As the Home Affairs Select Committee enquiry into the drug laws gets underway we look at the third and final paper from the Lancet Trilogy which looks at the only aspect that really matters; how well has it all worked?

How well do international drug conventions protect public health?

There are many issues around raised by the application of drug prohibition, many see the repression of the right to choose what to put into your own body as by far the biggest issue; the right to alter your state of mind is as old as humans and simply isn’t a proper area for the law to operate in. However, such issues did not concern the Single Convention, the UN convention that gave rise to the drug war we all know and respect (albeit it not very much) today. The whole point of what is laughably termed “drug control” –  prohibition – was to protect the health of the world’s population, whether we wanted it protected or not. So it is only fair and reasonable to ask how well it has done, some 50 years down the road?

Summary

A usual the paper starts with a summary, which is damning:

The Single Convention on Narcotic Drugs in 1961 aimed to eliminate the illicit production and non-medical use of cannabis, cocaine, and opioids, an aim later extended to many pharmaceutical drugs. Over the past 50 years international drug treaties have neither prevented the globalisation of the illicit production and non-medical use of these drugs, nor, outside of developed countries, made these drugs adequately available for medical use. The system has also arguably worsened the human health and wellbeing of drug users by increasing the number of drug users imprisoned, discouraging effective countermeasures to the spread of HIV by injecting drug users, and creating an environment conducive to the violation of drug users’ human rights.

But otherwise it hasn’t done badly… Sorry, that was sarcasm. Right from the start then we are looking at not just a record of failure, but one of compounding the problems. So what to do about it?

The adoption of national policies that are more aligned with the risks of different drugs and the effectiveness of controls will require the amendment of existing treaties, the formulation of new treaties, or withdrawal of states from existing treaties and re-accession with reservations.

Well, yes, but is there any other example of a convention which has proven to be so counter productive and damaging that we would even consider remaining a part of? It’s hard to think of one. In any case, the whole point of the “Single Convention” – as the name suggests – is to have one agreement which the whole world would stick to. If nations agree to join it only if they can have exemptions from the parts they don’t like, doesn’t it undermine the whole thing? Of course it does, as the supporters of this madness always tell us anyway.

Introduction

2011 marked the 50th anniversary of the Single Convention:

This convention prohibited the production and use of narcotic drugs—specifically cannabis, opioids, and cocaine—except for medical and scientific purposes. The primary policies pursued have been criminalisation of the production, sale, and use of these drugs for non-medical purposes.

The paper makes some key points, those which apply to cannabis are

The system has not effectively restricted the non-medical use of controlled drugs, and illicit drug production, manufacture, and use is now a global issue.

So it hasn’t worked, simple as that.

The system’s emphasis on criminalisation of drug use has contributed to the spread of HIV, increased imprisonment for minor offences, encouraged nation states to adopt punitive policies (including executions, extra-judicial killings, imprisonment as a form of treatment, and widespread violations of UN-recognised human rights of drug users), and impaired the collection of data on the extent of use and harm of illicit drugs, all of which have caused harm to drug users and their families.

How much worse can it get?

The international system precludes policies that are more aligned to the risks of drug use and the adverse consequences of prohibition, such as the regulation of producers, consumers, and the conditions under which drugs are used.

A drug control system that doesn’t control drugs! So what can be done about it?

Policy experimentation requires changes to the international treaties, which are possible in principle but unlikely in practice. Other options include renunciation of the treaties and re-accession with reservations, or adoption of a new treaty.

So the only way forward would seem to be out, either out totally or out partially, but to some extent or other, out.

Current international drug control system

There is a real problem here with a scientific paper which accepts the current policy does not control drugs referring to the current regime as “Drug Control Policies”, but its not a problem they address. Instead they list the three drug (non)control treaties:

 1961 Single Convention on Narcotic Drugs

• Required nations to make the non-medical use of cannabis, cocaine, and opioids a criminal offence
• Amended by a 1972 Protocol

Where it all began. The history of how it came about is somewhat dirty and well worth a google.

1971 Convention on Psychotropic Substances

• Extended the system to cover synthetic drugs—eg, amphetamines, benzodiazepines, opioids, lysergic acid diethylamide (LSD)

The establishment reacting to the hippies?

1988 Convention Against Illicit Trafficking in Narcotics and Psychotropic Substances

• Focus on police suppression of illicit markets
• Extended to cover drug precursor chemicals

Perhaps the start of the real war in some ways.

Aims and functioning of the international system

So indeed, what is all this actually trying to do? It has two aims: to suppress the production, distribution, and use of drugs for any use apart from medical or scientific and indeed to ensure that these so-called “controlled” drugs (especially the opioids) are made available for medical purposes. Cannabis, of course, was considered to have no medical use at all, a decision which to this day causes a great deal of suffering.

