http://www.compagnieasphalte.com/images/map23.php Hitler suffered from severe stomach cramps and colossal flatulence. He convinced the hypochondriac, Hitler, to swallow capsules of Mutaflor, which contained a strain of hydrolyzed E. Morell had succeeded where other doctors had failed. In addition, Morell was rotund, suffered from excessive sweating, halitosis and had a distinct body odor. Morell for his fragrance, I employ him to treat me medically. In August of , Hitler became seriously ill. Up until that moment, he had been receiving daily injections of vitamins and glucose, but they were no longer effective.
Nervously, Morell turned to more medically dubious animal hormones. The medical medley increased from there. Soon Hitler was on uppers and downers in tandem. If he needed to wake, then he received injections of ever stronger stimulants. In , Morell began injecting high doses of opiates into Hitler. His health was declining, often appearing stooped and considerably aged according to those closest to him.
It made Hitler euphoric, and with the frequency of high doses injected, it seems likely that he became addicted.
But soon even Eukodal would not be enough. This time, Dr. Erwin Giesing treated Hitler and he had a favorite remedy of his own called cocaine. From then on, the Fuhrer received Eukodal combined with two doses of high-grade cocaine daily. Wikimedia Commons Adolf Hitler. The Allies began bombing pharmaceutical companies, such as Merck in Darmstadt in December of Suddenly production of Eukodal came to a halt. In January of , Hitler ran out of opioids just before he descended into the Fuhrerbunker. According to Ohler, Hitler turned into a physical and mental wreck. He had been held together by his injections and now the most important substances for him to function, the opioids, were gone.
In the last days of the war, Hitler granted him permission to leave the Fuhrerbunker. Morell escaped Berlin on one of the last flights out. Hitler, without his doctor, allegedly flew into a rage informing those around him that he would commit suicide. In places where there is significant HIV transmission linked to unsafe injection, denying treatment to HIV-positive PWUD both ensures that they and their injection and sex partners will be at risk of HIV and violates the rights of all concerned.
People who use drugs in many parts of the world have no access to HCV screening and treatment. Interferon-based therapies as the treatment of choice are giving way to direct-acting antivirals DAA marketed since The cost of the DAAs, however, is orders of magnitude greater than interferon-based therapy. In this regard, there may be many applicable lessons from the well documented efforts that succeeded in bringing down the prices of HIV medicines.
Policy-making on HCV treatment is replaying a number of misinformed tropes from the HIV past, including the idea that PWUD — or even those with any history of drug use — do not adhere well to treatment and are not worthy of expensive care. From Wolfe et al. Unsafe injection-linked transmission of HIV sometimes overshadows sexual transmission in programme priorities for PWUD, but both are essential. UN reports and research in many settings have for years highlighted the importance of condom programmes for all men who have sex with men MSM , and particularly those who use drugs either to enhance sexual pleasure, to lower sexual inhibitions, to escape or cope with situations of discrimination, persecution, or uncertainty about sexuality, or for other reasons.
The UN recommendations do not include a number of interventions for which an evidence base exists to justify their contribution to an HIV or HCV response. Supervised injection sites are an example. In a number of European countries, Australia and Canada, there are legally sanctioned indoor locations where people can inject and sometimes smoke and inhale illegal drugs under medical supervision, obtain clean equipment, be referred to OST and learn HIV and overdose prevention education.
The harm reduction intended by these facilities is not only with respect to HIV transmission but also to prevent mortality and other adverse outcomes of overdose, as well as to reduce unsafe disposal of syringes. Preventable outbreaks of HIV in recent years have constituted graphic real-life demonstration of the value of ready access to harm reduction services and the cost of impeding access to them. EECA bear a heavy burden from the neglect of harm reduction measures.
Harsh anti-drug policies and moral judgments against PWUD contribute to making health services for this population a low political priority. In pure fiscal terms, preventing HIV through harm reduction measures should be an easy sell. Cost-effectiveness is high, and start-up costs for these services are low. But harm reduction continues to be resisted as a funding priority in too many countries. Civil society advocacy continues for governments to provide the funding no longer available from the Global Fund, but it is clear that when it comes to politics harm reduction will remain a hard sell in many places.
Some people who previously injected heroin shifted their consumption to these new stimulants. But heroin is injected two or three times a day, and the stimulants six to ten times. The number of persons injecting drugs is estimated to have risen from about 17 in to about 20 in — and with riskier and more frequent injection — and harm reduction services were largely curtailed in In Greece, even before the severe economic recession of —09, harm reduction services for PWUD were provided at a relatively low level of coverage.
For most of the period since the emergence of HIV as a public health problem, the US government banned the use of federal funds for NSP, though some states and municipalities supported them. Almost half the new infections were among women, and they spanned a wide age range as it was found that injection took place in multi-generational groups. For policy-makers interested in hard numbers on the value of comprehensive HIV and HCV prevention, the cost savings associated with these services are considerable.
