Last weeks blog looked at the first in a series of three papers in the Lancet regarding UK drugs policy (here)

The second in the series looks at how effective various policies are: Drug policy and the public good: evidence for effective interventions

Summary

As with the first paper, the summary at the start hints at the reason we see so much chaos around us:

Debates about which policy initiatives can prevent or reduce the damage that illicit drugs cause to the public good are rarely informed by scientific evidence.

In fact they never have been, as regards cannabis the whole prohibition regime came about through highly questionable means (Cannabis timeline UKCIA) if not downright lies, there was never any science involved at all. Cannabis, before prohibition came along, was not associated with any serious degree of harms and had a long tradition of use in many cultures. It is important to realise this, because the report in the Lancet doesn’t at all. From the start the assumption is that the correct policy is to make drugs less available,

Fortunately, evidence-based interventions are increasingly being identified that are capable of making drugs less available, reducing violence in drug markets, lessening misuse of legal pharmaceuticals, preventing drug use initiation in young people, and reducing drug use and its consequences in established drug users.

Some of that is good of course – although the desire to reduce violence neds to accept the role of prohibition in causing most if not all of it. Preventing drug use initiation in young people is a good aim, but again it is something which has increased greatly since prohibition. But should the aim simply be to reduce drug use and cut supply? Isn’t it better – at least as far as cannabis is concerned – to concentrate on the type of use, the way it’s used and so on. Simply, not all use is abuse.

For a science based approach, this comment in the introduction should raise a few eyebrows:

The reasoning behind the final decisions for action might be of a non-scientific nature, focused more on what the public and policy-makers deem of value. Nevertheless, important opportunities exist for science to inform these deliberations and guide the selection of policies that maximise the public good.

So if not science and therefore evidence, what other considerations might be valid when it comes to deciding drugs policy? Is this to be one area of public policy where politicians are free to make judgements based on whatever they decide is important? Right from the start the Lancet seems to accept that drug policy is never really going to be based on evidence and a real understanding of what’s going on. That’s not good.

Introduction

The introduction makes a huge assumption which simply is not generally true and is especially not true for cannabis

Illicit drugs are a substantial threat to the public good, not only because they adversely affect public health, but also because they can generate crime, disorder, family breakdown, and community decay.

Some drugs do, but they are not always the illicit ones. Cannabis on the whole doesn’t, neither do some other illicit drugs, especially psychedelics. What does far more to disrupt communities however is the illegal trade in illicit drugs.

Here we review effective interventions to draw attention to the drug-control policies available to governments, in much the same ways as evidence has contributed to debates about more effective tobacco and alcohol policies.

Now, being a scientific journal we might expect the word “control” to be defined here, but of course, it isn’t. But the aim of the paper is described as

we critically assess the scientific basis of interventions intended to prevent or at least minimise the damage that illicit drugs do to the public good. We examine the quality of evidence for different policies, estimate the likely magnitude of their effects, assess potential unintended consequences, and identify promising areas for future investment into research and interventions. We can thus help policy makers make informed decisions about which policy options will maximise the public good

Having not defined the word “control” above, they do define the phrase “public good”

By the public good we refer to social benefits such as better public health, reduced crime, and greater stability and quality of life for families and neighbourhoods

And of present policy

Contemporary drug-related public policy attempts to promote the public good through a broad range of administrative actions designed to prevent the initiation of drug use by non-users, help heavy drug users change their behaviour or reduce the consequences of their drug use, and control the supply of illicit drugs (and the supply of diverted prescription drugs used for non-medical purposes) through laws, regulations, and enforcement.

Again, a myth is presented as fact

Values and political processes (eg, voting) are important drivers of drug policy,

Prohibition and the drugs policy as a whole has never been subjected to the democratic process, it has simply been imposed, supported by rabid media reporting. The only near democratic imput to the formation of the Misuse of Drugs Act, the Wooton report, was ignored because it didn’t fit the then Prime ministers view of the world.

but evidence of effectiveness and cost-effectiveness can help the public and policy makers to select policies that best achieve agreed goals.

Maybe, but the government is aware of how ineffective and expensive the policy is, but it carries on anyway.

The key messages the paper wants to get across as regards cannabis are summarised:

• Drug policy should aim to promote the public good by improving individual and public health, neighbourhood safety, and community and family cohesion, and by reducing crime.

Fair enough

•  The effectiveness of most drug supply control policies is unknown because little assessment has been done, and very little evidence exists for the effectiveness of alternative development programmes in source countries.

Which is a damning statement for a policy half a century old, but it is all too true.

•  Supply controls can result in higher drug prices, which can reduce drug initiation and use but these changes can be difficult to maintain.

They also create violence, increase profits for organised crime and fly in the face of the driver of capitalism; the laws of supply and demand

•  Wide-scale arrests and imprisonments have restricted effectiveness, but drug testing of individuals under criminal justice supervision, accompanied by specific, immediate, and brief sentences (eg, overnight), produce substantial reductions in drug use and offending.

Perhaps

•  Screening and brief intervention programmes have, on average, only small effects, but can be widely applied and are probably cost-effective.

