It feels as if the tradeoffs involved in anti-drug policies are now up for discussion, in a way that they weren\’t 20 or 30 years ago. One signal is that the United Nations convened a special session about drugs back in 1998, with an underling theme of  of prohibitionism. Next week, the UN will convene another special session about drugs, and the tone may sound rather different. For a sense of how the argument is evolving, a useful starting point is \”Public health and international drug policy\”  from the Johns Hopkins-Lance Commission on Drug Policy and Health,  published at the website of the Lancet on March 24, 2016. \”The Johns Hopkins–Lancet Commission, cochaired by Professor Adeeba Kamarulzaman of the University of Malaya and Professor Michel Kazatchkine, the UN Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, is composed of 22 experts from a wide range of disciplines and professions in low-income, middle-income, and high-income countries.\”

Their report harks back to the tone of the UN discussions about drug policy in 1998 (with footnotes and references to figures omitted here and throughout):

The previous UN General Assembly Special Session (UNGASS) on drugs in 1998—convened under the theme, “A drug-free world—we can do it!”—endorsed drug-control policies with the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national laws in many countries. In pronouncing drugs a “grave threat to the health and wellbeing of all mankind”, the 1998 UNGASS echoed the foundational 1961 convention of the international drug-control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind”. But neither of these international agreements refers to the ways in which pursuing drug prohibition might affect public health. The war on drugs and zero-tolerance policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact. … The disconnect between drug-control policy and health outcomes is no longer tenable or credible.

The basic message here is simple enough: the goal of anti-drug policy is to improve public health. Thus, when evaluating anti-drug policy, it is reasonable to take into effect both how effective it is in reducing drug us and improving health, but also how the enforcement effort itself may be adversely affecting health health. Murders by drug cartels as one of the more obvious examples, but the Commission quotes a provocative comment from \”former UN Secretary-General Kofi Annan, `Drugs have destroyed many people, but wrong policies have destroyed many more\’.\”

Here are some of the tradeoffs of anti-drug policy as laid out by the Johns Hopkins-Lancet Commission. As a starting point, the gains from existing prohibitionist policies typically need to be phrased in terms of \”well, maybe they discouraged drug use from getting a lot bigger,\” because it\’s hard to demonstrate that drug use has been falling in more than a modest way.

In 1998, when the UN members states declared their commitment to a drug-free world, the UN estimated that 8 million people had used heroin in the previous year worldwide, about 13 million had used cocaine, about 30 million had used amphetamine-type substances (ATS), and more than 135 million were “abusers”—that is, users—of cannabis. When countries came together after 10 years to review progress towards a drug-free world in 2008, the UN estimated that 12 million people used heroin, 16 million used cocaine, almost 34 million used ATS, and over 165 million used cannabis in the previous year. The worldwide area used for opium poppy cultivation was estimated at about 238 000 hectares in 1998 and 235 700 hectares in 2008—a small decline. Prohibition as a policy had clearly failed. … North America continues to have by far the highest rates of drug consumption and drug-related death and morbidity of any region in the world, and drug policy in this region tends to influence global debates heavily. Between 2002 and 2013, heroin-related overdose deaths quadrupled in the USA, and deaths associated with prescription opioid overdose quadrupled from 1999 to 2010.

One of the most obvious tradeoffs of anti-drug policy has been gang violence. It\’s hard to measure this in any precise way, but the report cites evidence that in the Americas, about 30% of all homicides involve criminal groups and gangs, compared with about 1% in Europe or Asia. In Mexico,  the rise in homicide rates after 2006 has been so extreme–from a national rate of 11 per 100,000 to a rate of over 80 per 100,000 in the most heavily affected locations–that it actually reduced average life expectancies for the entire country. Of course, just looking at murders leave out other violence, including sexual assault. About 2% of Mexico\’s population is displaced from their homes by violence and risk of more violence. Colombia, Guatemala, and others have experienced a sharp rise in violence as well. Much of this is drug-related.

The illegality of drug use means that those who inject illegal drugs are likely to share needles, which in turn raises the rates of infection for HIV, hepatitis, tuberculosis, and other illnesses. One estimate is that outside Africa, 30% of cases of HIV infection are caused by unsafe drug injections. \”A landmark US study showed that over half of people who inject drugs were infected with HCV during their first year of injecting.\”

Illegality means that drugs are more likely to be taken by unsafe methods and in unsafe dosages –and when overdoses occur, the ability to get medical help may be quite limited. The Commission notes:

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. …  In 2014, WHO estimated that about 69 000 people worldwide died annually from opioid overdose, but that estimate might ot have captured the substantial increase in opioid overdose deaths especially in North America since 2010. In the EU, drug overdoses account for 3·4% of deaths among people aged 15–39 years.

The illegality of drug use boosts prison populations around the world. \”[P]eople convicted of
drug crimes make up about 21% of incarcerated people worldwide. Possession of drugs for individual use was the most frequently reported crime globally. … [D]rug-possession offences constituted 83% of drug offences reported worldwide.\” The evidence that incarceration for possession or use of drugs deters use in any substantial way is weak. But incarceration does tend to reinforce other social inequalities: in the US, for example, African-Americans are disproportionately affects by drug-related incarceration. In many cases, young people and women who are low-level carriers of drugs end up with significant sentences. Prison is of course a place where additional drug use and violence are common. Those who aren\’t in any way involved personally in the drug business, but who live in communities where the rates of incarceration are high, find themselves bearing high costs, too.

When it comes to drugs, most of us are not pure prohibitionists at heart. We regularly consume caffeine through the workday, and occasionally alcohol after the workday. Maybe we don\’t use nicotine ourselves, but we don\’t see a compelling reason why our friends who like a nicotine hit now and again should be locked up. A growing number of Americans live in states–Washington, Colorado, Oregon, and Alaska–where recreational use of marijuana is legal. Some countries like Uruguay are experimenting with legalization of marijuana, as well.

On the other side, most of us are not pure libertarians when it comes to drugs, either. Rules about age limits, time and place of use, and intoxication while driving or just walking down the street can make some sense. A country which gives serious considering to limiting the size and availability of sugared soft drinks is unlikely to take a hands-off attitude to drug use.

When it comes to policy proposals, the Commission is essentially arguing that reducing the costs of anti-drug policies should matter, too. Without endorsing all of these steps myself, here are some of the recommendations:

  • Decriminalise minor, non-violent drug offences— use, possession, and petty sale—and strengthen health and social-sector alternatives to criminal sanctions.
  • Reduce the violence and other harms of drug policing, including phasing out the use of military forces in drug policing, better targeting of policing on the most violent armed criminals, allowing possession of syringes, not targeting harm-reduction services to boost arrest totals, and eliminating racial and ethnic discrimination in policing.
  • Ensure easy access to harm-reduction services for all who need them as a part of responding to drugs, in doing so recognising the effectiveness and cost-effectiveness of scaling up and sustaining these services. OST [opioid substitution therapy], NSP [needle and syringe programmes], supervised injection sites, and access to naloxone—brought to a scale adequate to meet demand—should all figure in health services … 
  • Efforts to address drug-crop production need to take health into account. Aerial spraying of toxic herbicides should be stopped, and alternative development programmes should be part of integrated development strategies …
  • Although regulated legal drug markets are not politically possible in the short term in some places, the harms of criminal markets and other consequences of prohibition catalogued in this Commission will probably lead more countries (and more US states) to move gradually in that direction—a direction we endorse. 

Hat tip: I ran across a mention of the Johns Hopkins-Lancet Commission on Drug Policy and Health in a post by Emily Skarbek at the Econlog website.

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