Evidence from a number of countries indicates that drug law, policy, and law enforcement practices can be barriers to provision and use of harm reduction and other HIV prevention services. In some cases, there are legal prohibitions against or poor legal grounding for harm reduction services for PWID.
The case of the Russian Federation is extreme: OST is prohibited by law though opioid injection is widespread, and NSP have been allowed only sporadically and are generally not supported by the state. NSPs are banned by law or effectively blocked by policy, including zoning restrictions, in many jurisdictions.
While OST may not be banned outright or explicitly, in some countries methadone and buprenorphine, the medicines used most in OST, may not be registered or authorized for this use. There are many other ways in which drug-control laws or regulations limit the use or usefulness of OST, including arbitrary restrictions on numbers of patients; arbitrary limitation of dosages and the duration of treatment; prohibition of take-home doses; periods of drug or alcohol abstinence or having to try other kinds of treatment as a prerequisite to starting OST; limiting the neighborhoods or geographical zones where OST services can be offered; lack of integration with accessible community health services so that people have to make special trips for OST; and lack of access to OST in prison and pretrial detention.
According to a estimate by Harm Reduction International, significant drug injection is reported in countries, but only 90 have functioning NSP, most of which have very low coverage. In some jurisdictions, local health authorities have to declare emergencies periodically to continue to justify NSP; some states simply ban these services. In many countries, drug paraphernalia laws undermine NSP, often prohibiting the possession of syringes. In some countries health workers are required or strongly encouraged to register PWUD, and registries are turned over to the police see web appendix I.
In some places, there is no legal prohibition of possession of drug paraphernalia, but police nonetheless use possession of injection equipment as grounds for stop-and-search, arrest, and detention. The performance of drug police in many countries is judged by the number of arrests they make, and PWUD are likely to be easier to find to help bolster arrest totals than major drug traffickers.
It is perhaps for this reason that police may target facilities providing health and harm reduction services to PWUD. Crackdowns and other intensive policing, often targeting low-income, minority, or marginalized persons, can undermine harm reduction and add to drug-related risk. According to WHO, tuberculosis is the single most important cause of death among people living with HIV, responsible for one in four deaths. Some studies suggest that people who use drugs present later than other persons to seek TB testing or care. Diagnosis of TB with microscopy identifying acid-fast TB bacilli and molecular DNA detection using geneXpert systems is recommended, but in Central Asia, for example, TB diagnosis is still made mostly using chest radiography though x-ray results are compromised by the presence of HIV.
The importance of integrated and sustained care cannot be overstated. Deiss and colleagues report cases in which TB treatment was integrated with treatment for drug dependence but was lost after people left drug treatment. Family, friends, and neighbors were helped to understand the importance of treatment and to provide support to patients. The cost compared to hospitalization was small. A study in Malaysia demonstrated that TB screening and care in drug rehabilitation centres and facilities offering OST was a very effective targeting strategy. Possession defined, by UNODC as possession of drugs for individual use, was the most frequently reported crime globally Figure In some countries that have decriminalised drug use, possession for individual use remains an offense, or the amount defined for non-criminalised individual use is so low that possession is effectively a crime.
UNAIDS estimates that in places where drug use and small-scale drug possession are criminal offenses, the majority of people who use drugs may wind up in the custody of the state at some time in their lives. There is, moreover, no evidence that incarceration is an effective deterrent for drug use either in prison or afterward. Several studies conclude that criminal prosecution of minor use and possession infractions does not have the deterrent effect with respect to drug use, possession, or minor crimes that supporters of these sanctions claim.
A classic study comparing cannabis use in San Francisco and Amsterdam — cities with very different approaches to cannabis regulation — found that the partial decriminalisation of cannabis in Amsterdam was not associated with increased use or possession, and the rigorous criminalisation in San Francisco was not associated with reductions in use or possession. From Uprimny et al. Table 1 shows the most recent information for selected countries on the proportion of people incarcerated for drug offenses among all incarcerated persons.
But, as noted by Penal Reform International in a report, mandatory prison sentences are attached to possession of even a small amount of drugs in many countries. Incarceration for drug offences as percentage of all incarceration in selected countries. Aggressive prosecution of drug offenses along with mandatory minimum sentences for certain infractions helped to make drug-related mass incarceration a major engine for growth in US state and federal prison populations beginning in the s Figure From Snyder and Mulako-Wangota, The racially disparate application of drug-related incarceration in the US is a prominent feature of mass incarceration.
