Shifting the debate on the use of illicit drugs

Anna McG. Chisman In 2010, the Governments of the Western Hemisphere approved a major shift in how they deal with users of cocaine, opiates, marijuana and other illicit drugs. Their stated purpose is now to treat drug addiction purely as a health matter. People who are drug- dependent are to be given treatment and therapy for their addiction, which has been shown to be a disease of the brain, a chronic, relapsing disease similar to asthma, hypertension and diabetes. The action taken by the Western Hemisphere’s governments, in which the Inter-American Drug Abuse Control Commission (CICAD) of the Organization of American States played a leading role, is a milestone in the adoption of drug policies that are actually based on evidence and science, rather than on a hunch, opinion or moral outrage. This policy shift is precisely the approach recommended in 2009 by three former Western Hemisphere Presidents, Fernando Henrique Cardoso, César Gaviria and Ernesto Zedillo, in their paper on Drugs and Democracy: Toward a Paradigm Shift. Much work needs to be done to make this new policy a reality in thirty-four countries of the OAS. Changing the emphasis from law enforcement and incarceration of drug users to a health-based approach may well take years in some countries. Governments will have to upgrade their health and social welfare systems in order to provide treatment for drug-dependent people, update some of their laws and administrative practices, educate their judges and their police to a new way of thinking, and at the same time, ensure that parents and teachers understand that viewing drug dependence as a disease does not give people, particularly children, license to indulge freely. Drugs such as cocaine, heroin and methamphetamines are dangerous to health, and use of them should be strongly discouraged, which will mean a heavy emphasis on preventing the use of drugs in the first place. This paper discusses some of the implications of adopting a health-based approach to drug addicts, and attempts to move away from the sometimes inflammatory rhetoric that has characterized discussions about the “War on Drugs” and look in a more subtle way at the complex interplay of many social and economic factors involved in drug control policy. Decriminalizing drug use Treating drug addiction as a health matter does not mean “legalizing” drugs. It does mean that Governments would not prosecute drug use as a criminal offense (already, drug use in not a crime in several Western Hemisphere countries). Instead, Governments would commit to providing counseling and therapy for those who need treatment. Providing good quality treatment that is affordable and accessible is a huge challenge, and will mean a massive shift of resources into the health and social services sectors. Large numbers of counselors and therapists will need to be trained and certified, and doctors and nurses in particular will need to be taught to recognize potential addiction and to refer the patient to qualified care. In July, 2001, the Portuguese Government decriminalized drug use. At the same time, it put in place an array of health measures to cope with what was anticipated to be a sharp rise in the use of drugs. Government-run health clinics operate in every part of the country, and people found by the police in possession of drugs are told to go to a “dissuasion counselor”, a trained professional who tries to motivate the individual voluntarily to seek treatment for his or her drug use. The Portuguese drug control institute has collected excellent statistics on the outcome of that policy shift, and the data show that while there was indeed an uptick in drug use in the years following the change in the law, the numbers of people seeking treatment for their addiction also increased, largely because the stigma of being addicted had been removed. Now, twelve years after decriminalization, the data show that drug use has leveled off, and that the major health crisis that had been feared did not materialize: rates of drug use in Portugal are around the median for all European Union countries. The Portuguese model has much to teach us as Governments grapple with a major policy change. First, with a new emphasis on the health of the drug user, Governments will need to transfer large amounts of money and personnel away from law enforcement and interdiction into the health and social services departments. Turf battles and budget wars will surely precede any reallocation of funds and authority, because over the last fifty years, most of the emphasis and most of the resources have gone to law enforcement efforts and very small amounts to the health and other problems faced by drug users. Another issue Governments will face is how to move discussion of drugs away from inflammatory rhetoric to a sober and subtle understanding of a very complex interplay of many social and economic factors. Governments and citizens alike will need to understand the fine line between doing as one pleases and protecting the common good. We all have an interest in protecting the health of the public so that medical costs that affect us all do not go through the roof, and therefore we want to discourage any behavior that will make a person ill—whether that behavior is eating too much, smoking cigarettes, driving dangerously without a seat belt, or doing dangerous drugs. A third issue that flows from the new health policy is how do Governments, NGOs and universities make sure that there are enough people are properly trained and educated to deal with drug abusers in the public health system? When the emphasis shifts away from law enforcement into health and social services, it will be very important to ensure that there are enough qualified staff to cope with the increase in people who need care. CICAD has already done a great deal to train drug treatment counselors, nurses, social workers and medical personnel. But much remains to be done, including making sure that every medical and nursing student is required to take a course in the addictions. Decriminalizing drug use does not mean that all transactions in dangerous drugs would become legal. Selling drugs, producing them and transporting them would still be criminal offenses under national laws and international