The supposed aim of all this was to prevent addiction, which the Single convention describes as

a serious evil for the individual

and that it was

fraught with social and economic danger to mankind

and saw it mission as having

duty to prevent and combat this evil

It’s worth noting that the people who passed this moralistic rubbish were probably (almost certainly) puffing away on tobacco at the time, gleefully being addicts themselves. But the big thing about the Single Convention is it was designed to prevent something that hadn’t happened in the past few millenia of human existence.

Over the years a wider selection of voices has been heard in the meetings of the committees, in recent years activists form areas such as human rights and even drug reform have got involved, but thus far  the effects of civil society organisations in the drug control system have been much less than in other areas of public health such as AIDS, baby formula and breastfeeding, and tobacco control … The upsurge in international NGO activity is associated with substantial policy changes in several countries, such as decriminalisation measures and a ballot proposition to legalise cannabis in California. But people in the official policy community—ie, on national delegations to the Commission on Narcotic Drugs, or in international bureaucratic positions—have a vested commitment to the existing system and have kept civil society at bay

Of course, some would day all this is the doing of the common enemy of all mankind; the USA. Actually it’s sort of almost true, sort of

Informally, the USA has long had a leading role in the international system. The USA has strongly opposed harm reduction approaches to illicit drug problems (eg, needle and syringe programmes, supervised injecting centres, and heroin maintenance treatment), with support from other nations such as Japan and Russia.

Indeed, the USA was behind much of the creation of the Single Convention, but that’s the dirty story mentioned earlier. The idea that the drugs conventions are driven by science or concerns of the wellbeing of the population are simply not true and the rigid and inflexible nature of prohibition has been carefully safeguarded. For example

In 2002, the WHO (World Health Organisation) Director General, under pressure from the UNODC (UN Office of Drug Control), declined to transmit to Vienna a recommendation by the 33rd expert committee that pharmaceutical delta-9-tetrahydrocannabinol (the main psychoactive constituent of cannabis) should be reclassified from schedule 2 to the lowest schedule of the 1971 Convention. A similar recommendation by the 2006 expert committee was rejected by the Commission on Narcotic Drugs.

and

the international system devotes more of its resources (as shown in its budget allocations and the topics of debates by the Commission on Narcotic Drugs) to suppression of illicit drug markets than to direct protection of public health and wellbeing.

National drug policies

Although all countries are signed up to the treaties, actual regimes differ somewhat, depending on the attitude of the government to the idea of human rights. The carnage seen in Mexico where the effort to keep the drugs from the huge American market, leading to 35 000 deaths between 2007 and 2010 has not been seen in Europe where much less violence is associated with the drug markets.

Amazingly we learn

Assessments of drug programmes have had a marginal role in the formulation of policy even in developed countries that have heavily invested in research

Is that true of any other area of public policy? We are also told that

The evidence is clear that incarceration is an ineffective way to increase the price and reduce the availability of drugs

So what can be done?

National policy reforms within the international system

In the case of cannabis, the main legislative experiments in the past 50 years have been to reduce or eliminate criminal penalties, or to substitute civil penalties (eg, fines) for the use or possession of the drug. This policy has been extended to all illicit drugs in Brazil, Colombia, the Czech Republic, Mexico, and Portugal. Often a statutory criminal penalty is retained to avoid conflict with the international treaties.

These countries have moved as far as they can away from the demands of the treaties without actually leaving them. Does it lead to an explosion of use of cannabis?

No evidence is available on whether the presence or absence of criminal penalties for use and possession of cannabis substantially affects the prevalence of use or levels of health-related harm. Criminal penalties are frequently enforced in a discriminatory way against socially excluded minorities. Therefore to justify the criminalisation of cannabis use as a strategy to reduce use is difficult.

You couldn’t make this up. Interestingly reducing penalties doesn’t mean a reduction in the number of people caught up in the law

The reduction of penalties for cannabis possession and use while the international treaties are complied with has often had the converse consequence of so-called net widening. Because the implementation of offences with reduced or non-criminal penalties is not time-consuming for police, more young people might receive police records for failure to pay fines than if criminal penalties had been retained. Studies in North America and many European countries show that arrests for cannabis use have risen substantially in recent years, alongside reductions in the severity of penalties for use.

But does it reduce the use or potential for harm?

The Netherlands has moved the furthest away from criminal penalties by de facto (but not de jure) legalising retail sales of small amounts of cannabis in coffee shops. Evidence that this form of legalisation has affected rates of use or harm is scarce, although commercialisation could have done so. The prevalence of cannabis use in the Netherlands is less than in countries such as the UK, France, and the USA, which have retained criminal penalties

So it would seem that allowing a noncommercial trade actually leads to lower levels of use. This flies in the face of the prohibition case.

How successfully has the international system achieved its goals?

So how well has it all worked? well, the access of patients to pain relief has not been good

The International Narcotics Control Board acknowledges that such difficulty with access “continues to be a matter of concern”.