Persons of color, particularly African Americans, have been disproportionately affected by drug-related mass incarceration. In , amongst men aged 30—34, 1 in 13 African Americans were in prison, 1 in 36 Hispanic Americans, and 1 in 90 whites, though prevalence of drug use in these populations was similar. From Carson Bureau of Justice Statistics , Beginning in the late s, New York City undertook to clamp down on cannabis infractions, resulting eventually in nearly a half million arrests through — of young people for the most part — for minor cannabis infractions. From Snyder, H.
The striking racial disparity in arrest and incarceration in the US parallels racially disparate patterns of HIV, and some investigators conclude that the two phenomena are closely related. Racial and ethnic minorities are over-represented in prison and in arrest figures in countries other than the US, including aboriginal people in Canada and Australia and people of African origin in Brazil, but the contribution of drug-related arrests and convictions to these patterns is not clear. In October , the US government announced that it would release 6, federal prisoners incarcerated for minor drug offenses, meant to be the first tranche in a release of a possible 46 federal prisoners of the convicted of federal drug offenses.
Table 1 illustrates a striking gender disparity in drug-related imprisonment.
While in any given drug market there are likely to be many more men than women involved in use, possession, and sale of drugs, a higher percentage of women than men are imprisoned because of drug-related convictions in virtually all countries where data exist on this point. Giacomello asserts that a large proportion of women convicted for small-scale sale and other non-violent offenses in Latin America are uneducated women living in poverty who had limited opportunities to earn licit income.
Overall in Europe and Central Asia, about one quarter of women in state custody are convicted drug offenders. Women who use drugs in prison are also at risk of HIV from sexual violence or unprotected coercive sex as well as from drug use. Pretrial detention of children and adults for drug offenses also poses health risks web appendix IV. The over-reliance on incarceration as a response to drug use may have a profound effect on the well-being of relatives and partners of people imprisoned for drug offenses.
Many studies document that incarceration of a family member imposes unique forms of financial strain, psychological distress, and logistical hardship on the family and is associated with deleterious health outcomes. Caring for a family member who uses drugs has its own challenges, but incarceration may generate further difficulties by increasing geographical distance between PWUD and their families, erecting barriers to communication, and subjecting family members to correctional surveillance and regulations when they maintain contact with their incarcerated loved one.
See web appendix V. A survey of people visiting family members in Mexican prisons indicated similar kinds of challenges in that setting. Prisons and pretrial detention facilities worldwide are high-risk environments for infectious disease transmission.
UN agencies estimate that prevalence of HIV, other sexually transmitted diseases, hepatitis C and hepatitis B infection, and TB is from 2 to 10 times higher in prisons than in the community. In Argentina, for example, people living with TB who had a history of incarceration were 6 times more likely to be HIV-positive and 18 times more likely to have HCV infection than the general population. Drug injection does take place in prison, even where very restrictive measures are in place. As noted above, risk of sexual transmission of HIV may persist after prison if incarceration destabilises existing sexual relationships.
Numerous studies have documented HIV and HCV transmission in prison linked to drug injection, and others have demonstrated high prevalence of HIV and HCV among formerly incarcerated persons compared to other populations. There is not a recent comprehensive accounting of HIV prevalence in prison worldwide. People living with HCV infection are also over-represented in prison in many countries.
HCV prevalence in prisons may be high even where harm reduction services are available in the community. The Commission sought to investigate through mathematical modelling the contribution of incarceration to HCV transmission among PWID in several countries.
Therapy Manuals for Drug Abuse, Manual 2. The numbering of the schedule classifications in the convention is somewhat counter-intuitive. In Vietnam, compulsory rehabilitation centres existed for both people who use drugs and sex workers, but in it was decided to discontinue detention of sex workers in these centres. Although he is constantly distressed, he leaves the hospital and tries to meet good In other contexts, abuse has referred to non-medical or unsanctioned patterns of use, irrespective of consequences.
Given the high incarceration rate amongst PWID — and association between HCV infection or high risk behavior and a history of incarceration, , — it is unsurprising that incarceration could play an important role in driving HCV transmission among PWID. TB in prison and other closed settings has long been a public health concern, but TB risks increase in the presence of drug injection in closed settings. Overcrowding, poor sanitation, inadequate ventilation, the relatively high prevalence of HIV, and the insufficiency of basic services all contribute to TB transmission in prison.
Infectious disease in prisons is a heavy burden in EECA. Central Asia is estimated to have the highest rate of HCV prevalence among prisoners of any region. It is an international norm that people in prison and other custodial settings have a right to health services at the level of those offered in the community in their jurisdictions. Making these measures a reality, however, is proving challenging. OST has been shown in many countries to be very effective in custodial settings where people can be directly observed in taking medicine and can be followed if they have problems with dosage.
