.146 Over 70% of high-risk patients completedtreatment. The cost compared to hospitalisation wassmall. A study in Malaysia demonstrated that screeningand care for tuberculosis in drug rehabilitation centres

and facilities offering OST was a very effective targetingstrategy.147

Tuberculosis and drug-use experts at WHO, writing in2013 in the WHO Bulletin, asserted that it was urgent toaddress the undermining role of “punitive drug policiesand laws in fueling the tuberculosis epidemic amongpeople who use drugs”.148 Not only do punitive laws drivepeople who use drugs away from health services, theymight also contribute to stigma or disrespectfultreatment in health services.148 For these reasons, in its2014 guidance on HIV services for key populations,including people who use drugs, WHO recommendeddecriminalisation of drug use and training andprotections for health workers to reduce fear of treatingpeople who inject drugs.149

Drug-related incarceration and health

Use of incarceration in drug controlIn 2014, the UNODC estimated that people convicted ofdrug crimes make up about 21% of incarcerated peopleworldwide. Possession of drugs for individual use wasthe most frequently reported crime globally (figure 11). 32 On the basis of data from 2011 annual country reports,the UNODC estimated that drug-possession offencesconstituted 83% of drug offences reported worldwide.32 Although not all of the crimes reported by the policeresult in incarceration, mandatory prison sentences areattached to possession of even a small amount of drugsin many countries. In some countries that havedecriminalised drug use, possession for individual useremains an offence, or the amount defined for non-

criminalised individual use is so low that possession iseffectively a crime.150

UNAIDS estimates that in places where drug use andsmall-scale drug possession are criminal offences, mostpeople who use drugs could wind up in the custody ofthe state at some time in their lives. 55 In central Asia,one estimate suggests that more than 50% of peoplewho inject drugs have been arrested at least once.75 Although there have been some reform efforts, manycountries have drug laws that impose extendedcustodial sentences on people convicted of non-violentoffences including drug use, possession of amounts ofdrugs intended only for individual use, and sale of verysmall amounts of drugs.74 The over-representation ofpeople who use drugs in prison and the lack of essentialcare and support for them while they are in statecustody are among the most devastating health legaciesof pursuing drug prohibition. There is, moreover, noevidence that incarceration is an effective deterrent fordrug use either in prison or afterwards.151 Indeed, the

Figure : Global trends in crimes reported by police, 2003–12

Trends are calculated as weighted crime rates per 100 000 population relative to the base year (2003). Reproducedfrom the World Crime Trends, 2014, by permission of the UN Office on Drugs and Crime. 32

2003 2004 2005 2006 2007 2008 2009 2010 2011 201250

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150

I n d e x : 2 0 0 3 = 1 0 0

Year

Drug possession

(45 countries)Drug trafficking(47 countries)Robbery(63 countries)Rape(61 countries)Homicide(126 countries)Burglary(51 countries)

Motor vehicle theft(67 countries)


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Vancouver Injection Drug User Study (VIDUS),152 along-running cohort study, found that recentincarceration was negatively associated with cessationof injection.

Several studies show that criminal prosecution of minoruse and possession infractions does not have the deterrenteffect with respect to drug use, possession, or minor

crimes that supporters of these sanctions claim. A classic

study

153

comparing cannabis use in San Francisco, USA,and Amsterdam, Netherlands—cities with very differentapproaches to cannabis regulation—showed that thepartial decriminalisation of cannabis in Amsterdam wasnot associated with increased use or possession, and therigorous criminalisation in San Francisco was notassociated with reductions in use or possession.

The OAS, in its landmark 2013 report on drugs anddrug policy in the Americas, lamented the large rise inprison populations linked especially to prosecution ofminor offences because the people charged with these areless likely than major traffickers to be able to afford legalassistance in attaining “access to justice”.15 This increase,at least in some Latin American countries, is a detrimental

outcome of steady increases in legislated penalties fordrug offences since the 1950s (figure 12; appendix).154

Table 1 shows the most recent information for selectedcountries about the proportion of people incarcerated fordrug offences among all incarcerated people. UNODCdata for the prominence of possession offences and thedata informing table 1 do not distinguish the proportionof drug-related offenders who are incarcerated for minor,non-violent offences from those incarcerated for moreserious drug offences. But, as noted by Penal ReformInternational in a 2015 report,157 mandatory prisonsentences are attached to possession of even a smallamount of drugs in many countries (panel 4).

