There remain crucial areas in public health in which the gap between evidence and public policy persists, and there are few more striking than in the global response to illicit drugs.1 In the USA, for example, annual federal budgets for drug-law enforcement have exceeded US$15 billion since the 1990s, and, at a global level, untold billions more have been spent on drug-law enforcement. Over the past several decades, considerable effort has also gone towards evaluating the “war on drugs” approach.
In this context, the evidence that drug-law enforcement has failed to prevent the availability of illegal drugs is unambiguous.2 National and international surveillance systems have shown a general pattern of falling drug prices and increasing drug purity.2 Furthermore, there is no evidence that intensifying the penalties for the use of drugs meaningfully reduces the prevalence of drug use.3 Not only has drug interdiction been shown to be ineffective in eliminating the supply of drugs,2 but the over-reliance on prohibition has also resulted in a range of unintended negative consequences, including the enrichment of organised crime, fuelling of drug-market violence, and record rates of incarceration of non-violent drug offenders.4 Drug law enforcement practices have also inadvertently increased HIV risks and human suffering, while exacerbating human-rights violations (panel 1).
Harms of traditional drug policies listed in Vienna Declaration
- HIV epidemics fuelled by criminalisation of people who use illicit drugs and by prohibitions on provision of sterile needles and opioid substitution treatment.
- HIV outbreaks in incarcerated and institutionalised drug users as result of punitive laws and policies, and lack of HIV prevention services in these settings.
- Undermining of public health systems when law enforcement drives drug users away from prevention and care services, and into environments where risk of infectious-disease transmission (eg, HIV, hepatitis C, tuberculosis) and other harms is increased.
- Crisis in criminal justice systems as result of record rates of incarceration in several nations. This high rate of incarceration has negatively affected social functioning of entire communities. While racial disparities in incarceration rates for drug offences are evident in countries worldwide, effects have been particularly severe in USA, where about one in nine African–American men aged 20–34 years is incarcerated on any given day, mainly because of drug-law enforcement.
- Stigma towards people who use illicit drugs, which reinforces political popularity of criminalising drug users and undermines HIV prevention and other health-promotion efforts.
- Severe human-rights violations, including torture, forced labour, inhuman and degrading treatment, and execution of drug offenders in several countries.
- Massive illicit market worth US$320 billion annually. These profits remain entirely outside governmental control. They fuel crime, violence, and corruption in countless urban communities and have destabilised entire countries, such as Colombia, Mexico, and Afghanistan.
- Billions of tax dollars wasted on “war on drugs” approach to drug control that does not achieve its stated objectives, and instead directly or indirectly contributes to above harms.
The data also show that, against the backdrop of the international legal conventions that support drug prohibition, the number of countries in which people inject illegal drugs is growing.5 As a consequence, outside sub-Saharan Africa, injecting drug use accounts for about one in three new cases of HIV.6 In some areas where HIV is spreading most rapidly, such as eastern Europe and central Asia, HIV prevalence can be as high as 70% in people who inject drugs, and in some areas more than 80% of all HIV cases are in this group.6
Unfortunately, both the fact that drug-law enforcement has failed to achieve its stated objectives and the clear evidence of unintended negative consequences of these policies have been largely ignored or discounted by governments and international bodies responsible for illicit-drug regulation.1, 2 The reasons for the persistent investment in ineffective and harmful policies are many: some stem from a well-intentioned concern provoked by the damage caused by problem drug use, while others are related to the vested interests of an industry seeking to maintain its funding stream.7
While some scientists and health practitioners have chosen to speak out about the clear discordance between scientific evidence and global drug policy, it has not always been easy for them to do so. Advocates for reform have often faced political pressure, threats to funding, or other bullying techniques8 which have had a chilling effect and contributed to a collective reluctance to speak out on this issue. These pressure tactics have also hamstrung community groups, public health agencies, and non-governmental organisations that aim to address drug-related harms through the implementation of evidence-based tools.9
Physicians and scientists can look back with pride on the moments when they have spoken out collectively and addressed ineffective or harmful policies. In 2000, more than 5000 physicians and scientists signed a declaration affirming HIV as the cause of AIDS. This declaration was published to coincide with the XIII International AIDS Conference in Durban, South Africa.10 Although its local impact was slow to materialise,11 the Durban Declaration is credited with helping to set the stage for the “3 by 5” initiative to place 3 million people in low-income and middle-income countries on antiretroviral therapy that culminated in the clarion call for universal access launched by the G8 and the UN General Assembly in 2006.