As was noted by authorities in Scotland in the s, however, it is as unrealistic to aspire to a drug-free prison as it is to aspire to a drug-free society. As noted by Kopak, the failure to provide effective treatment and care to people with problem drug use in the enormous US prison population perpetuates crime when people are released and returned to their previous circumstances.
Provision of sterile injection equipment in prison is even rarer than OST, having been established and sustained in prisons in only eight countries, mostly in Western Europe. But in the case of Germany, when closure of NSP in prisons was proposed, prison workers protested, knowing that the programme protected them from injuries with contaminated needles as well as protecting the prison population. HCV diagnosis and treatment services are limited in prisons in many countries. Diagnosing HCV is not a good investment if treatment cannot be provided, and the cost of HCV medicines as well as the need to ensure treatment over a long period are likely to have impeded treatment as a priority in prisons, especially in Western Europe where some drug sentences are relatively short.
HIV and HCV services other than these harm reduction measures are equally important and frequently lacking in prisons and pretrial detention settings. A study of randomly sampled prisoners found that HIV-positive prisoners with a history of drug use were more likely to be receiving ART partly because they had been incarcerated for longer periods than other prisoners.
Prisons are an extremely high-risk environment for tuberculosis, but prison TB services remain inadequate in many countries, making TB a risk of incarceration. The significant representation in prisons in many countries of people with HIV, people who use drugs, people living in poverty, and formerly incarcerated people means that many people in custodial settings have been exposed to TB before they even face the TB risks of prisons. TB testing does not take place systematically in many prisons.
Capacity to address HIV, HCV and TB in prisons, using the best medicines and diagnostic tools available in the community, is obviously dependent on financial resources. Even where services are available to people in state custody, delivering them in a patient-centred way is a particular challenge given the coercive nature of incarceration. Another central challenge is ensuring continuity of care upon release. Previously unpublished work in northern California by Commissioner Megan Comfort and colleagues illustrates that a lack of discharge planning and coordination of services virtually ensures the disruption of care.
Among the 60 persons living with HIV in an in-depth qualitative study, many described being released from county jail around midnight. Although it was standard practice to provide a day supply of medications at release, if people were discharged when the jail pharmacy was closed, they left with no medications at all.
Furthermore, participants characterised leaving jail in the middle of the night as generally destabilising for them, especially when public transportation was not running. The importance of continuity of care is illustrated quantitatively using data from the US and Canada reported by Iroh and colleagues Figure From Iroh et al.
Drug overdose should be an urgent priority in drug policy and harm reduction efforts. Overdose can be immediately lethal and can also leave people with debilitating morbidity and injury, including from cerebral hypoxia. A systematic global review concluded that overdose was a leading cause of mortality of PWID in all regions.
In the European Union, drug overdose accounts for 3. Data on overdose are not systematically reported in many countries, but survey data in a number of countries indicate that nonfatal overdoses are not rare events among PWID. In , WHO issued its first guidance on community management of opioid overdose, underscoring evidence accumulated over four decades of the effectiveness of naloxone in averting death from opioid overdose.
Naloxone administration by police or emergency medical teams as well as by organizations providing services to people who use drugs has been documented to avert many thousands of deaths. The literature suggests there are a number of ways in which pursuit of drug prohibition can exacerbate overdose and the risk of death from overdose. These include:. Overdose risk has been linked to lack of access to treatment for dependence on opioids, including for people using prescription opioids. Vulnerability to overdose is very high when people are released from abstinence-based detoxification and residential programmes or if they are abruptly dropped from medication-assisted maintenance therapies.
In recent years, heroin sold on the street in North America and Europe has been found to contain anthrax, fentanyl, and benzodiazepenes in addition to more benign additives such as caffeine and sugar. Countries that pursue the goal of drug prohibition may object to heroin-assisted therapy as feeding rather than eliminating an addiction. Policing and police crackdowns can add to the risk of overdose. When police pressure leads to injecting hurriedly without testing the strength of drugs, overdose risk increases. In countries where drug use itself is criminalised, people experiencing overdose may not seek emergency help if it comes in the form of police with authority to arrest them.
A study in New York City found a strong correlation between police activity and overdose deaths, which the authors suggested was due to the reluctance of people who injected drugs to seek help for fear of arrest. Multiple studies confirm that the period soon after release from prison is a time of very high overdose risk. Between and , for example, the SIS in Vancouver, Canada, witnessed overdoses among people using the site, but there were no deaths. Pharmaceutical technology has made possible a range of formulations and packaging of prescription medicines, especially opioids, that are designed to reduce the possibility of non-medical use of these medicines and overdose.
