Data on illicit drug use are sorely lacking. It is no coincidence that public policy in this area is abysmal.
Our response to drug use is, by and large, moralistic and vengeful, not evidence-based.
While we spend billions of dollars on the "War on Drugs," there has been a pittance spent on research to understand the root causes of drug use (and addiction in particular), little dispassionate examination of the harms that result and, especially, analysis of the responses that will minimize those harms.
If you want to fashion sound public-health policies, you need good data.
So a new series of studies, published in the Lancet, is a welcome contribution.
The paper prepared by Louisa Degenhardt of the National Drug and Alcohol ResearchCentre in Sydney, Australia, has received the most attention. It shows that at least one in 20 people aged 15 to 64 used illicit drugs in the past year.
That includes an estimated:
- 125-203 million cannabis users (marijuana);
- 56 million amphetamine users (speed, crystal meth);
- 12-21 million problem users of opioids (heroin, oxycodone);
- 14-21 million cocaine users.
The researchers did not include data on use of drugs like hallucinogens, inhalants, steroids, or prescription drugs that are abused because data are unreliable.
Dr. Degenhardt said the numbers are no doubt an underestimate. "Drug use is often hidden, particularly when people fear the consequence of being discovered for using drugs, such as being imprisoned," she said.
Worldwide, illicit drug use accounts for about 250,000 deaths each year. That is significant but still doesn't not compare to the deadly impact of legal drugs like alcohol, which kills 2.3 million a year, and tobacco, which causes 5.1 million deaths annually.
Still, the vast majority of users of illicit drugs – particularly so-called soft drugs like cannabis – do not suffer appreciable harm. There are some societal costs like injuries from drugged driving, lost productivity and the violence sometimes associated with drug misuse.
But the real problems, individually and socially, stem from the minority of problematic or dependent users – addicts, in the common parlance. The new research estimates there are about 39 million addicts worldwide, most of them injection drug users.
Addiction is a disease, not a choice. But there is no doubt the disease and the drug-seeking leads to many poor choices.
In addition to the overdoses they suffer, IV drug users are at high risk of contracting infectious diseases like hepatitis and HIV-AIDS, and often turn to risky practices like selling sex and committing crimes like break-ins to fuel their addiction.
Paradoxically, it is those who suffer the most harm physically who bear the brunt of public policies, most of which focus on repressive measures.
The key question: Do those policies achieve what we want – to make the general population healthier and safer? For the most part, the answer is "No," according to a second paper in The Lancet that was prepared by a team led by John Strang of the National Addiction Centre in London (which included Benedikt Fischer of Simon Fraser University in Burnaby, B.C.) The main anti-drug strategy worldwide is to try and control supply in a bid to drive up prices and make drugs less accessible. This includes imprisoning drug suppliers and dealers. Enforcement and sanctions vary dramatically from country to country.
The research shows that incarcerating high-level dealers – like Colombian drug barons – can have an impact on supply and prices, at least temporarily, but street-level enforcement is generally costly and ineffective.
Prolonged imprisonment of drug users is also very expensive and does little to reduce illicit drug use. Researchers found, however, that specific, immediate and brief sentences – with mandated testing of offenders – is quite effective at reducing drug use and associated crime.
Legalization, or decriminalization, is often touted as a solution, but the study notes that most research in this area is of poor quality. However, there is good circumstantial evidence that decriminalization is effective at moving cannabis users away from other drug markets.
On the prevention front, the news is rather grim. School-based and mass media programs alike are generally ineffective at influencing behaviour. There is a little bit of evidence showing that family-based or parenting programs might help young people make better choices. What works best, though, is secondary prevention – intervening early with those who misuse drugs (or alcohol). In other words, they need treatment, not didactic lectures and not punishment.
Similarly, this is the approach that has shown to be the most influential with problematic users.
There is good evidence, for example, that opioid substitution with drugs like methadone or buprenorphine reduces mortality, heroin use, crime, HIV and hepatitis infections. Residential rehab programs gets good marks, but the quality of the research is mediocre. Rehab is also expensive, although less expensive than prison.
In short, the research shows that when it comes to illicit drugs, the focus needs to be on the problematic users, and that public-health measures work better than criminal sanctions.
There is no magic bullet – not zero tolerance and not supervised injection facilities. Rather, a broad range of interventions are required, targeting different drug problems.
The hardest part of this approach may be setting aside our prejudices and preconceived notions to adopt evidence-based approaches that are not always politically popular.
As The Lancet notes in an editorial highlighting the new research: "Few diseases can compete with addiction in their capacity to generate misinformation, misjudgment, or misunderstanding."
Addiction is a complex disease – a global problem that has no global solution, but rather many community-based solutions.
André Picard