treaties. This carries its own set of contradictions: my use of cocaine is not an offense, but under the Conventions, possession of cocaine is still a crime. Obviously, in order to use cocaine, I must possess at least a small quantity of the drug. Some national laws have decriminalized drug use and possession of small amounts “for personal use” (and legislators have debated for years what constitutes “personal use”). In many other countries, the predicate offense is “possession” of drugs, which leads to felony charges. Let us say that use and possession of small quantities of drugs are not criminal offenses—and not even misdemeanors punishable with a fine—the street dealer who sells the drug is, under the Conventions and most national laws, still a criminal offender. I can buy my cocaine from him without penalty, but he sells it to me and therefore commits a crime. This distinction between buyer and seller of illicit drugs can perhaps be compared to the regulation of alcohol and tobacco: the merchant who sells alcohol to a minor can be prosecuted, fined or his business shut down for a period. The minor is not prosecuted or fined. A new drug policy must be absolutely clear about the legal treatment of the dealer in illicit drugs and the buyer or user. Legalization The President of Uruguay recently called for the legalization of marijuana in his country. President Mujica was entirely clear that legalizing marijuana would remove any criminal or administrative penalties associated with its use, possession, production and trafficking. Legalization would make it lawful to grow and process marijuana plants, sell marijuana at wholesale or retail, and pocket the proceeds. He suggested that the Government itself could grow and market the marijuana. Policy-making is never a clear science. It is an untidy mix of political, economic and social factors, pressures and vested interests who have put much time, money and effort into either maintaining or opposing the status quo. While Mujica did not elaborate on the consequences of marijuana legalization, we should drive the argument further and look dispassionately at some of the outcomes that such a policy might have. The police would not pursue marijuana traffickers, dealers or money-launderers, and thus be free to concentrate on other types of crime. Users of marijuana would not be arrested or prosecuted. Legalizing marijuana sales would allow the government to charge a sales tax or VAT, and thus raise some needed revenue. The Government would also be able to regulate the sale of drugs to minors, and ensure the quality of the drugs through inspection. Marijuana would, then, be treated like tobacco and alcohol—it would be regulated as a public health matter. Regulation might include prohibiting the sale, possession or use of marijuana in or around schools, hospitals, churches or Government buildings, for example. A regulatory approach might prohibit marijuana use by members of the military and the police, and those who work in high-risk occupations, such as train and bus drivers, air traffic controllers, health care personnel and teachers. Measures could be taken to ban the sale of marijuana to minors, the mentally impaired and pregnant women. Police would arrest drivers under the influence of marijuana, and subject them to the same procedures as those arrested for drunk driving. So far, some of the arguments in favor of legalization or regulation seem attractive. However, legalization has a down-side, which is the potential for an explosion of drug use, with the consequent harm to human health. If Governments would undertake a long-term program of preventing drug abuse and treating the consequences, the health impact could be mitigated. Such a program—to be set in place and funded for at least a generation, and maybe more--would probably be well received by the general public as being a positive step at home, not a law enforcement action in a far-away land. Drug abuse prevention would take place at home, in the schools, and in sports teams, youth clubs and religious institutions. Preventing drug use should begin at an early age, when teaching children to wash behind their ears, brush their teeth and eat healthy food. Treating drug dependence must be a health priority, in order to return the drug addict to a functioning life. While legalization or regulation would set stringent administrative controls over dangerous drugs, it is difficult to imagine that the drug cartels would give up their huge profits without a whimper. Most probably, they would try to create a black market of sales of drugs to minors, in order to maximize their profits. It is also likely that they would simply use their existing distribution networks to sell products other than drugs, such as smuggled weapons, people sold into prostitution, pirated music and fake designer clothes. The third way The quandary that some policymakers face as they listen to calls for legalization of drugs or decriminalization of drug use is this: on the one hand, they want limit people’s access to drugs in order to protect public health and safety, while on the other, they are tempted to ease the extremely heavy burden of funding the seemingly endless “War on Drugs”. There is a third and better policy, which is to reduce the demand for drugs around the world. Although many governments pay lip service to programs that seek to prevent drug use and treat drug addiction, their efforts to fund them have often been puny by contrast to the vast sums of money poured into law enforcement and the criminal justice system. Those calling for decriminalization of drug use should at the same time make a commitment to make a significant increase in their drug demand reduction budgets and staffing over the long term. Demand reduction programs should be brought into the mainstream of existing health care and social programs, to build on the resources and capacities already in place. And it should become government policy to minimize the stigma with which drug-dependent individuals are too often regarded: they are people with an illness – albeit of their own making—and need qualified care. Care will of course include dental treatment, eye examinations, testing for and treatment of HIV/AIDS, sexually transmitted diseases, and hepatitis, among other health problems.