These include formulations that are resistant to crushing, chewing, smoking, dissolving and injectability; extended-release formulations; addition of naloxone or other aversive ingredients to the formulation; and formulations that chemically isolate the active form of the opioid. Advocates for improved health services for PWUD have long asserted that naloxone should be widely available, even without a prescription. But naloxone remains out of reach in many places because of tight legal and regulatory restrictions. Part of the challenge in some jurisdictions is that physicians fear legal liability in prescribing naloxone, just as people who may witness an overdose and be in a position to assist may fear legal liability in administering naloxone if something goes wrong.
In many countries, PWID fear health services but may frequent pharmacies for injection equipment and other supplies. They found a variety of legal barriers and practices. Even where naloxone can be prescribed by any physician, it was unlikely to be stocked in pharmacies but rather supplied directly to emergency personnel under so-called standing orders. Similarly, in China only health facilities could receive and use naloxone. Since the study by Hammett and others, there have been some positive changes in the US.
In addition, as of , 14 US states have authorized over-the-counter — that is, non-prescription — sale of naloxone in some pharmacies to some first responders or family members. A small minority of people who use drugs develop drug dependence. But in many parts of the world, many PWUD are assumed to have problematic use or to be criminals, and compelling them to undergo drug treatment is a widespread practice. Human Rights Watch did ground-breaking from to , documenting heinous human rights abuses in these centres — including many forms of forced labour, torture, beating, humiliation and degradation, and denial of basic health care and adequate sanitation and food.
Compulsory drug detention centres are extreme in the scale and nature of abuses committed in the name of treatment, but there are many other examples of abusive and scientifically unsound practices brought to bear to address drug dependence. In many countries, treatment of drug dependence is one of the most unregulated and unmonitored of all health services, left often to private actors not required to adhere to standards of quality and clinical soundness.
Though there are general recommended standards and position papers from the UN, there are no agreed quality-control standards approved by UN member states. Coercion to enter treatment, with or without the help of local police. In the Russian Federation, there are cases of family members colluding with treatment facilities effectively to abduct people and deliver them to treatment centres. Some private treatment facilities lock people up and even chain them to beds or trees without offering them any means of challenging or appealing involuntary commitment.
In Nigeria, young people report abusive behavior by the police, in some cases when they are taken to facilities that are meant to offer health services. See web appendix IX. Decades of research on OST have helped to inform consensus on treatment standards and good practice. In the European Union, for example, nearly all countries have OST minimum standard and quality-of-care guidelines, though they often do not have such guidance for treating non-opioid dependence. With regard to dosage, there are many controlled studies and research reviews indicating that higher doses of methadone in OST programmes are associated with better retention in and outcomes of treatment as well as lower likelihood of use of illicit drugs.
In a number of European countries and Canada, OST is complemented by heroin-assisted therapy HAT usually for the limited number of people with long-time use for whom other medication-assisted therapies have not had the desired results. A substantial body of research, mostly from the Global North, includes several meta-analyses and large evaluations of drug dependence treatment investigating these factors. Options for treatment of dependence on many types of psychoactive drugs are very limited and remain a challenge for addiction science.
Research on new treatments for dependence on stimulants, including amphetamine-type stimulants and cocaine, has been called for by health professionals for some time, particularly medication-assisted treatments that would be the analogue of OST for opioids. There remain many gaps in access to and affordability of care for those who need it. The annual report of UNODC regularly documents drug seizures and drug crop production but only for the first time in reported information from UN member states on availability of treatment for drug dependence.
The information from countries reflects only the existence of services and a rough estimate of the level of coverage low, medium, high and says nothing about quality. Cognitive-behavioral therapy, for example, is frequently recommended to treat dependence on stimulants for which there is not currently a consensus recommendation for medication-assisted therapies. But it is virtually unavailable in Africa and much less available in Asia and the Americas than in Europe. Drug dependence can be impoverishing, and treatment of it can be expensive.
Subsidized treatment slots may be scarce and waiting lists long, even in countries with well-developed health systems, as in Western Europe and Canada. In many countries, women are particularly disadvantaged by the lack of access to good-quality, affordable treatment for drug dependence that is tailored to their situations and needs.
In EECA, for example, women in some countries would be justified in fearing that just the act of seeking treatment would brand them as users in official drug registries, which could trigger loss of child custody in some circumstances. Pregnant women who use drugs are often confronted with concerns about their newborns that are not scientifically sound.
A global review by a UN-convened group of experts in concluded that treatment programmes for women rarely account for the differences between men and women in the speed with which they may develop drug dependence, their responses to varied forms of treatment, and the psychological co-morbidities with which they present. Numerous countries have established special drug treatment courts, which are generally meant to offer court-supervised drug treatment to as an alternative to incarceration for some categories of drug offenses.
Emerging evidence raises concerns about some of these models. See web appendix X. Many drug courts as well as other treatment providers use drug testing, not always in rights-based ways. See web appendix XI. The Single Convention on Narcotic Drugs of has the dual purpose of 1 ensuring that controlled substances, including opioids, are available for medical and scientific purposes and 2 preventing their misuse and diversion.