Maybe, especially with children

•  The collective value of school, family, and community prevention programmes is appraised differently by different stakeholders.

Some education tactics may actually serve to recruit drug users. Some studies have shown the DARE programme to be spectacularly bad at this

The paper then looks at various regimes

Supply Control

Illicit drugs are ultimately consumer goods, typically produced and distributed through illegal markets operated by people motivated by profit. The goal of supply control programmes is to reduce access to drugs by interfering with drug suppliers’ activities.

So how effective has this been?

Ideally, effective supply control would make a drug so scarce that users could not find suppliers without great difficulty or expense. The policy objective in the case of non-users is to reduce exposure to drug sellers, which can be achieved in some circumstances. For most of the 20th century, heroin was largely absent from smaller towns and rural areas in the USA and for whole countries elsewhere in the world. Even at present, cocaine is not readily available in many parts of Asia

In other words, it hasn’t been effective at all. We’ve moved from a situation where no trade exists to one where it’s almost universal.

Law enforcement also creates risks for sellers directly (arrest and incarceration) and indirectly (eg, being defrauded without legal recourse for compensation). Drug market operators, therefore, receive far greater monetary compensation than do people engaging in legal markets. The distribution system passes these costs on to users via higher drug prices.

Which means more acquisitive crime from addicts desperate to get their next fix

Cocaine and heroin are semi-refined agricultural products that retail for many times their weight in gold—their legal, untaxed price would be like that of coffee.

The underground trade isn’t a simple matter of supplier and customer

The distinction between drug use and involvement in drug-selling or distribution is often unclear. In the USA, more than 90% of people imprisoned for drug-law violations admit playing some—perhaps minor—part in drug distribution

Which is why drug law enforcement is compared to squeezing a balloon; repress one area of trade and it appears somewhere else. Supply reduction is as easy as nailing jelly to the ceiling.

Prevention

Young people are an obvious and important focus for prevention because the period between being a child and being a young adult is when most people are initially exposed to drugs, and when they are most likely to initiate use. Ideally, preventive interventions should stop young people from starting drug use, but they can also delay initiation of drug use and prevent young people from becoming regular and dependent drug users.

All well and good, but children are also drawn into the black market trade and there is nothing to protect them from the effects of the trade, which goes on all around them. Interestingly over the past few years much emphasis has been placed on school based drug education programmes, but apparently

Cochrane systematic reviews of randomised controlled assessments and other high quality reviews show that psychosocial developmental interventions can be effective, whereas knowledge and awareness are generally ineffective for prevention of use of illicit drugs, tobacco, and alcohol

It has always seemed perverse to me (I work in education) to expect that kids could ever be educated not to be interested in something. The whole point of education has to be to get kids interested in the subject being taught, if you get them interested in drugs, they will be curious about them.

The ineffectiveness of didactic educational tactics is a serious challenge for mass media approaches and also many traditional community and classroom programmes. For example, Drug Abuse Resistance Education (DARE) is a school-based preventive intervention widely adopted in the USA in which police officers provide classroom advice on the dangers of drug use. In many studies it has been shown to neither prevent nor delay drug use. Likewise a large-scale assessment of a mass media campaign to prevent cannabis use also showed that it had, at best, no effect, and possibly increased use.

Hold the front page…

Support for drug users

The paper describes various support programmes for problem drug users, but doesn’t touch on cannabis.

Drug Policy to promote the public good

Scientific research can make important contributions to the construction of more effective drug policy, but final resource allocation involves wider public and political processes of priority-setting

This seems to accept the shape of the drug policy will be decided not by evidence, but by the editor of the Daily Mail. They present this diagram in summary:

Drug Policies To Protect the Public Good (diagram)

The figure presents a four-tier pyramid that describes potential for the maximsation of the public good as well as individual benefit and can constructively inform the political and economic considerations of different policy initiatives. This model is informed by similar frameworks in tobacco control, communicable disease control, and injury prevention

Pity it doesn’t include control of the trade anywhere in that, which is an important element of the framework used for tobacco and alcohol. Regarding the bottom section – supply control it states

Although the evidence is mixed, and the quality of the research is poor, supply control can have a substantial population effect, if effective methods are used (as is the case with tobacco and alcohol).

But which are not available for illicit drugs of course. Of the second and third tiers – Prevention

Some universal prevention programmes—those aimed at the prevention or delay of use of drugs by young people—have evidence of effectiveness, albeit with a small to medium-sized effect. The effective early intervention prevention programmes concentrate on the psychosocial development of young people and also have benefits beyond the prevention of drug misuse.

——————-

This paper is hardly a ringing endorsement of the present policy, yet it is based on the assumptions that underpin the regime, why no examination of those basic assumptions? Other than the desire to reduce crime and the desire to protect children by delaying the age of first use, very little of this is really relevent to cannabis, yet no distinction is made and the paper talks only of “illicit drugs”. It has to be remembered that cannabis is by far the most used illicit drug, yet it causes the least problems and the problems it does cause are very different to those caused by heroin etc.

The papers use of the word “control” without having defined it is a serious criticism, especially as it did define the term “public good”