Drug policy affects health. Legalisation is needed not because drugs are safe but because they are risky, write members of the Global Commission on Drug Policy, Michel Kazatchkine, Pavel Bém, and Ruth Dreifuss

Doctors are well aware of the health risks associated with different illicit drugs.
What is often underappreciated, though, is that however risky a drug may be, its risks inevitably increase when it is produced, sold, and consumed in an unregulated criminal environment, as the Global Commission on Drug Policy’s latest report, Regulation: The Responsible Control of Drugs, discusses.

Drugs of unknown potency and purity, often cut with other agents, are sold without quality control or any guidance about content, risk, or safety. Consider the epidemic of overdose deaths associated with street heroin cut with fentanyl in the US and Canada for the past three years, now also occurring sporadically in parts of Europe. These risks stem directly from prohibition, which, rather than reducing drug markets, has generated a huge global illegal trade.

Prohibition drives epidemics of infectious disease
Prohibition and enforcement-based drug policy have other negative effects on health. Criminalization of drug use drives people to inject in risky conditions and has led to an epidemic of HIV and hepatitis C among people who inject drugs. Two thirds of the estimated 16 million people who inject drugs globally are infected with hepatitis C virus (HCV), and one in seven have HIV. Incarceration is the origin of up to 75% of tuberculosis cases among people who use drugs. Current epidemic trends in HIV, HCV, and multidrug resistant TB prevalence in eastern Europe underscore the health harms of criminalization and punitive drug laws.

In many jurisdictions, restrictive policies also limit access to proven harm reduction interventions, including provision of clean needles and syringes and agonist maintenance therapy. The current drug control regime also obstructs the provision of opiates for the management of pain and for palliative care in much of the world.

Policy reform must start by redefining drugs as primarily a health and social, rather than a criminal, matter. For several years, the Global Commission on Drug Policy has been calling for an informed and evidence based global drug policy debate, and the commission recommends prioritising individual and public health and safety.

Stop criminalising people who use drugs
This must start with decriminalizing drug possession for personal use and ending incarceration of people for minor drug offenses. The commission advocates for a model of decriminalization that removes all penalties for possession of small quantities of illicit drugs. Decriminalization of possession for personal use is supported by WHO and several other medical bodies. De-emphasizing law enforcement that focuses on possession and minor trade would generate savings that could be invested in harm reduction, drug treatment, and social interventions.

Decriminalization will not, however, reduce the risks associated with a criminal market providing captive consumers with more and more addictive and dangerous products. This is why the control of drugs should shift from unregulated criminal markets to government, with regulation similar to that for other risky products, including alcohol, tobacco, and some legal drugs.

Legally regulated supply should not be misrepresented as uncontrolled liberalization but instead as enabling responsible authorities to control which drugs are available, where, and how. Regulating risk can be applied to all elements of a drug market, from the licensing of producers and safety of products (as it is the case for equivalent medical products) to the price, potency, and packaging, and modalities of sale.

Take back control from criminal markets
Access and availability can be regulated in terms of age but also by licensing vendors or buyers or with medical prescription models. None of this menu of regulatory tools, nor the expertise of regulatory agencies, are available in markets under criminal control. Obviously, the more potentially dangerous a drug, the more stringent regulation should be. Drugs should be regulated not because they are safe but because they are risky.

There is still a long road ahead before drugs, starting with the less harmful ones, are legally regulated. Implementation will have to be incremental, careful, and continuously and independently evaluated. Yet it is time to begin the journey towards new policies that will bring together in a coherent manner, responsible management of drug related risks by governments and better individual and public health.

Drug policy has huge health implications, and doctors have an essential part to play in its reform.

Michel Kazatchkine, doctor and former executive director of the Global Fund to Fight AIDS, Malaria, and Tuberculosis.

Pavel Bém, doctor and former mayor of Prague and drug czar of the Czech Republic.

Ruth Dreifuss, former minister of health and president of Switzerland.

The Global Commission on Drug Policy is a panel of world leaders and experts that campaigns to bring to the international level an informed, science based discussion about humane and effective ways to reduce the harm caused by drugs to people and societies. Its latest report is Regulation: The Responsible Control of Drugs.

Competing interests: None declared.