WHO explicitly highlights the role of drug control policy as a barrier to access to licit controlled medicines:. Yet the obligation to prevent abuse of controlled substances has received far more attention than the obligation to ensure their adequate availability for medical and scientific purposes, and this has resulted in countries adopting laws and regulations that consistently and severely impede accessibility of controlled medicines. There are numerous ways in which drug control policy and regulations exceed the measures recommended in the UN drug conventions and contribute to impeding access to and utilisation of controlled medicines , Table 2.
Even-numbered columns include as one of the controls in the estimations the proportion of the municipality with coca crops, whereas odd-numbered columns do not. This control is important to include to avoid confusing the effect of aerial spraying on health outcomes with the effect of coca cultivation on health outcomes. The inclusion of coca cultivation as a control does not change the results. All regressions include the following controls: age, age squared, health regime, municipal tax income, population, area in km2, rurality index, municipal spending on education and health, year and month dummy.
The fact that 9 months is included in parentheses because it refers to the amount of aerial spraying during the 9 months before birth is used in the model. Standard errors are in parentheses. Striking a balance in national policy between maintaining adequate access to and availability of controlled medicines and retaining strong measures to prevent diversion or misuse is an important goal.
Among the measures that countries should take to strike this balance, international bodies, including WHO and the Global Commission on Drug Policy, recommend the following:. Establishing a national authority for controlled medicines that enables health-care and law enforcement interests to be represented equally in policy-making and procedures;.
Ensuring competence of health professionals on the latest science of use of controlled medicines; and.
Monitoring to recognize and define points of high risk for misuse and diversion within the distribution system, and refining policies to address these specific points without undermining access to and availability of controlled medicines. Balanced policy on controlled medicines has been difficult to achieve in many countries in all regions of the world.
India, for example, is a major producer and exporter of opium destined for medical and scientific use. This led most institutions to refrain from stocking and dispensing opioids to avoid the legal complexities and punitive consequences. But changes are under way in India.
A civil society alliance, driven by the health and humanitarian need, helped to spearhead a amendment to the NDPS Act, which reoriented the law, incorporating simplified procedures for improving access and availability of opioid medications in the country. Nonetheless, practices cannot change overnight. Sustained advocacy and reorientation of training and research is called for. The challenge of ensuring adequate access to controlled medicines is related closely to the way in which international and national authorities assess the degree of danger or potential harm associated with specific substances.
For the international regime, the Single Convention article 3 explicitly confers on WHO the responsibility to judge whether substances are dangerous and in need of strict control. The numbering of the schedule classifications in the convention is somewhat counter-intuitive. The scheduling system of the drug convention on synthetic psychotropic substances is more straightforward, with Schedule I being the most restrictive and Schedule IV the least.
Widely cited articles in the Lancet in and report on exercises in which drug dependence specialists in the UK ranked drugs by their potential to cause physical harm to the user, their potential to induce dependence, and their harms to families and communities. Alcohol, which was deemed more dangerous than many controlled substances, is obviously not scheduled in the conventions. A later assessment by addiction experts from across the European Union made a similar ranking. In the international drug conventions, WHO is mandated to oversee the application of the latest scientific evidence to the classification of the potential harms of psychoactive substances, but its conclusions are not always the last word on these issues.
See web appendix XII. A large body of research has helped to advance many aspects of the drug policy debate. Opioid agonist therapy, for example, has benefited from decades of clinical research in numerous settings to the point where good practises are well documented and can be adopted and adapted readily. The benefits and cost-effectiveness of NSP and programmes to address opioid overdose are also supported by a strong research base that should inspire scaling up these programmes to reduce the needless morbidity and mortality suffered by millions because of the absence of these services.
The same is not true of empirical research on larger drug policy decision-making, including social science research on alternatives to traditional prohibition-oriented policy. Hall notes that funding research that would draw lessons on drug market regulation from alcohol and tobacco regulation, for example, has not been a priority of major research funders, especially compared to more abundant funding for neurological and clinical harms of drug use.
Academic debates abound on the physiological and psychological basis for assessing drug-use disorders. With cannabis having been the centre of drug policy reform discussions in North and South America and Western Europe, medical uses of cannabis are of great interest to researchers. Cannabinoids have been approved for medical use in numerous jurisdictions and have been the object of enough research to warrant systematic reviews and meta-analysis.
Both a review by Deshpande and an analysis by Madras undertaken for the WHO Expert Committee on Drug Dependence concluded that while there are many reports of benefits from medical cannabis users, there is a need for more controlled studies. The Expert Committee itself undertook to collect more evidence on medical use of cannabis and cannabis resin for a future comprehensive review.