Racial discrimination in drug-related mass incarcerationThe USA has the highest rate of incarceration in theworld at about 707 people per 100 000 population, about50% higher than that in Russia, and more than five timeshigher than that in China.166 Drug-related offencesaccount for a substantial proportion of this incarceration(table 1). Aggressive prosecution of drug offences alongwith mandatory minimum sentences for someinfractions helped to make drug-related massincarceration a major engine for growth in US state andfederal prison populations beginning in the 1980s(figure 13).167

The racially disparate application of drug-related

imprisonment in the USA is a prominent feature of massincarceration. People of colour, particularly AfricanAmericans, have been disproportionately affected bydrug-related mass incarceration. In 2011, among menaged 30–34 years, one in 13 African Americans were inprison compared with one in 36 Hispanic Americans andone in 90 white Americans, even though prevalence ofdrug use is similar in the three populations.168 TheSentencing Project, a non-governmental organisationfocused on criminal justice, calculated in 2014 thatAfrican American men had a 32% probability of being inprison or other state custody at some time in their lives,compared with 17% for Hispanic men and 6% for whitemen.169 Figure 14 shows the racial disparity in drug-relatedincarceration at the federal and state level in 2013.170

Proportion imprisoned

for drug offences overall

Proportion of

women imprisoned

for drug offences

Argentina 33% 68·2%

Australia 12% 17%

Bolivia 45% ··

Brazil 24·8% 53·9%

Canada (federal) 26·3% ··

Canada (provincial) 15·7% ··

Colombia 17% 45%

Ecuador 33·5% 77%

Ireland 19·6% ··

Italy 38·8% ··

Latvia 14·3% 68%

Mexico* 57% 80%

New Zealand 10% ··

Peru 23·8% 68·4%

Russia 20% ··

Thailand 68% ··

USA (federal) 49% 59·4%

USA (states) 16·8% 25·1%

In the USA, about 86% of prisoners for all offences are imprisoned in the statesystem. Sources: Penal Reform International, 2015,155 Giacomello, 2014,156

Organization of American States–Inter-American Commission of Women, 2014,157

Carson, 2015,158 and Perez Correa and Azeola, 2012.46 *Based on a 2012 study of

eight prisons.46

Table : Incarceration for drug offences as percentage of all incarceration

in selected countries

Figure 12: Highest minimum penalty for drug offences in selected Latin

American countries

Based on data from the Colectivo de Estudios de Drogas y Derecho, 2013. 154

1950 1960 1970 1980 1990 2000 20130

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r i s o n

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BrazilEcuadorPeruMexicoColombiaBolivia

Argentina


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This pattern reflects documented racial disparities at

all stages of US law enforcement, from stop-and-searchpolicies and arrest to sentencing and incarceration.Beginning in the late 1990s, New York City attempted toclamp down on cannabis infractions, resulting eventuallyin nearly a half million arrests by 2013—of young peoplefor the most part—for minor cannabis infractions.171 There was consistent evidence that marijuana use washigher among white populations than among AfricanAmericans or Hispanic Americans. In the decadebeginning in 2004, African Americans comprised 25% ofthe population of the city but accounted for 54% ofcannabis arrests; Hispanic Americans made up 27% ofthe population but accounted for 33% of arrests.171 Arrestsfor drug-related infractions among teenagers across the

USA from 1980 to 2012—mostly for cannabis—show asimilar racial disparity (figure 15).173

The striking racial disparity in arrest and incarcerationin the USA parallels racially disparate patterns of HIV,and some investigators conclude that the two are closelyrelated. Although African Americans comprise 14% ofthe US population, about 40% of new HIV cases andabout half of AIDS cases in the US occur in them. 174 Various studies show that a history of incarceration isassociated with incidence and prevalence of HIVinfection among African American men and women.173–175

Racial and ethnic minorities are over-represented inprison and in arrest figures in countries other than theUSA, including Aboriginal people in Canada andAustralia and people of African origin in Brazil, but thecontribution of drug-related arrests and convictions tothese patterns is not clear.176 In Canada, Aboriginal peopleaccounted for 3% of the adult population but 20% ofadults sentenced to prison in 2013–14.177 Afro-Braziliansreportedly receive longer sentences for all categories ofcrime than do Brazilians of non-African origin, and theyare disproportionately targeted in drug policing andcrackdowns.178

In October, 2015, the US Gover

the lancet: public health and international drug policy (2016)

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