Richard Hurley: Replace the war on drugs with a war on harm

Richard HurleyIllicit drugs should be decriminalised. Prohibition has not achieved the stated aim of reducing supply, and criminalisation acts as a barrier to reducing harm in users. Punishment of drug users through criminal justice is costly; is ineffective in terms of public health, particularly the spread of HIV; and infringes on the human rights of users, denying them dignity and autonomy.

These themes underpinned the 21st conference of the International Harm Reduction Association last week in Liverpool. Programmes to reduce harm in drug users, such as provision of clean syringes and opioid substitution therapy, help users to stabilise their lives, and make a choice of abstinence possible.

Many of the dangers that the popular press and politicians associate with drugs arise not from the drugs themselves but from the black market in which they are traded and consumed (see, for example, A review released last week shows a strong connection between law enforcement surrounding drugs and more gun violence and homicide.
Between 11 and 21 million people in more than 150 countries inject illicit drugs worldwide. Most are in China, the United States, and Russia. An estimated three million worldwide are HIV positive, and infections can spread rapidly among drug users.

Many countries embrace the concepts of harm reduction, which is supported by international health agencies. Harm reduction works: the UK, which has established programmes, has only about 150 new HIV infections a year among injecting drug users compared with Ukraine, for example, where there are 7000. And harm reduction is cheaper than antiretroviral drugs, at about $39 compared with $2000 for every disability adjusted life year saved, says the Commission on AIDS in Asia.

Needle programmes exist in about 80 countries, and the heroin substitute methadone is available in 65, but coverage is generally nowhere near that needed. Only three US cents are spent in poorer countries per injector per day—at least 15 times less than needed.

Harm reduction is hampered by criminalisation, for example, methadone is illegal in Russia, and safe injecting rooms are not allowed in the UK. In his opening address at the Liverpool conference, Michel Sidibé, executive director of UNAIDS, called for an end to the criminalisation of drug users worldwide, but three prohibitionist United Nations conventions on the control of drugs make alternative approaches difficult. The conventions do afford some flexibility in interpretation, however, which countries such as Portugal and Argentina have explored. Criminalisation can also lead directly to human rights abuses—for example, the torture and forced treatment of heroin users Cambodia (see, for example,,8599,1967672,00.html).

Recent events expose the UK’s hypocritical attitude to drugs. In April the Royal College of Nursing said that the National Health Service should prescribe heroin to users. Both Conservatives and Liberal Democrats indicated in the run up to the UK general election that they are prepared to discuss a change in punitive policy in the UK. However, we’ve just witnessed the government sacking its own drugs adviser Professor David Nutt because it didn’t like his advice (BMJ 2009;339:b4563, doi: 10.1136/bmj.b4563). And then we saw a hysterical rush to criminalise thousands of people who use mephedrone (BMJ 2010;340:c1784, doi: 10.1136/bmj.c1784). Clearly prohibitionist ideology, politicking, and pandering to a reactionary popular media still carry at least as much weight as scientific evidence.