There is also a need for research on the health impact of different patterns recreational use of cannabis — research that should be greatly facilitated by the availability of legal cannabis in more and more locations. At a time of enormous policy-level concern about dependence on prescription opioids, for example, there are a few ecological studies that suggest the possibility that greater access to cannabis might reduce use of opioids for pain relief. The Reference Group no longer meets as an independent body. We believe its job is not done, and it, or something like it, would be very valuable to reconstitute.
In some countries, there is a dearth of data on fundamental elements such as the extent and nature of drug consumption. Respected scholars who have endeavoured to bring the best new research to drug policy decision-making have sometimes been attacked for their efforts. People may become involved in drug markets for many reasons, but poverty and exclusion from mainstream economic opportunities are important factors in many cases.
Nonetheless, it is rare that drug policies are evaluated by the way that they affect people living in poverty or human development more broadly. Enforcing prohibition-oriented drug policy means not only policing use, possession, and sale but also terminating the supply of these drugs at the sources. Historically the obligations of obligations of international drug control have rested heavily on states in South America and Southeast and Southwest Asia to curb supply of coca leaf, opium poppy, and cannabis, rather than consumer countries of the North to reduce demand.
In spite of aggressive prohibition, these crops nonetheless are widely grown. Cultivator communities are typically located in regions or countries where basic state services are deficient and where there is an absence of health services and infrastructure. In UNODC estimated that some 4 million persons were in households deriving income from cultivation of coca leaf and opium poppy without attempting an estimate for cannabis , 8 and there is little reason to suppose that the figures today are smaller.
Decades of investment in initiatives to eradicate these crops have failed to make a sustained dent in global production. Figure 22 shows estimated production of opium poppy destined for non-medical use from the countries that account for the great majority of production.
Motivations for relying on drug crops for household income may differ, but the decision to grow drug crops is generally highly rational. Opium and coca are non-perishable, robust crops, well suited to the poor agricultural conditions in which farmers in coca, poppy and cannabis-growing areas often find themselves.
Another important factor that may influence the decision to grow drug crops is insecurity of land tenure or lack of access to land. Coca bush, for example, produces four to six crops per year after only six to eight months of growth of new bushes, whereas coffee and some fruits, for example, require a longer growth period before there is revenue.
Opium poppy yields returns after a short growing period and requires few inputs. In Afghanistan, according to Mansfield and Pain, poppy growing has at times enabled poor farmers to arrange land tenancy or sharecropping that would be impossible without the effective credit-worthiness that comes with poppy-growing. In the Andes, rural households have persisted in coca production in spite of herculean efforts to cut them off from this source of livelihood. Forcible eradication of coca — through burning, use of chemical herbicides or manual deracination — has been part of drug supply reduction strategies for decades.
Under Plan Colombia — , an average of , hectares per year in Colombia alone were subjected to aerial spraying of glyphosate — a product also known under the Monsanto brand name of Round-Up. That is, as eradication efforts intensified in one place, cultivation moved elsewhere. The health impacts of crop eradication have been relatively little studied. While the US provided high levels of assistance for the mobilization of the needed aircraft, contractors, and herbicide supplies, rigorous and independent evaluation of the health and social impact of aerial spraying were not a priority of Plan Colombia.
The study concluded that there were no significant risks to human health from the aerial spraying and that spraying was much safer than the alternatives of burning coca in farm fields or manual deracination of the plants. Numerous complaints of health problems associated with aerial spraying were made to human rights bodies and other authorities over the years.
The case was settled in before the International Court was to hold final hearings on the matter. Colombia reportedly provided compensation for damages to people and livestock and agreed to a buffer zone of no spraying near the border. Investigators at the Universidad de los Andes undertook research using a large data set capturing millions of individual records of medical consultations among people affected by unannounced incidents of spraying in the heart of the period of intensive spraying from to The authors also had daily data on the level of spraying in all the municipalities in Colombia.
Exposure to aerial spraying was significantly associated in this large sample with increased incidence of dermatological and respiratory symptoms in the 15 days following exposure to the herbicide. The relationship between spraying and miscarriages was somewhat stronger in low-income communities but also highly significant in higher-income municipalities.
Signaling an end to over 20 years of the practice, in May the government of Colombia decided to stop using aerial fumigation of coca fields. With respect to coca eradication and other forcible crop eradication programmes, the effects of exposure to herbicides are far from the only health concern. Farm households in the Andes have complained that aerial spraying and some other eradication activities have affected food crops or food from animal husbandry on which they are also dependent for income or direct consumption.