No mention is made of the huge number of medical cannabis users who are denied their medication. As to the reduction in the production of “controlled” drugs, the mantra of “a drug free world, we can do it” has been forgotten

The system has failed to achieve its original goals of elimination of illicit markets and the non-medical use of controlled drugs. In 1998, the UN system set the more restricted but still ambitious goal of “eliminating or significantly reducing the illicit cultivation of coca bush, the cannabis plant, and the opium poppy by the year 2008”. However, by 2009, this goal was as distant as it was in 1998. Between 1998 and 2009, the production of synthetic drugs such as 3,4-methylenedioxymethylamfetamine (MDMA) and metamfetamine increased, as did domestic cannabis cultivation in many developed and developing countries.

It’s also worth mentioning that not only did the domestic cultivation of cannabis increase, but it also brought about a market shift form imported hash to “home grown” herbal cannabis, which prohibition supporters claim has led to cannabis becoming more dangerous. Whether there is any truth in that is highly debatable, but it does seem that the prohibition lobby are digging a hole for themselves with that one. However, it does flag up the so-called “unintended consequences” of prohibition, of which there have been many

The aim of eliminating drug use in order to improve the health of populations has not been met

although global health burden related to cannabis use has not been estimated, estimates in countries with high rates of use (such as Australia and Canada) suggest that cannabis accounts for a small part of the health burden attributable to illicit drugs

Despite cannabis being by far the most widely used prohibited drug.

Has the international system improved human health and wellbeing?

Major challenges exist in assessment of the effects of the international control system on human health and wellbeing. First, to separate the effects of the treaties from the effects of the national policies implemented in accordance with their provisions is impossible. Second, criminalisation of the non-medical use of these drugs ensures that we have poor data on the extent of and the harm caused by their use.

So we can’t even tell

These challenges notwithstanding, to argue that the effects have been beneficial is difficult. Illicit drug use and the contribution of illicit drugs to the burden of disease have increased worldwide over the past decade.  Anti-trafficking efforts have harmed many nations where these drugs are produced and through which they are transshipped. Criminalisation of drug use has many adverse consequences for drug users and their families. The system’s emphasis on criminalisation has substantially increased imprisonment, with drug offences accounting for a large proportion of all imprisonments in most high-income countries. Evidence that the adverse effects of imprisonment of drug offenders can be justified by reductions in availability of illicit drugs or in rates of use is absent.

As has already been said, this is awful. After 50 years of what is at the very least a disruptive policy to not be able to demonstrate any improvement in human health or wellbeing is, well, unacceptable.

Moving towards risk-based drug control systems

The paper identifies four options available for drug control:

• Prohibition

As has been argued here many times, prohibition is not “drug control” because it doesn’t control drugs. In addition there is everything else:

• Prescription systems, in which a licensed health practitioner controls access to the drug

• Market regulation, in which the state distributes or licenses producers and retailers to sell the drug under various conditions (often includes contexts of use)

• Regulation of consumers—eg, by setting age limits, requiring ration cards, or prohibiting certain behaviours, such as driving after drug use

These are all options which could be employed in different ways for different drugs, they are not mutually exclusive. They all require an end of prohibition, but they would all count as “drug control”, because they would control the market in drug supply, which is what is required to control drugs.

Cannabis is the drug whose inclusion in the international system is most often seen as anomalous because it is widely used by young adults in many countries, and its health effects are much less harmful than those of the opioids and stimulants. However, the treaties prevent any experimentation with alternative policies for reduction of harm associated with this drug.

Amending the treaties

How can we get out of this mess? It’s not easy.

Any system that allowed the regulated availability of controlled substances for non-medical use would contravene the international drug conventions. Hence, any government that wished to experiment with such a system for cannabis must either ignore international legal obligations or go beyond the conventions in one of the following ways:
  • Countries such as the USA with a constitution in which national law has equal status with international law could pass a new national law that conflicted with the treaties. Under the constitution, this new law would take precedence. A country that adopted this option would have to withstand substantial international opprobrium.
  • A nation wishing to establish a regulated cannabis system could withdraw from the applicable conventions and then re-accede with specific reservations. This procedure is recognised in international law.
  • A group of nations could adopt a new treaty in conflict with the existing treaties; under international law this treaty would take precedence between the signatory nations. A framework convention on cannabis control has been drafted along these lines, modelled on the Framework Convention on Tobacco Control.

So for us in the UK, the only option is to withdraw from the conventions, then rejoin with specific recommendations.

Conclusions

The restrictions imposed by the treaties make any change difficult but

The cultural positions of different drugs vary enough to preclude universal policies on how to deal with all illicit or indeed licit drugs. From the perspective of public health, we need to move towards a control system that is more aligned with the risks that different drugs pose to users and shows an understanding of the effects of different regulatory approaches on drug use and harm.

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So now we wait to see what the Home Affairs Committee will recommend, but it won’t report before the end of the year or later, then the government will probably sit on it for a while before ignoring the advice, as it has so often done in the past. politicians are the problem, as always.