As thousands of delegates gather in Vienna for the XVIII International AIDS Conference, the international medical and scientific community again is making its voice heard. Too many opportunities to prevent new HIV infections and drug-related deaths have been missed because of our collective failure to implement evidence-based responses to illicit drug problems.1, 9, 12 This situation must change. The Vienna Declaration is available online for endorsement,13 and calls for both greater acknowledgement of the unintended harms of current drug policies and, in view of the successful alternatives to drug prohibition in a range of countries, the immediate implementation of evidence-based public health models to reduce drug-related harms (such as HIV infection) in people who use drugs (panel 2).
Drug-policy recommendations from the Vienna Declaration
- Undertake transparent review of effectiveness of current drug policies
- Implement and evaluate science-based public-health approaches to address individual and community harms stemming from illicit drug use
- Decriminalise drug users, scale-up evidence-based drug-dependence treatment options, and abolish ineffective compulsory drug-treatment centres that violate Universal Declaration of Human Rights
- Unequivocally endorse and scale-up funding for implementation of comprehensive package of HIV interventions spelled out in the WHO, UNODC, and UNAIDS Target Setting Guide14
- Meaningfully involve affected community in developing, monitoring, and implementing services and policies that affect their lives
Basing drug policies on scientific evidence will not eliminate drug use or the problems stemming from drug injecting. However, reorienting drug policies towards evidence-based approaches that respect, protect, and fulfil human rights has the potential to reduce harms deriving from current policies and would allow for the redirection of the vast financial resources to where they are needed most: the implementation and evaluation of evidence-based prevention, regulatory, treatment, and harm-reduction interventions.
The global illicit-drug problem will continue to worsen unless policy makers accept the scientific and practical realities of drug-law enforcement’s limitations and unintended consequences, and seek to enact evidence-based measures that can meaningfully—and in communities globally—reduce the harms of drugs.
JM has received grants from, served as an ad-hoc adviser to, or spoken at events sponsored by Abbott, Argos Therapeutics, Bioject, Boehringer Ingelheim, Bristol Myers Squibb, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho, Merck Frosst, Panacos, Pfizer, Schering, Serono, TheraTechnologies, Tibotec (J&J), and Trimeris; he has also received research grants from Merck, Gilead, and ViiV. The other authors declare that they have no conflicts of interest.
- The Lancet. Rethinking America’s “War on Drugs” as a public-health issue. Lancet. 2001; 357: 971
- Reuter, P. Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals. Addiction. 2009; 104: 510–517
- Degenhardt, L, Chiu, W-T, Sampson, N et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLOS Med. 2008; 5: 1053–1067
- Wood, E, Werb, D, Marshall, BD, Montaner, JS, and Kerr, T. The war on drugs: a devastating public-policy disaster. Lancet. 2009; 373: 989–990
- Mathers, BM, Degenhardt, LJ, Phillips, B et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008; 372: 1733–1745
- UNAIDS. 2008 Report on the global AIDS epidemic. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp; 2008. ((accessed June 2, 2010).)
- Wood, E, Montaner, JS, and Kerr, T. Illicit drug addiction, infectious disease spread, and the need for an evidence-based response. Lancet Infect Dis. 2008; 8: 142–143
- Pearson, H. Science and the war on drugs: a hard habit to break. Nature. 2004; 430: 394–395
- Lurie, P and Drucker, E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. Lancet. 1997; 349: 604–608
- Anon. The Durban Declaration. Nature. 2000; 406: 15–16
- Chigwedere, P, Seage, GR 3rd, Gruskin, S, and Lee, TH. Estimating the lost benefits of antiretroviral drug use in South Africa. J Acquir Immune Defic Syndr. 2008; 49: 410–415
- Finnerty, E. Opiate substitution treatment in the former Soviet Union. Lancet. 2006; 368: 1066
- The Vienna Declaration. http://www.viennadeclaration.com. ((accessed June 28, 2010).)
- WHO, UNODC, and UNAIDS. Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injection drug users. http://www.unodc-us.com/documents/eastasiaandpacific//Publications/DrugsAndHIV/WHO_UNODC_UNAIDS__IDU_Universal_Access_Target_Setting_Guide_-_FINAL_-_Feb_09.pdf; 2009. ((accessed June 2, 2010).)