Crop eradication activities have forced poor rural households to be displaced, often to more marginal and hostile environments and at times with deadly consequences. In her extensive review of the history of forced eradication programmes, Buxton notes the following: About , households or over 1 million people were forcibly displaced and faced starvation and lethal epidemics of infectious disease during opium eradication campaigns in Myanmar in the mids. Displacement compounds socio-economic and cultural differences in diet, nutrition, health habits, and housing, and it can exacerbate or cause psychological problems associated with vulnerability and forced re-location such as post-traumatic stress disorder.
In addition to large-scale displacement and the disruption and poverty it brings, people who grow crops linked to drug production often face violence as a fact of life. Drug traffickers purchasing coca for the manufacture of cocaine or opium for heroin production for illicit markets may enforce the obligations of crop producers through violence.
UN Women in its pre-drugs UNGASS reflection concluded that crop eradication in the Andes destroys food crops that are the domain of women and enable them to have some economic autonomy in the household. In Africa, rural households depend on cannabis as a cash crop in numerous countries. In the Andes, one of the most important health consequences of crop eradication may in fact be the horrific violence being experienced in Mexico and Central America.
Some forced eradication programmes are judged by experts to be highly cost-ineffective, even without accounting for their impact on health. The United States [and its allies] are not going to go around assisting or participating in the destruction of poppy fields anymore.
The United States has wasted hundreds of millions of dollars doing this…. The public health harms of the pursuit of drug prohibition have led some cities and countries to rethink approaches to drug control. Their experiences with respect to many of the health problems described in previous sections are largely replicable and show the path to drug policies that support health and development and do not undermine human rights.
Opening its doors to the world brought Portugal a new place in international relations but also a flow of illicit drugs for which it was ill-prepared. By the s, the Portuguese people considered drugs to be their most pressing social problem. In , a multi-sectoral expert committee was convened by the national government to address the drug problem. Its proposed solution, eventually written into a law that came into force in , was to remove criminal sanctions from individual-level use and possession of all drugs. Individual-level drug infractions were still illegal but only under administrative law; they could not be punished by a prison sentence and were not attached to a criminal record.
Larger-scale offenses such as trafficking and sale of large amounts of drugs retained penal sanctions. The results of this experience may be judged by numerous outcomes, but for one of the main harms being addressed, unsafe injection-linked HIV transmission, the experience can be said to have succeeded.
As shown in Figure 25 , new HIV transmission among people who inject drugs declined from almost cases in to less than in From J. Critics of the Portuguese policy decision feared that drug use in Portugal would increase overall. Faced with an extensive open scene of heroin injection and a rapidly growing drug-related HIV epidemic in the late s, the Swiss public regarded drugs as a major social scourge. Like Portugal, Switzerland witnessed a precipitous decline in HIV incidence linked to drug injection and sustained that decline for a long period. The Czech Republic in the late s emerged from a long period of Soviet occupation at a time when HIV and drug injection were on the rise across Europe.
The Czech experience is especially notable as visionary health professionals helped lead the country to invest in low-threshold HIV prevention services before an injection-linked HIV could take hold, thus sustainably averting the run-away epidemics seen elsewhere in Europe. The drug law of the newly independent country established possession of drugs for individual use as and administrative — not criminal — infraction.
Drug use became a major political issue in the cities in the s. In , the Czech Republic changed its approach and criminalized penalties for all drug offenses involving a certain quantity of drugs that was not clearly specified. Remarkably, the government commissioned academic researchers to study the impact of the new law.
The Czech experience is also remarkable in that the national drug policy coordinators in the post-Soviet period have all been persons with frontline health or social service experience with people who use drugs. Decriminalisation of or at least removal of custodial penalties for minor drug offenses is more the rule than the exception in Western Europe. A review noted that EU countries have instituted a range of practices at the time of arrest or with respect to prosecution and sentencing that have effectively reduced criminal sanctions for minor drug offenses. These factors have together led to a situation in which HIV transmission by means of injection with contaminated equipment, while not eliminated, is no longer a significant contributor to HIV epidemics at a population level Figure With an annual incidence of Faced with dual epidemics of HIV infection and overdose, in the local health board declared a public health emergency in the DTES.
First, responsibility for the delivery of methadone shifted from the federal to the provincial government, resulting in a large increase in the number of individuals receiving methadone in the DTES. A fourth important development was the implementation of two supervised injection sites in Vancouver where PWID can inject pre-obtained illicit drugs under the supervision of nurses. The sites include a large stand-alone facility that accommodates an average of injections per day, and a smaller program within a large integrated day program and residence for people living with HIV.
The larger program, named Insite, has been shown to have reduced syringe sharing among PWID, and modelling studies suggest that the site is reducing HIV incidence. The HIV epidemic was successfully reversed through a comprehensive combination prevention approach involving harm reduction and addiction and HIV treatment. In addition to dramatic declines in syringe borrowing and lending, the annual HIV incidence rate declined from